HomeMy WebLinkAbout0319 STRAWBERRY HILL ROAD - Health 319 STRAWBERRY HILL, CENTERVILLE
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UPC 12543
No.531-OR
HASTINGS, f1N
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COMMONWEALTH OF MASSACHUSETTS
U9 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 319 Strawberry Hill Road r�LL Cae ���° �A
Centerville, MA 02632
Owner's Name: Judith Petri
Owner's Address:
Date of Inspection: Me 2. 2005
Name of Inspector: (Please Print) Janes M. Ford
Company Name: James M. Ford VE
VE
Mailing Address: P.O.Box 49 °
4.
Osterville,MA 02655-0049
Telephone Number: (508)862-9400 _
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CERTIFICATION STATEMENT :z —°
nK cr
I certify that I have personally inspected the sewage disposal system at this address and that the inf(rmationwe orte3V
below is true,accurate and complete as of the time of the inspection. The inspection was performe based o't�'ny rr-
training and experience in the proper function and maintenance of on site sewage disposal systems. I am ad)EP rn
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste :
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: May 4. 2005
The system inspector shall sul copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 319 Strawberry Hill Road
Centerville, MA
Owner: Judith Petri
Date of Inspection: Ma 2. 2005
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:
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.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 319 Strawberry Hill Road
Centerville, MA
Owner: Judith Petri
Date of Inspection: May 2. 2005
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
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 colifonn
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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 319 Strawberry Hill Road
Centerville, MA
Owner: Judith Petri
Date of Inspection: May 2, 2005
D. System Failure Criteria applicable to all systems:
You must indicate either"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 'h day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 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.]
No (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 fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
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
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 319 Strawberry Hill Road
_Centerville. MA
Owner: Judith Petri
Date of Inspection: Me 2. 2005
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 inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes No
✓ _ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _ 319 Strawberry Hill Road
Centerville. MA
Owner: Judith Petri
Date of Inspection: May 2. 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): epd
Basis of design flow(seats/persons/sgft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Approximately 1974-per owner
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 319 Strawberry Hill Road
Centerville. AM
Owner: Judith Petri
Date of Inspection: May 2. 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 8"
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: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage
Recommend pumping.
GREASE TRAP: None (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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 319 Strawberry Hill Road
Centerville, MA
Owner: Judith Petri
Date of Inspection: May 2. 2005
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no.):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Commments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (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: None (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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 319 Strawberry Hill Road
Centerville, MA
Owner: Judith Petri
Date of Inspection: May 2. 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I-6'x 6'(1000 goal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The leach pit had P o li uid on the bottom. There didAQLappear to bLgfly si ns o ailure. The bottom to grade was 8.5. The
cover was 12"below vrade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
` Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 319 Strawberry Hill Road
Centerville, MA
Owner: Judith Petri
Date of Inspection: May 2. 2005
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.
i AJ( Q\
a 15 ag
10
Page 11 of 11
OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 319 Strawberry Hill Road
Centerville, MA
Owner: Judith Petri
Date of Inspection: May 2, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours snaps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours traps, the maps were showing approximately 25'+/-to ground water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report.
I1
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C�
4 10/1 /99
DATE: _
PROPERTY ADDRESS:-!1-9 Strawberrr_Hill_Road
-- Centerville ,Mass_
02632
------------------------ L y Y S 5
On the above date, I inspected the septic system at the abo dress.
This system consists of the following:
1 . ) -1000 gallon septic tank.
2 . 1-1000 gallon precast leaching pit . °
0 OCT 1 5
Based on my inspection, I certify the following con ns: a 1999 w
3 . This is a title five septic system. ( 78 Code )
4 . Lthe septic system is in proper working order
at the-pr.esent time . - ` g
9
5 . Pumped after inspection . Tank only
SIGNATURE:1 J. -
Name:_1 mber. Jr-,______
Company: Joseph-P . Macomber &. Son , Inc .
Address:- Box-66
--- ---------------
Centerville , Ma . 02632-0066
--------------------
Phone: 508_775_3338_______
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
�JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-LeachfleIds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
I
i I
COMMONWEALTH OF MASSACHUSETTS I
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS s
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
TRUDY COxE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PtopertyAddress:319 Strawberry Hill Road NameofOwnerCharles & Nancy yArchibald
uenterville ,Mass . 02632 Address of Owner:
Date of Inspection: 10/14/9 9
Name of Inspector:(Please Print) Joseph P .Macomber J r .
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Cornpany Narne: J. P.Macomber & Son Inc .
Maav Address: Box 66 e n v; 1 1 a ,M a c c 0 2 6 3 2
Telephone Number: 5 O 8—7 7-5,�2 2 2
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: f
The System Inspecto 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 oKnvironmental Protection. The original should'be sent to-"
system owner and,copies sent to the buyer, if applicable, and the approving authority. .
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
�1 Printed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (corrtLwed) y
Prop*mAd&"3: 319 Strawberry Hill Road Centerville ,Mass .
own«: Charles & Norma Archibald
Dau of)nspectton: 10/14/9 9
INSPECTION SUMMARY: check A, B, C, or D:
A. SYSTEM PASSES:
IA-1-9I have not found any Information which Indicates that any of the failure conditions described In 310 CMR 16.303 exist. Any failure
.criteria not evaluated are Indicated below.
COMMENTS:
s. 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 daterminatlon 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 exfiltfation, 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.
4A0 $swags backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of
Health).
broken pipets) are replaced
obstruction Is removed
distribution box Is levelled or replaced
The system required pumpirig•mm than•fourthnes t+•year•due to broken or obstructed pipe(31. The iyrtrm wiltZresr
Inspection If(with approval of the Board of Health): -
broken pipes) are'replaced
obstruction Is removed
revised 9/2/98 Pap 2orIt
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ♦`
CERTIFICATION(continued)
Property Address: 319 Strawberry Hill. 'Road Centerville ,Mass .
Owner: Charles & Norma Archibald
Date of Inspeco°n:10/14/9 9
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, 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 W A MANNER WHICKYWILL.PRQTECT THE PUBLIC HEALTHAND SAFETY AND.THE EM.=OkMENT:
Cesspool or privy is within 60 feet-of 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 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 60 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 a ce 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 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
r
CERTIFICATION (continued)
pr.oWtyAd&.s.-: 319 Strawberry Hill Road Centerville ,Mass .
Owner: Charles & Norma Archibald
Dist.of Inspection:10/14/9 9
D. SYSTEM FAILS:
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 es 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•towage i►+tofeciNtjrer-vyetertt component-due Ko an overloaded orcbggedSAS•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.
_Jf.&Ve_ Static liquid level In the distribution box bove outlet Invert due to an overloaded or clogged SAS or cesspool.
;11r
Liquid depth in seaapeeFis less than 6" below Invert or available volume is less than 1/2 day flow.
_ !/� Required pumping more tharl 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped .
4Z 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.
J/ 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
TT 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:
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:
i( 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•ia•vrhNn 200 feet of a t++butayr to a surfaoa drinking awier+upPly -
_ 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 4of11
{
jSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddres3:319 Strawberry Hill Road Centerville ,Mass .
Owner: Charles & Norma Archibald
Date of Inspecton10/14/9 9
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 cornpoaants.ham&A"n pua►ped4opat•Jaasi two.woa"and tha•rystam has bawvsceiving waeaoi Clow
rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
Inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was Inspected for signs of breakout.
_ All system components,deluding the Soil Absorption System, have been located on the site.
_ The a tic tan anholes were uncovered, opened, and the interior of the a tic tan 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 orr the site has been determined based on:
- /
Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation f distance Is unacceptable)
115.302(3)(b)1
'Ie ' _ The facility owner.(and.or , aats,lf dif w&U r^fnrMa an*!gip spar mAirjt-^f
SubSurface Disposal Systems.
I
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 319 Strawberry Hill Road Centerville ,Mass .
owner: Charles & Noima Archibald
Date of In O :10/14/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: //0_g•p.d./bedroom.
Number of bedrooms d Sig Number of bedrooms(actuaq:
Total DESIGN flow
Number of current residentsL19
Garbage grinder(yes or no):
Laundry.(separate system) ( es ora._ If yes, separaielnspection.roquired --•
Laundry system Inspectede or no) '
Seasonal use(yes or no): ,/�
Water meter readings,If available(last two year's usage(gpd):/ ,00,—
Sump Pump(yes or no): S� 9 J ff",
Last date of occupancy:��
COMMERCIALIINDUSTRIAL• `'�
Type of establishment: I/
Design flow: .V gad I Based on 15.203)
Basis of design flow
Grease trap present:(yes or no)9.0
Industrial Waste Holding Tank present: (yes or no)IV//
Non-sanitary waste discharged to the Title b system: (yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS A�sourcaAt in�rma 'r 4.+
System pumped as part of inspection: (yes or no) j-
If yes, volume pumped: goWd gallpns o� � 9 '
Reason for pumping: //`lszsvi )Ir�f1r� Y /uv� '!5j
TYPE OF SYSTEM
_, Septic tank/giairtbuttoa-bozlsoil absorption system
Single cesspool
At Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous Inspection records,if any)
I/A Technology a c.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other ZIA `/p
O IMF AGE of all components, date instagediif known)-and Bourse of inforn►ation:,; �
Sewage odors detected when arriving at the site: (yes or no)iVU
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Addrw-: 319 Strawberry Hill Road Centerville ,Mass .
owner. Charles & Norma Archibald
DoWof �n:10/14/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: ov
Material of construction:_cast iron/40 PVC—other(explain)
Distance from private water supply well or suction line _
Diameter V" _
Comments: (condition of Joints,venting, evidence of leakage,-etc.)
Joints ap, Par tight No avi dPnra of I t-nlcngP
jWC% ?.:W%ttkthrettgh the hoese Tent .lic
(locate on site plan)
Depth below grade:
Material of construction:2oncretedJ-4metal.WbFibergla3s4/A PolyethyleneV other(expiain)
WA
It tank Is Enetal,list ago &a Is.age.conf�}umed by Certificate of Compliance A (Yes/No)
Dimensions: O r Lr'r,�1 a
Sludge depth:
Distance from top of sludge to bottom of outlet tee ort affle
Scum thickness:_ Q
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bott of outl t tee or baffle: !�
How dimensions were determined:
IF
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level In relation to outlet invert, structurel••integrity,
"donee of leakage, etc.) Pump tank every 2-3 years . -Inlet & outlet tees are
i n pl are - The tank i s etriirrnrnI I q n rl gUri Qbnurg 11d1_eiTi fiPnr0
99 leakage .
GREASE TRAP:
(locate on site plan)
Depth below grade:4A
Material of constructionAJ,4concreta4metall),4Fiberglass2p,PolyethylenetLlother(explain)
A
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 4M
Distance from bottom of scym to bottom of outlet tee or baffle: 8
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.)
- Grease trap is not present .
6 I
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ft-WtyAddrms: 319 Strawberry Hill Road Centerville ,Mass .
Owner: . . Charles & Norma Archibald
Date of hupe�on:10/14/9 9
TIGHT OR HOLDING TANK(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grader
Material of construction:&concreteametalVAFiberglassNAPolyethylene 4�4other(explain)
424 -
Dimensions: to
capaci
llons
Design
gaallon
Design flow: gallons/day
Alarm present AM
Alarm level:Alarm in working order:Yes40 NoA!,9
Date of previous pumping: 101—
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
Tight or holding tanks are not :scant
DISTRIBUTION BOX:A Ae,
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note-if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Distribution box is not nragant-
PUMP CHAMBER:_&141Q.
(locate on site plan)
Pumps in working order:(Yes or No) A4
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Pump chamher ig not nraeellt
revised 9/2/98 Page 8ofII
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(coertirwed)
i
Prop—yAddrass: 319 Strawberry Hill Road Centerville ,Mass .
Owr."t Charles & Norma 'Archibald
Dau of lrupecdw: 10/14/9 9
SOIL ABSORPTION SYSTEM(SAS):J—/
(locate on afts plan,If possible; excavation not required,location may be approximated by non•Intruslvs methods)
If not located, explain:
Type:
lesching pits, number:
leaching chambers,number:
leaching galleries,number: n
leaching trenches, number, length: (J
I.aching fields, numbsr, dime slops:
overflow cesspool,number:
Altarnadve system:
Name of Technology: GCS
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loam w
WAS i a •A AN) �' Lil/LtPI. Jr
CESSPOOLS: T
(locate on site plan)
Number and configuration: _
Ospth•top of liquid to Inlet Invert:
Depth of solids layer:
Depth of scum layer:
Dimanslohs of cesspool:
Matsria:s of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of Inspsction)
• esspooFs are not present --
Commsnts:
(note condition of &oil, signs of hydraulic failura,.lsvel of ponding,condition of.vsgetatlon, etc.)
Cesspool s are not present .
PRIVY: 4/4/1,
(locate on site plan)
Malerjals of eonstrucu n: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
Privy is not
present -
revised 9/2/98 Page 9of11
I I
r '
1-4 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECnON FORS.!
PART C ""
SYST' a WFOR"noN(continual) •��
N0gft-tYAd&"4; 319 Strawberry Hill Road Centerville ,Mass .
owr,«' Charles & Norma Archibald .
o"�'r SDK ' 10/14/9 9
SKETCii OF SEWAGE DISPOSAL SYSTEU:
Include Via to at least two pstmansnl r►fat►ncs landmarks of benchmarks
locals ►II wills wlWn 100'(Locsts whits publlo w►tsf supply comas Into house)
� w
i
revised 9/2/98 , Pitt loot I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 319 Strawberry Hill Road Centerville ,Mass .
Owner: Charles & Norma Archibald
Date of Inspection: 10/14/9 9
NRCS Report name
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:
Obtained from Design Plans on record
�b ed.Sita (Abutting propert observation hole, basement sump etc.)
I,/Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
YChecked
ecked pumping records
local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map .
Gahrety & Miller Model
12/16/94
e I
revised 9/2/98 Page 11of11
�r•wwnr�.—nlT�r,•eT�,rnrmr•nmrwr�.ns�+�.mrnr+K�r�.�..+n•I..fray rn-�rr�nr� T�r�-T�!�.+m-..�..r',
TOWN OF Barnstable BOARD OF HEALTH
SUnSURFACE SEKAUE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
--win
J .rT•:�::1—T.Ili{�•T.TTNr,)"11•IItTIT\.r.ft.fTr'TTT.��b•.T`{1IiT7>tI IR�T—T�IR�f�.�.TR1 I�II.R •T�t'T'1+'11
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPE'CTE0
STREET ADDRESS 319 Strawberry Hill Road Centerville ,Mass . '
ASSESSORS MAP, BLOCK AND PARCEL # Z � Z
OWNER' s NAME Charles & Norma Archibald
PART D - CERRTIFICATION
NAME OF INSPECTOR _Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Svfi 'Inc .
COMPANY ADDRESS ' Box , 66 Centerville ,Mass . 02632.
Street Town or city State EIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of.-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check ne ,
Systeui PASSED t ,
The inspection ;rhich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con cted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303, arnd as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signatur 4
Z - Date
e copy of this certification must be provided to the OWNER, the BUYER
3Fn
where applicable ) and the 130ARD OF HEAL11I1.
If the inspection , the owner or0" erator shall u* ecti FAILED h "* p pgrado ' the eystem
within one year of the date of the inspection, unless allowed .or required
otherwise as provided in 3,10 CMR 16 . 306 ,
partd.doc
I
DATE:_
PROPERTY ' ADDRESS:_�1�_Strawberr� Hill Road
___Centerville JMass
02632
On the above date, I inspected the septic system at the above ad
This system consists of the following: dress.
1 . 1 -1000 gallon septic tank. -
2. 1 -1000 gallon leaching pit .
Based on my Inspection, I certify the following conditions:
1 . This is a title five septic system.
2. The septic system is in proper working order )
at the present time.
SIGNATURE-
Name: - --
Company; J_p_Macomber
Address: Box_66------------- cc RfCf/yf®
Centerville ,Mass 02632 o�T
-------------------- ,� Igg
Phone:
---5Q$=27_�_-_3338-------
4 �
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRAN
m
LJOSEPHP. MACOMBER & SON, INC.
nks-Cesspools-Leachfields
Town Sewer 'Connections
66 Centerville, MA 02632-0066
.775-3338 775-6412
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
111IMi. Environmental Protection
Wliilam F.Weld
Govemor
Trudy Coxe e
Seue'. ,EOEA •
David B. Struhs
Commi"ioner .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
erty Address: 319 Strawberry Hill Road Address of Owner: Irene & Walter Lesniaski
of Inspection: 1 0/3/95 (If different) 173 Timber Trail
e of Inspector:,Josepphh pp Ma omber Jr. Weathersfield Conn. 06109
any Name, Address aS Telephone t5umber:
IFICATION STATEMENT
if) that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
omplete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
tenance of on-site sewage disposal systems. The system:
,Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
actor's Signature: �+"-rf "`' Date:
System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
coon. 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
eport to the appropriate regional office of the Department of Environmental Protection.
original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
ECTION SUMMARY:
heck A, B, C, or D:
YSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
YSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection:
ate 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; cracked, structurally unsound, shows substantial infiltration or.exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health. or.
ised 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)55b-1049 • Telephone (617)292-5500 r•::i - +w�a�..,
Ij
• ' C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:319 Strawberry Hill Road Centerville ,Mass .
Owner: Irene & Walter Lesniaski
Date of Inspection: 10/3/9 5
B] SYSTEM CONDITIONALLY PASSES (continued) o
�Q 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
�t! 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:
&6 Cesspool or privy is within 50 feet of a surface water
A�D 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 cvstem nay a septic tank anu suit absorptiun systen) and is within 100 feet to a surface water supply or tributar j- 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.
No 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.
D] SYSTEM FAILS:
IV6 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
r:
i
®ri
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 319 Strawberry Hill Road Centerville ,Mass .
Owner: Irene & Walter Lesniaski
Date of Inspection: 10/3/9 5
D) SYSTEM FAILS (continued): •
AN 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 1/2 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.
do Any portion of a cesspool or privy is within a Zone I of.a public well.
fl_b Any portion of a cesspool or privy is within 50 feet of a private water supply well.
f 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
g1 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 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 local regional office of the Department for further information. .�
(revised 8/15/95) 3
r
4,YA �y4it
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Irene & Walter Lesniaski ,
Owner: 319 Strawberry Hill Rojtl Centerville ,Mass .
Date of Inspection: 10/3/9 5
Check if the following have been done:
4/—Pumping information was requested of the owner, occupant, and Board of Health.
YNone 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.
2As 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.
V All system components,Axxcluding the Soil Absorption System, have been located on the site.
Zhe 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 or
a proximated by non-intrusive methods.
The facility ov.ne: (and occupants, if different from owner).were provided with information on the proper maintenance of Sub.
Surface Disposal System.
Recommendations
1 . Cover On the leaching pit should be .raised.
(revised 8/15/95) 4
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{fit. `,:
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i
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION
Property Address: 319 Strawberry Hill Road Centerville ,Mass .
Owner: . ' Irene & Walter Lesniaski
Date of Inspection: p/3/9 5
FLOW CONDITIONS
RESIDENTIAL: •
Design flow: tffd s allons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):ND .. j
Laundry'connected to system (yes or no): g
Seasonal use (yes or no): N/
Water meter readings, if available: V9 'V'4' '4i2e''us d
l !'6 doe;�,�ktiuS
• I
Last date of occupancy:G �
COMMERCIAUINDUSTRIAL:
Type of establishment:"
Design flow: allons/day
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)
n-sanitary waste discharged to the Title S system: (yes or no)44'
Vater meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECO S and ource of into m tipm, .
System pumped as part of inspection: (yes or no)&&>
If yes, volume pumped: ti/� Eallons
Reason for pumping:
TYPE O SYSTEM =
Septic tank/d6Wbu4oa4aerJsoil absorption system
_�. Single cesspool
_n Overflow cesspool
') Privy
O Shared system (yes or no) (if yes,attach previous inspection records, if any)
n _ Other(explain)
j
I
i
APPROXIMATE A
PRXIMATS GE of all components, date installed (if known)and source of information:
wage odors detected when arriving at the site: (yes or no)
i
(revised 8/15/95) S
,,/°`• P� .fit a��..�v
-C7)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: Irene & Walter Lesniaski
Owner: 319 Strawberry Hill Road C.enterville,Mass .
Date of Inspection: 1 p/3/9 5
SEPTIC TANK:IX,�9QA4*V 1
(locate on site plan)
Depth below grade: 'P
Material of construction: _Lconcrete_metal_FRPother(explain)
Dimensions: ' ' 7"' 0 '
Sludge depth•_ ,6CP
Distance from top of sludge to bottom of outlet tee or baffle: j
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: el '
Comments:
(recommendation for pumping, conditi n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) c
A — K
\� YAW I
GREASE TRAP:O `
(locate on site plan)
Depth below,grade-&Z
Material of constructiory g ncrete_metal —FRP other(explain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle
Distance from bottom n( scum to bottom or outlet tee or bahle::
Comments:
(recommendation for pumping, condition f inlet and outlet tees or baffles, depth-of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) B�7.1.
(revised 0/is/95) 6 sf �aJ
A i
Y •x
® `
SUBSURFACE SEWAGE DISPOSAQSYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION (continued)
Property Address: 319 Strawberry Hill Road Cent erville ,Mass .
Owner: Irene & Walter Lesniaski j
Date of Inspection: 1 p/3/9 5
TIGHT OR HOLDING TANK:/, e• ' ,'
(locate on site plan)
Depth below grade:
Material of construction: _Aconcrete_metal _FRP other(explain)
I
Dimensions:
Capacity: Ilons
Design flow: allons/day ,
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float is Nwtches, etc.)
DISTRIBUTION BOX:,6vlel '
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note ii level and distributic,r, ii equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
k,d1y,r
PUMP CHAMBER:Aff
(locate on site plan)
Pumps in working orden(yes or no) '
Comments: '
(note condi 'on of pump chamber, condition of pumps and appurtenances, etc.)
dllJ. ,
(revised 8/15/95) 7 Mai
5•�it e.
SUBSURFACE SEWAGE DISPOSAL.SVSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 319 Strawberry Hill Road Centerville ,Mass .
Owner: Irene. & Walter Le�sniaski
Date of Inspection: 10/3/9 5
SOIL ABSORPTION SYSTEM
(locate on site plan, if possible; excavation not required, but:*y be approximated by non-intrusive methods) '
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:12•
leaching galleries, number:
leaching trenches, number,length: Cl
leaching fields, number, dimensions: l'9
overflow cesspool, number:,
Comments: (note condition of soil, signs of hydraulic"failure, level of ponding, jondition of ve etation,etc.)
d e Z' 'a M/.
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: AIM _
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool muse p mped as part of inspection)
Comments: (note c dion 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 ote condition of soil, signs of hydraulic:failure, level of ponding, condition of vegetation, etc.)__T 1'a
t ,
(revised 6/15/95)
' 5I
�J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C i
SYSTEM INFORMATION (continued)
Property Address:
P Y
Owner:
Date of Inspection:
I
SKETCH OF SEWAGE DISPOSAL SYSTEM:.
include ties to at least two permanent references la marks.or benchmarks
locate all wells within 100' �/ G
• i
I
U
n
DEPTH TO GROUNDWATER
Depth to groundwater.—! � feet
method of determl tion or approximation: e .
lr$v4844 8/16/951 9
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T..•T7'��•1.TfRr'•1.Rr.T•
TOWN OF Barnstable. BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
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-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 31 Q R'+r,at.X'h. 'Pi l l Rnari ( An+Arvi 11 A �Ma
ASSESSORS MAP., BLOCK AND PARCEL #
e
OWNER' s NAME Irene & Wa`a.lter Lesniaski
PART D - CERTIFICATION t
NAME OF INSPECTOR jose h p Macomber Jr.
COMPANY NAME T P_MannmhAr Rr Snn TNP _
COMPANY ADDRESS jox 66 CentPrville .Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have. personally inspected the sewage disposih system at
this address and . that the information reported is true , accurate, and
u complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on
site sewage disposal systems .
Check one:
Systeui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15. 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system' faiki "'tol
Protect the public healt1i and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date _jo/jfA_ '
One copy of this ertification must be provided to the OWNER$ the _.B IER(where applicable) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner ors"op operator shall u t p pgrade ' the aYBte :W
within one year of the date of the inspection, unless allowed or require '•:� x
otherwise as provided in 310 Chjn 16 . 305 , �y+}
.Ilf a`,.](j14ti�lk i Y�
•C w
Cc mnTcnN ea-r C' MassCC7 .`e 7,s
Office
Executive Of ice
Department of
Environmental Protection
' Water Pollution Ccntrel Tecnnlccl Assocnce ana Training SeC71ons
WlUU= F.Word
GO-.
Trudy Coz•
Soavmy.EOEA
Thomas 8. Powwa a
06/12/9 �
ATTN: Joseph P. Macomber, Jr .
Joseph Macomber and Scan
PO Box 66
Centerville, MA 02632-
Dear Joseph P. Macomber, Jr. ,
I am pleased cc inform you that you have attended training, met
the experience qualifications,. and have passed the Title 5 System
Inspector exam, pursuant to 310 CMR. 15 . 340 . The passing grade for
the exam was 39/52 or 75% .
This is an official notification that you are a Certified Department
of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340 .
You will receive a System Inspector certificate at a later date.
If you have any father questions, please write to me at the following
address :
Kimball Simpson
D. E. P. Training Center
30 Route 20
Millbury, MA 01527
Thank you very much for %!c)jf tune acid consideratioi: in this matter.
Sincerely,
Kimball T, S'-nmson,
DEP Train,nq . r Directci-
f2405�
Route Millbury, MA FAX 38.755-9253 • ,n♦ 508-756-77O'
` Y
Water
. •y�V .
Cotis'ervation
sauE Tips . •
ME! , .
CHECK FOR LEAKS
Water loss in-Gallons Due to Leaks
ffl
Loss•Per Day Loss Per Month
.
120 3,600
360 10,800
693 20,790
1,200 36.000
• '1,920 57,600
3,096 92,880
.0 4;296 128,980
® 6,640
191,210.
6,984 200,520
8,424 252,720
., .9,888 296,640
® 11,324 339,720
12,720 381,600
14,952 448,560
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