HomeMy WebLinkAbout0544 PRINCE HINCKLEY ROAD - Health 544 PRINCE HINKLEY RD. C- VILLE
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LO CATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME & ADDRESS.
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S U I L D E R OR OWN EN
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DATE PERMIT ISSUED "
DAT E COMPLIANCE ISSUED
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THE 0 COMMONWEALTH MASSACHUSETTS
BOARD 0 HEALTH
--- .-------------OF...... +7�6_.Lp................................
Appliration for Disposal Workii Tunstrurtion Prrmit
Application is hereby made for a Permit to Construct (/) or Repair an Individual Sewage Disposal
System at:
.......E.F.-D .....tD.- MA--- 6�.........................................
Location-Address .. . r Lot
.0 . .....
......WA aJ. ....M.... ...... ....il� ......................................................
wneess...........................................
Installer
.... ld. .........
i1-1 .;eA re�ss
M
d Type of Building Size LotA_r2,i_'5)Z1-------Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
'_l
PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
PAOther 6x-Wres ......................................................................................................................................................
Design Flow.............9.r2..........................gallons per person per day. Total daily flow-___.___.___..---- ----------_----gallons.
1:4 Septic Tank—Liquid capacityt.4743Ctallons Length................ Width.._.._..___.___. Diameter________-____ - Depth................
Disposal Trench—No..................... Width............._..._.. Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No............t------- Diameter.......17-�....... Depth below inlet.....40........ Total leaching area.Z.+V....sq. f t.
Other Distribution box (4 Dosing tank ( ) X Percolation Test Results Performed byWA4-,WAfA&)
K4---(AN.:..... Date......[0.11b.lCe..........
Test Pit No. 1...:4:Z...minutes per inch Depth of Test Pit______f2........ Depth to ground water.....................
Test Pit No. 2................minutes per inch Depth of Test Pit____._.............. Depth to ground water____._.............._...
--------------------------*...........................................).......... ....I------------ ----------r--------------------
0 Description of Soil....,��._.Z..... - l ...sMj 4z---API.-AtJD
X .... / Y
U ........................................................................................................................................................................................................
W
I ............... ------------------------------------------------------------ ...........................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
e Me(l
scr
the provisions of TLITHE 5 of the State Sanitary ode—T e dersigned further agrees not to place the system in
operation until a Certificate of ompliance has h ue e of health.
............................................. ..... .......
�ign .1. - _.
t
Application Approved By........ ....... ................................................... ..... ......�
----------
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo. <Z Z..... ....................... IssuedL.......................................................
Date
Y.
--------�'' Fps.... .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
! .4J.1�...............OF...... l.t-..........................................................._..
Appliration for Mi ipoii al Workii Tomitrurtion nutit
Application is hereby made for a Permit to Construct (/) or Repair ( ) an Individual Sewage Disposal
System at:
L t•- = (? i 1Ji .._{::�I,�JG .l j7.. ..L: 4�-' V ...�- 4>.-•-------------------------------•--•--•--
Location-Address or It No.
......................................-� -1 _.._ 1._.1 ! , L>....._...'!.n..
Owne ---ress...........................................
a •----- -/ ` ............................................ i>� %r1.>tS� . - ' J . -•-------------------------------------------
�/ Installer Address
d Type of Building Size Lot.f!�, ') '_j_......_Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fiures -----•-------------------------- .
W Design Flow...........................................gallons per person per day. Total daily flow.............. ...............gallons.
WSeptic Tank—Liquid capacitA.f2v<?egallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No----------- --------- Diameter......!2_.______. Depth below inlet....4"�........ Total leaching areaZ.4,1V.....sq. ft.
Z Other Distribution box Dosing tank( ) g ( )'-' Percolation Test Results Performed U.)�:•_..__. Date-----f 6111 Ll e_14..........
Test Pit No. 1_.L:z.....minutes per inch Depth of Test Pit.....J.;:......__.. Depth to ground water------ ..............
GL, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water---_-._____-____---._-_.
(� ._...-------••------•-•-----•-•------•-•------•-----•....................................................................t---------f----.-------------- -
D Description of Soil--` 2 '-'�/�s.2. !'411�..
x -
�.,
W ------------------------------------------------------------------------------------------------------------------------------------------ ............................................................
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
•---------------------------------------------------------------------------------------•---------••---------•---------------...--------------------------------------------------------........_...••--
Agreement:
The undersigned agrees to install the aforedescribed Indiyidtial Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary,Code—The,Adersigned further agrees not to place the system in
operation until a Certificate of Compliance has be Wi3'sued by/the4gafja of health.
...EStM
-s.--- �-----=� -------atti.,gried,,
Application Approved BY .�C.- •-•--•--
I. f Date
Application Disapproved for the following reasons:...................................................... t
-•-------------------------•----------.....-----...--------------------------------•-------...-------------••--••---•-•------••-------••---•-------------------•--••-•-•---••---••--•---•-----------_---
Date
Permit No.
—ry
------- _ ._.. Issued_
Date
THE COMMONWEALTH OF MASSACHUSETTS
" BOARD OF HEALTH
ate.. f.
1 `.r�✓.. ....................OF.....TY—�..a..t^� 7`l..:f.'�� ..............
Qlrrtifirabr of hunt li�anrr
THIP 14�7 ,C,ERTIFY,Tha the Individual_Stewa Disposal System constructed or Repaired ( )
j.. J'
r
b -( srt�� �( % ------•---------------- -
I --------
Ito
has been installed in accordance with the provisions of TI T L=, The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated_._..-----.-._-_-_-___-_-___-___----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL FUNCTION SATISFACTORY.
DATE...... _..l`? 5 --- Inspector............/ ----------------------------.....................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
No..........� - .._ FEE_,,.-.�.0.......•---
�tu�ruu I ku �onutratrtion , r�anit,
Permission Is h reb ranted. ;___l _____�a, "., ,,,.f
to Construc or Re it ( ) an Individual Semag isposalr)yst
at No.... ,. = `y�' � r--ll�r�"'' -�'�� . r` v. �!g�-
r c
as shown on the application for Disposal Works Construc"tion Permit tNo`......_��... Dated-----
� .....::`�..............
..........:�: � _ .........------------------------------------------------------------_
Board of Health
DATE......--•----------------------------------•--•-----------------------.........
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
S/TE PLAN I sNEer i or P
[ <a 44 SCALE; 20
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47 XZ- /!E��19 7!
STD. PK'E'GAST �o,c/6. •� ('
SEOTIe_ Ti MK
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47 S
1 STp.: PRE�et.S 4
� GONG,�C,EAGN/Alec ig5�,t/ � In
3� 5 Z?,e.lE ARO&AIP
47 )(9
1) iP 6-5 ER V ACE o
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48
wKLIAM M. 6
WARWICK. a�i+
No. 19771
IS
®"SOKYE`�
RMVERED LAND SIIRYEY P •'". '"" '..._
ZONE
PLAN REF DATA 2 5 S
BENCH MARK DATUM , '110, M.. N'AAIM/CA' 40 1#SO ., /MC.
DOMESTIC WATER o w w W'A TA•A2
FUM ZONE N o M - M A z.4'R ► -.�c " ' • EA'/�'� #t. *� �
� .
~LEACHING BASIN SECT/ON Nor ro sCACE shec 2 �� 2
24'C.I.MH COVER
EARTH F/LL BRICK AND MORTAR COURSES AS R£0'0• 7-0 BRING,
COVER TO GRADE
1 /NLE7•" +B FLOW LINE y p"_ "TO�' wASHED PEA STONE FREE OF IRONS,
PIPE FINES AND DUST IN PLACE
n ':•' 11 OPENING WITH 4%g" �V4 TO l%p"WASNEO CRUSHED STONE FREE OF
•��J IRONS, FINES AND DUST /N PLACE
5� OUTER D/AM£TER
AND I314" INSIDE
k D/AMETEK I• CONCRETE TO BE 4000 PSI '28 DAYS
2. REINFORCED WITH 6"x 6° NO. 6 GA. W.W.M.
L.EA ZA P't S. 2'AND 4' S_ ECTIONS ARE AVAILABLE FOR
GREATER DEPTH REQUIREMENTS
410„ 4. NUMBER OF .PITS REQUIRED a'N
MIN 12 NOrE. EXCAVATE TO ELEVATION *11A OR
A I EFFECTIVE DIAMETER
NOT To£xcE£D.3 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL
warER TABLE LOAM AND CLAY BENEATH PIT. REPLACE
EXCAVATED MATERIAL WITH CLEAN
TYPICAL PROFILE GRAVEL TO DESIGNED GRADE..
O /B"STO. LT. WGT. C.I. MN COVER
4"81r FIBER P/PE
4'C/.PIPE T/GHT JO/Nr �, OUTLET LEVEL
DWELLING , FLON'_L!N£ TO FIRST JOINT --7-• r. .- 4.—
/4„ OO I ID�OO 1
�y 25 C.I. TEE 4�.6 14�•'I! ° 1 10 O O 1
!/ r11100�00 11 I
PRECAST CONC. 44.�jlo !SQ T BOX TO BE L�f�f I i f 0 00 O 0 1 1 1 i .
GAL.SEPTIC TAN INSTALLED ON LEVEL 11 100 O 0 0 ► I I
1 11 100 0 0 1 1 11
STABLE BASE , II100 00e1
NseprIC TANK TO BE I '0 600 O 0 1 1 I
INSTLEVEL, I If 100100 1 1
STABLE BASE. I I 1 0 0 0
11f00 00 11 „
LEACHING BASIN
BASE TO BE LEVEL i It It
0100 1 1 , , �L�f✓.
SOIL AND PERC. DATA .
PERC. RATE � GZ MIN. /IN.
O TEST PIT NO. P 3&o)9 Ot TEST PIT NO. 2
Z+ TBP/5ut��o11-
TEST BY �''RUL� t�l✓L.C� hILT%( hAtQp
WITNESSED BY (ZO►�1 lnllFFOfzD
TEST PIT GR. EL. 4-7
DATE: Iv-elp- f-A
DESIGN DATA GENERAL NOTES
BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
DISPOSAL SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO.BE STANDARD
EST. TOTAL DAILY EFFL33`76PD. PRECAST REINFORCED CONCRETE UNITS.
SEPTIC TANK I o0o GAL. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE,
SIDEWALL AREA Z'yGAL./SQ.FT. MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF
BOTTOM AREA 1.a GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY 11 1977.
LEACHING REQUIREDgop SQ.FT. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
ACTUAL LEACHING AREA OF HEALTH.
Z-Q.FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE
41vgwjALL_: BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
I0.7-if c., ►.- PITCH ALL SEWER LINES I/ � / FT. UNLESS INDICATED OTHERWISE.
Morro M
ri o .�
SEWAGE DISPOSAL SYSTEM!
9.
/or MARTIN �yG CO•P �.I�G �J I.•. - 6j!7 L L O 1.t) Lj
E. FOR'
1,3 MORAN h I,O"( (,4: 11(Z11-1[.r 14 I N c-4.L1---Y f.D.
123417�Q
SCALE AS INDICATED DATE
WM. M. WARWICK 8 ASSOC., I NC.
8OX 801 - NORTH FAL MOUTH
` MASS. 02556 - (6ln 565-2658
PROFESSIONAL ENGINEER
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
M
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�t
V
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner's Name: COLLEEN HARRINGTON
Owner's Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632
Date of Inspection: 12/1/00 RECEIVED
Name of Inspector:(please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS D E C O 8 2000
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
TOWN OF BARNSTA13LE
Telephone Number: 508-564-6813 FAX 508-564-7270 HEALTH DEPT.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Passes
_ Needs Furt Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 12/1/00
�,r ,,
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspec on.If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall.submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies'sent to the buyer,if applicable,and the approving authority.
Notes and Comments }r
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE EVERY TWO YEARS TO PROLONG
THE SYSTEM'S USEFULL LIFE. , ;t
""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.
.'ia ny
Title 5 IncnPctinn Fnrm F/I VIM()
Page 2 ofil 1
a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAR
T A
CERTIFICATION (continued)
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON
Date of Inspection: 12/1/00
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
4.3.
X 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.
t ,
Comments:
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a 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 ol'dtis available.
ND explain: n/a
n/a Observation of sewage backup or`lreak out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain:n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
+,
7
Page 3 of,11
A
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON
Date of Inspection: 12/1/00
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
. .i,
1. System will pass unless Board of 1169lfh determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or 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 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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
z
Page 4 of•i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON
Date of Inspection: 12/1/00
D. System Failure Criteria applicable to all systems:
You mast indicate"yes"or"no"t6'dach of the following for alLinspections:
Yes No '
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
_ X Required pumping more than 4 times in the last year Nt7T due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy js within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy'is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
_ _ (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system tfails.`The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems: ' "
To be considered a large system the s'stem must serve a facility with a design flow of 10,000 d to 15 000 d.
g Y Y Y g gP + gP
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a.iAbutary to a surface drinking water supply
X the system is located in a nitrogewwhsitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed,The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
�i�i d
Page 5 of.l I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON,,
Date of Inspection: 12/1/00
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
l:
X _ Was the site inspected Tor signs of break out?
X _ Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
N.
battles or tees,material of construction,'dimensions,depth of liquid,depth of sludge and depth of scum?
rI
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems? V
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no i
X _ Existing information. For example;a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
'.6
5
Page 6 of,11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON
Date of Inspection: 12/1/00
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents:2
Does residence have a garbage grinder(yes or no):NO
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO •r
Last date of occupancy: n/a
COMMERCIALANDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203) n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title�5 system(yes or no):NO
Water meter readings,if available: n/a :.
Last date of occupancy/use: n/a
OTHER(describe): n/a
r
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How wasp quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soiNbsorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date-installed(if known)and source of information:
1985 PERMIT 85-82
Were sewage odors detected when arriving at the site(yes or no):NO
i
iu i.
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON
Date of Inspection: 12/1/00
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yeG or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7"W 4' 10
Sludge depth:4"
Distance from top of sludge to bottom of outlet tee or baffle:30"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle:6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
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.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING
NOW AND EVERY TWO YEARS T®PROLONG THE SYSTEM'S USEFULL LIFE.
GREASE TRAP:_(locate on site plan)1
Depth below grade: n/a
Material of construction:_concrete_metal`_fiberglass_polyethylene_other(explain): n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
li 9
4
16 I
7
Page 8 of,1 i i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
4
Property Address: 544 PRINCE HINKL'EY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON
Date of Inspection: 12/1/00
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction: concrete metal fiberglass_polyethylene—other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow:n/a gallons/day ,
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order(yes or no):NO
Date of last pumping: n/a ,.
Comments(condition of alarm and float switches,etc.):
n/a
F�
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:,LEVEL WITH BOTTOM OF PIPE
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 DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
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N;
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i'
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON
Date of Inspection: 12/1/00
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
t
If SAS not located explain why:
n/a
Type
1000 GAL 6'X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT
HAD 1'OF LEACHING LEFT AT THE TIME OF THE INSPECTION.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction:n/a
Indication of groundwater inflow(yes or no):NO
Comments(note condition of soil,signs othydraulic failure, level of ponding,condition of vegetation,etc.):
n/a ,t;
PRIVY: (locate on site plan)
Materials of construction:n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a
4
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON
Date of Inspection: 12/1/00
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet.Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 544 PRINCE HINKLEY RD CENTERVILLE,MA 02632 L643
Owner: COLLEEN HARRINGTON
Date of Inspection: 12/1/00
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
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