HomeMy WebLinkAbout0441 SHOOTFLYING HILL RD - Health 441 l-ina Mill Re d, Centerville
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11 2014
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, (� � `use only the tab 1. Inspector:. jif /U,(3
key to move your
cursor-do not David D. Coughanowr, IRS
use the return Name of Inspector
key.
Environmental
Company N
Company Name
P.O. Box 1265
Company Address
» West Chatham MA 02669
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
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 m a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15���N asgc em:
s
o�
® Passes DAVID�� D. ElConditionally Passes ElFails
COUGHANOWR
❑ Needs F h r gWI9*jig Local Approving Authority
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��SgppROV�Q��Q
TFM INS �G n
N J- April 11, 2014
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approviylg Authority'(Bo rd
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 T'i"3nctiontle 5 0 Form:Subsurface Sewage Dis ll posal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5, or
specified by local regulations. No estimate or guarantee of system longevity is made or implied by a
passing determination.
System is over 40 years old yet continues to function hydraulically under current flow conditions. A
voluntary upgrade of the system to conform to Title V to address environmental and structural
concerns is recommended.
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.
Check the box for"yes", "no" or"not determined" (Y, N,,.ND)''fo'(the following statements. If"not
determined," please explain. `
The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or,tank failure,is imminent. System will pass
inspection if the existing tank is replaced with a complying;septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it'is struc0allyisound`not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years oWis'available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is Centerville MA 02632 Aril 11 2014
required for every P
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high,static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
N
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11 2014
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
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:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® 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 '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or,mQre'of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
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
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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
NA
inspected for the condition of the baffles or tees material of construction
Taht< dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): n/a Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM , 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Age unknown—system predates Title V permitting regulation.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): 59 gpd
Detail:
2012: 21,000 gallons 2013: 22,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age unknown—system predates Title V permitting regulation.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer lines appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11 2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in workingorder: ❑ Yes El No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 1
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Overflow cesspool was uncovered and found to have approximately 1 foot of effluent with no staining
on upper blocks.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 3 total -2 primary, 1 overflow
Depth—top of liquid to inlet invert primary A full, primary B
empty
Depth of solids layer few inches
Depth of scum layer none in either
Dimensions of cesspool 5 ft x 5 ft approx
Materials of construction concrete block
Indication of groundwater inflow ❑ Yes ® No
t5ins-3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11 2014
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspool A was full and overflowing to cesspool C. Cesspool B was empty.
NOTE ON BLOCK CESSPOOLS—Block cesspools consist of concrete blocks arranged in a beehive
formation and are held in place by gravity and soil pressure. Driving vehicles over or near block
cesspools could potentially destabilize the structure and lead to collapse. DO NOT DRIVE VEHLICES
OF ANY SORT NEAR CESSPOOLS.
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.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
F ,
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M SVB',W 441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate
where public water supply enters the building.Check one of the boxes below.-
hand-sketch in the area below
❑ drawing attached separately
-OF SEPTIC COMPONENTS
-DISTANCES IN DECIMAL FEET E S T
2 4 BEDROOM
A 54 67
8 55 60.5 D W L UNG
C 62 72.5
I 2
I I
> PRIMARY
3 Q CESSPOOLCr
.
Uj
2
rn
W
OVERFLOW
Qa CESSPOOL C� o
8 �
PRIMARY r
CESSPOOL
'e•
508 364-0894
SG-y 0 00 T FLU YOnNIG HILL L rl-R 0A D
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner Owner's Name
information is required for every Centerville MA 02632 April 11, 2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 25+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
Observed site (abutting ro ert /observation hole within 150 feet of SAS
Checked with local Board of Health -exp
lain:
p
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A survey instrument was used to determine that the bottom of the cesspools are over 10 feet above
the elevation of nearby Wequaquet Lake, the elevation of which is artificially controlled by means of a
wier.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
441 Shoot Flying Hill Road Assessor's Map 213 Parcel 6
Property Address
Kristina B. Hemenway
Owner
Owner's Name
information is Centerville MA 02632 Aril 11, 2014
required for every p
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
GEOHYDROLOGICAL PROFILE
- NOT TO SCALE
iq
BOTTOM
OF
LEACHING
LEACHING IS PIT
ABOVE HIGH
GROUNDWATER
ELEVATION OF
ADJACENT LAKE
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17
COMMONWEALTH OF NLASS.ACHLSETTS �S
EXECUTIVE OFFICE OF ENNIRONME\TAL AFFAIRS
.; DEPARTMENT OF ENNIRONNIENTAL PR I Vl
OBE wlNTER STREET. BO5T0,. NIA 02)OS 61'-:9: .Q0 �d�a
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B STRURS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECFIO F Commission;
PART A
CERTIFICATION S
Property Address: t1�-\ Address of Owner: Marilyn Tyler
Date of Inspection: ' (If different) 441 Shoot Flying Hill Rd.
Name of Inspector: P4% eN�� ko Centerville,MA 02632
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: 011-fri,311 - v , n rti jCS2, =F*L--
Mailing Address: '�,p�t'?��,y d.3� t-lyptc Qt MIP►, o'Z,t•yq
Telephone Number: 5 6S k"\
CERTIFICATION STATEMENT
I certify that I have perso lid �r,peclecl the sev%aee disposal system at this address and tha' the information reported below is true, accurate
and complete as oi'the t� e of mspectoo-. The inspection was performed based on my training and experience in the proper function and
maintenance of or)-s to s wage disposa- systems. The system:
Passes
_ Conait,o,4 \ Passes
1,eea� Fun•her E\a'jat,or.. 5� the local Approving Authority
_ Fa.!s
Inspector's Signature-
t Date:
The System Inspector sha!' subrnit a cope of this inspection report to the Approving Authority within them' (30) days of completing this
inspection. If the system is a shared system o• ha: 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 origma! should be sent.to the system owner
and copies sent to the buyer, if applicable, and the approving authorir)
INSPECTIO% SUMMARY: Check A, B, .C, or D:
A] SYSTEM PASSES:
1 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: S 14 0.t.A ONX cj.�\ %eSI� _ hC,T �c ,.a .�.lc bc� -M.w. UCLI`t 16. e}
Z' t)�1pyv� M*T ego c Q o I I TyryA
01 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 conforming septic tank
w approved by the Board of Health.
(rav:�ad D�/25/97) Page 1 of 10
DE0 o me Womd Woe WeD htto/nvww magnet state ma usicer
Pnntee on Recyued Pace'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
BJ SYSTEM CONDITIONALLY PASSES tconnn.,-d
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approva' of the
Board of-Health). Describe observations:
broken pipets) 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 p;pe(s) are replaced
obstructior. is removed
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 the
public health, safer\ 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:
Cesspooi or prn-, is within 50 feet of a surface water
Cesspool or pri%-, is y+ithm 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 suppy.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supn'v 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
(revioad 04!25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propert. Address:
Owner:
Date of Inspectio
D) SYSTEM FAILS:
You must indicate eithe "Yes" or No' as to each of the following
I have determin ' that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303 The oasts
for this determinate n is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backyp of sewa a into faciliry or system component due to an overloaded or clogged SAS or cesspool.
Discharge or pon g of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
Sta;lc hcu,d level in th distnbitior, boa above outlet invert due to an overloaded or clogged S45 or cesspool.
Liowd death: in cesspoo! i less than 6" below invert or available volume is less than 112 day floe.
Recu+red pumping more than 4 times in the last year NOT due to clogged or obstructea pipe's,
Number o'times pumped_. '
An. pon,on o`the Soy! Absorption vstem, cesspool or privy is below the high groundwater elevation
An% poi;or. o'a cesspool or privy is ithir. 100 feet of a surface water supph• or tributar to a surface Ovate- supple.
i
And por:ion of a cesspoo' or privy is wit r` a Zone I of a public well
pc^10-. ci a cesspoo! or pn.v is within feet of a private water supph well
An. por:.or. o:a cesspool or prooy is less than 1 0 feet but greater than 50 feet from a private water supp!v well with no
acceptable water quahr� anaivsis If the well has n analy2ed to be acceptable, attach cope of well water analysis for
coliform, bacieria vo!atile organic compounds, am is nitrogen and nitrate nitrogen.
E) URGE SYSTEM FAILS:
You must indicate ether "Yes' or "No" as to each of the following:
The ioliow;ng criteria app;. to large systems in addition to the criteria above:
The system serves a facility with a design floe of 10,000 gpd or greater arge System: and the s\,stem is a significant threat to
public hea!th and safer and the environment because one or more of the Ilowing 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 sup v
the system is located in a nitrogen sensitive area (Interim Wellhead Protection rea - 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 a groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for rther iniormation.
(revised 04/25/97) page 3 of 10
SUB$URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propert% Address: Kull
Owner: -�%A\9,VL
Date of Inspection:
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 pan of this inspection
As bu:l: plans have been oota+ned and examined. Note if they are not available with N/A
_ The facnlin or d%.elirng \tins inspected fo, signs o;sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site %%as inspected for signs _)i breakout.
All s\stear components. excluding the So-!. Aosorption System, have been located on the site. v
•. _ The septic t2nk manhoies were uncovered. opened. and the interior of the septic tank was inspected for condition of
banies or tees. mater,a' o'construction, dimensions, depth of liquid, depth of sludge,,depth of scum.
The size and loca:,on of the Sol' Absorption System on the site has been determined based on
_ The facJ,t, o\%ne• ;ano occupants. if difteren;trom owner were provided with information on the proper maintenance of
Sub-Surface Disposal Svsterr.
Existing inio•mation Ex Plan at B.O.H.
_ Dvermined in the field -t•.'an% of the failure criteria related to Part C is at issue, approximation of distance is
unacce:)tah-e 115.302.3;b t
r
(revised 04/25/91) Faye 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properh Address: tAM
Owner:rl4t;4.
Date of Inspection:(0(•Z-1 Cq
FLOW CONDITIONS
RESIDENTIAL:
Design floe. _�•1U a p.d./bedroom for S.A'c
Number of bedrooms oL
Number o'current residents .'�•
Garbage g•, der (yes or no -
Laundry c&—ected to system (yes or no` %j—
Seasonal use ryes or no, ►3
Water meter readings, if available (last two i2 yea usage tgpd,. \SSttE&
Sump Pump Ives or not lV
Las dare o'occupancy t aAjN —
COMMERCIAL9NDUSTRIAL•
Type of establishmen:
Design fto\% _gallonsda\
Grease trap present tyes or no
Industrial %%aste Holding Tani: present •ves or no \
Non-sanitan %ante discna,gec to the Tale 5 system Ives or no_
\%ater meter readings if a�ailabie
Las:pave o: o c6;;2,-c,
OTHER: Describe
Last pate ot. occ za^c.
GENERAL INFORMATION
PUMPING RECORDS and source of mformatior.
\10%0Q N GQ.
System pumpec as Dar, of m c speion: (yes or no UO (v�AsnsTigrl*�C.re„
If ves, volume pumped eallons
Reason for pumping
TYPE OF SYSTEM
Septic tank/distribution box'soil absorption system
Single cesspool(50-- t C��••r,tpsol ( ovc,a,Fo'4
Overflow cesspool
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. COPY of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 101Sd ♦Ns yt� 9
Sewage odors detected when arriving at the site. (yes or no)MD
(revised 04/25/9'7) sap. 5 of 10
SUBSURFACE SBA AGE DISPOSAL SYSTEM INSPECTIO% FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(locate on site plan)
Depth below grade
Material of construction _cast iron _ 40 PVC _other (explain)
Distance from private water supply well or suction Ire
Diameter
Comments: (condition of joints, venting. evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site p:an
Depth beloN grade
material of construction _concrete _meta _Fioerglass _,Polyethvlene _ot/kexplain*
If tank is me:a�. Iis: age _ Is age conf;rmec o\ Ce^:+ica:e o'Compnance es'no
Dimensions
Sludge depth
Disiance from top o: sludge to bortorn o' ou:ie: tee o• ba-.e
Scum thickness
Distance from top o'scum to top o; outle: tee or bade
Distance from botto-n o;scur to bo-o-: of outie: tee c• b2*'•e
Now dimensions \ere determined
Comments
trecommenda:icn for pumping condition o' inlet and outlei t or baffles, depth of liquid level in relation to outlet invert, strucural
integrity, evidence of leakage. e:c.)
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 ou et tee or baffle.
Distance from bottom of scum to bo m of outlet tee or baffle:
Date of last pumping
Comments: .
(recommendation fo, pumpin condition of i:ilet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural
rntegnt), evidence of leakag , etc.;
(re,ised 04125,11) tag* 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA
PART C
SYSTEM INFORMATION (continued)
Propert% Address:
Owner:
Date of Inspection:
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 galions
Design flow galions,da,
Alarm leve! Alarm in working order _ Yes: _ No
Dace of previous pumping
Comments
(condition of inlet tee. condition o- alarm and float switches. etc.i
DISTRIBUTIOI BOX:_
(loca-ze on site p;an.
Depth o' iio�id ie%e! aoove outle: ime"
Comments
tno,.e r ieve' and distfibutior t; eoual. evidence of solids carryov/evidenceakage into or out of.box,eta.)
PUMP CHAMBER:_
(locate on site plan
Pumps in working order: (Yes or No,
Alarms in working order (ties or No,
Comments: _
(note condition of pump chamber, condition of umps and appurtenances, etc.)
(revimed 04/25/5?) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: IJL(f %n60Tf14tWj Lo
Owner:Ty�-vC,,
Date of Inspection: t'D
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, cli-nensions
overflow cesspool, number_I
Alternative system
name of Technoicip
Comments
(note condition of soil, s:gr.s of hydraulic failure, lev' o:ponding.ccconditlon of vegetation, etc.)
1 4QAQ�� 1 13'J&au C o`E'hJ.� «�..., ��� I t 10� V Q�mn �AAAartA
GQArJCL� ��^•tiA QYe.L�tO_"` .
CESSPOOLS: its to
(locate on site plar
Numbef and conitgura:-on
Depth-top of liquid to inlet Inver, l-a" 3 (AWVt
Depth of solids lave,: 1" *3- (o t
Depth of scum layer a 1 `0" *30"
Dimensions of cesspool 16 \ Sx1�"A _$- (eQ
Materials of construaior C ;,.,.ir°✓ �`ccaE_
Indication of groundwater w]d
inflow (cesspool must oe pumped as par of mspection)_tz—,es
Comments:
(note condition of soil, signs of hydraulic failure, level of pondin condition of vegetation, et*)
A-V T�vrt of t,NS{P.cJCww Sy9T{.w� wits �vw�cl�iors b•1 WIZ"i Nis 4c'%
�Snc.9+..+. lPvc�l.&rA 1!1 Sviit'.111k%61 k,'FINCAA
PRIVY: Na
(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.)
(rev&ved 01/25/97) page / of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION' FORM
PART C
SYSTEM INFORMATION (continuedi
Propert. Address: yy\ g'lum�Q�tyrlNa1�nvh �
Owner:TAkc r
Date of Inspection:
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)
t•Q.4N
. p
?•PL 5..�. t�PSt'rlNttrS
� - • 3 � a� _ Sys
- oo'
(revised O4i25!57) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION' (continued)
Propertm Address: y�� Stioo`r��y�a�k��\ t4
Owner:t%1Vk_
Date of Inspection: '�Z���,
Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Cnec� %%ith loca! Board o, nea!tn 4
Chec:. FE:vmA maDs ,
Check purnping records
Check iota' exca.acors installers
L°se L S'--S Da-a �,t�►�
Describe in +'DJ O++'^ ++0,0 ^O++ \0 eStdDLSheC the High Grou ,Elevation. (Must be completed-
V.J. �t.o\o9�co� So.,,�,y � �`'�O �aycc.�4NVa+iTbe�'Ra�+N�� �,^• (0�2�Ssh...ir T'y
�6 11 2 ,' a, �.-..v.�. ,8--%;L v% 1,,..►.,Sr eaa-Kasd \c) ,
J
lr,v.bod 04;2515-. Page 10 of 10