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HomeMy WebLinkAbout0032 VALLEY BROOK ROAD - Health 32 VALLEY BROOK RD, CENTERVILLE A= 188169 E No. 42101/3 ORA ESSELTE 10% ® O O O c rr TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM \\ PART A CERTIFICATION Property Address:_32 Valleybrook Rd.Centerville Mass.02632 Owner's Name: John Finn Owner's Address:_same as above Date of Inspection:_8/11/08 Name of Inspector:(please print)_Eric Stevens Company Name:_E.Stevens Construction,Inc. Mailing Address:_P.O.Box 71 Marstons Mills,Mass.02648 Telephone Number:_(508)776-9054 CERTIFICATION STATEMENT e I certify that I have personally inspected the sewage disposal system at this address and that the n}formation reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage ._, disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Titles(310 CMR 15.000). The system: _X Passes c, Conditionally Passes t-0 4> Needs Further Evaluation by the Local Approving Aul hority c_n Fails A __j rn Inspector's Signature: Date: Q II The system inspector shall submit a 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; System is in good working order and all components are sound 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. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Valleybrook Rd. Owner:_John Finn Date of Inspection:_8/11/08 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ R X_ I have not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System passes titleV inspection on 8/11/08 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: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Valleybrook Rd. Owner:_John Finn Date of Inspection:_8/11/08 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_32 Valleybrook Rd. Owner:_John Finn Date of Inspection:_8/11/08 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 x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _x_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x Liquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe (s).Number of times pumped x Any portion of the SAS,cesspool or privy is below high ground water elevation. T x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x Any portion of a cesspool or privy is within a Zone 1 of a public well. _x_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _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 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. 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. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 32 Valleybrook Rd. Owner:_John Finn Date of Inspection:_8/11/08 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health _x Were any of the system components pumped out in the previous two weeks? _x _ Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of this inspection _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? x _ 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? _x_ _ 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 x _ Existing information.For example,a plan at the Board of Health. _x_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 32 Valleybrook Rd. Owner:_John Finn Date of Inspection:�8/11/08 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330 Number of current residents: 2 Does residence have a garbage_grinder(yes or no):_no_ Is laundry on a separate sewage system(yes or no): no_ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):no Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy:_present COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 2pd 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):` i Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 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 _x_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: System was installed in early eighties.(82-84) Were sewage odors detected when arriving at the site(yes or no):no OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Valleybrook Rd. Owner:_John Finn Date of Inspection:_8//11/08 BUILDING SEWER(locate on site plan) Depth below grade:_24" Materials of construction:_cast iron _x_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:_x (locate on site plan) Depth below grade:_18" Material of construction: x_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:_20" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:_12" Distance from top of scum to top of outlet tee or baffle:_5" Distance from bottom of scum to bottom of outlet tee or baffle:_4" How were dimensions determined:_Measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tank is sound but full.Recommend pumping now,and every 2 yrs after. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: concrete metal_fiberglass_polyethylene_other(explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_32 Valleybrook Rd. Owner:_John Finn Date of Inspection:_8/11/08 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_x_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0" 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.): D-box is sound and level.little to no evidence of solid carryover. PUMP CHAMBER: (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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_32 Valleybrook Rd. Owner: John Finn Date of Inspection:_8/11/08 SOIL ABSORPTION SYSTEM(SAS):_x (locate on site plan,excavation not required) If SAS not located explain why: Type x leaching pits,number:_1 (1000 gal.)_ 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.): Pit is sound.20"standing water in pit.No signs of hydraulic failure. CESSPOOLS: (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: (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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Valleybrook Rd. Owner:_John Finn Date of Inspection:_8/11/08 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. �zc tc Noc:S� Gzray� - 3 oec 1 � �� = 2a i ,; z ' 93 o OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Valleybrook Rd. Owner:_John Finn Date of Inspection:_1/11/08 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_>15 feet Please indicate(check)all methods used to determine the high ground water elevation: x Obtained from system design plans on record-If checked,date of design plan reviewed:_1982 _x_Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) x Accessed USGS database-explain:_website You must describe how you established the high ground water elevation: USGS website and original install plans. ' ..-,No. Fee Fee ¢ $ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for �Dis�ponl *pgtem Construction Permit Application for a Permit to Construct( )Repair(k�Upgrade( )Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. 3 q f,41I FY JO p`j- IPJ Owner's Name,Address and Tel.No. Assessor's Map/Parcel t� C EA.er ��/�/�'f�f�F L C 11AN6:£L SST Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. So is 5 T tt.- YOl t Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) J j9 OX eF C&I£tiT' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is d by this Board of Health. Signed Date Application Approved by Date -d$---,/—15-�e Application Disapproved for the following reasons Permit No. - 7 Date Issued , ,S No. Fee THE COMMONWEALTH OF MASSACHUSETTS _ Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for ;Digpogar *pgtem Congtruction Permit . Application for lPerrtut to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System eIndividual Components LocatiAAddress or Lot No. .3 a'�� r/ ®gypp0Ar 1P). Owner's Name,Address and Tel.No. �— Assessor's Map/Parcel C £/r �A/�/T F 4. 1•C_r�' �Sl� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling,, No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.SV A-- erg` Description of Soil Nature of Repairs or Alterations(Answer when applicablq), - '!J 7 Rate last inspected: 1�, Agreement: The undersigned agrees to ensure the construction and maintenance of the afore'described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to pta"' the`system in operation until a Certifi- cate of Compliance has been iss d by this Board of Health. Signed Date `S -/- Application Approved by Date Application Disapproved for the following reasons Permit No. - ' Date Issued ————————— — ---------- ------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed'( )Repaired ( k)Upgraded( ) Abandoned( )by A g 6 r,41 e-G at ILpak' OP) .v7- has been constructed in accordance °with the provisions of Title 5 and the for Disposal System Construction Permit No. fly datedlam- Installer C�N C a Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date / - Inspector h , No. r►''�r-l Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Oigpogat *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )(1 Upgrade( )Abandon( ) System located at 43 22 i/,417 4 `' Y i9l yak /P� e r&&/� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of th it. A Date: Approved pP r 1 1019/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) , i t hereby certify that the application for disposal works construction permit signed by me dated S -1"F a' ,concerning the property located at_ a� 1���L ' Q��°+� c'£�-% meets all of the following criteria: There are no wetlands located within too feet of the proposed leaching facility Vo There are no private wells within 150 feet of the proposed septic system proposed use in� a ro• There is no increase to flow and/or change p p e/e There are no variances requested or needed. `//4 If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will mi be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) _ B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: S ��~f P LICENS D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed Installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cat COMMONWEALTH OF MASSACHUSETTS Op EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' DEPARTMENT OF ENVIRONMENTAL PROTE I ONE WINTER STREET. BOSTON. NIA 02108 61 7-292-5j00 WILLIAMI F WELD ` 6 1 TRUDY C• XE 350 MAIN STREET 'cy�TtiG 9 Govcmof 9� Se'cr'tan WEST YARMOUTH, MA F� a ARGFO PAUL CELLUCCI 6 508-775-2800 �FDAVID B..CS,,TRUHS Lt.Govcmor Um rssioncr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 9. PART A CERTIFICATION MAP 188 PAR 169 PROPERTY ADDRESS: 32 Valley Brook Road, Centerville ADDRESS OF OWNER: DATE OF INSPECTION: April 28, 1998 Raphael Evangelista NAME OF INSPECTOR : James D. Sears I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A& B Canco MAILING ADDRESS: 350 Main Street, West Yarmouth, MA 02673 TELEPHONE NUMBER: (508)775-2800 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: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: ._ DATE: April 30, 1998 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design Flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D A] SYSTEM PASSES: ' X I have not found any inform9tion 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: B SYSTEM CONDITIONALLY PASSES: N/A 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 b the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NO). 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 is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 09/25/97) Page 1 of 10 DEP on the World Wide Web:http://www.magnet.state.ma.un/d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 32 Valley Brook Road, Centerville Owner: Evangelista, Raphael Date of Inspection: April 28, 1998 B] SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 32 Valley Brook Road, Centerville Owner: Evangelista, Raphael Date of Inspection: April 28, 1998 D] SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: N/A 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. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded 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 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 surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or 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 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 32 Valley Brook Road, Centerville Owner: Evangelista, Raphael Date of Inspection: April 28, 1998 Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components, including the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. X Existing information. Ex. Plan at B.O.H. X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 32 Valley Brook Road, Centerville Owner: Evangelista, Raphael Date of Inspection: April 28, 1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 g.p.d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 3 Garbage grinder(yes or no): NO Laundry connected to system (yes or no): NO Seasonal use(yes or no) YES Water meter readings, if available(last two(2)year usage(gpd): 1995-96 25,000/ 1996-97 46,000 Sump Pump(yes or no): NO COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no): Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: PRESENT GENERAL INFORMATION PUMPING RECORDS and source of information: 1996 System pumped as part of inspection:(yes or no) NO If yes, volume pumped:. gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 1982 PERMIT#82-392 Sewage odors detected when arriving at the site: (yes or no) NO (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32 Valley Brook Road, Centerville Owner: Evangelista, Raphael Date of Inspection: April 28, 1998 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: X (Locate on site plan) Depth below grade: 20" Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,000 GALLON PRECAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How dimensions were determined ASBUILT&TAPE 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.) TANK AT WORKING LEVEL,TANK AND COVER 20" BELOW GRADE, OUTLET BAFFLE GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32 Valley Brook Road, Centerville Owner: Evangelista, Raphael Date of Inspection: April 28,1 998 TIGHT OR HOLDING TANK: N/A (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: Design flow: gallons/day Alarm level: Alarm in workingorder Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc,) D-BOX IS NEW 5-1-98 BY A&B CANCO, BOX IS 30" BELOW GRADE, BOX IS 9" X 15" NEW, CLEAN AND LEVEL. ONE LINE IN, ONE LINE OUT. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32 Valley Brook Road, Centerville Owner: Evangelista, Raphael Date of Inspection: April 28, 1998 SOIL ABSORPTION SYSTEM (SAS): X (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: 1 leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number, alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ONE 1,000 GALLON PRE CST, PIT IS 3' BELOW GRADE. COVER IS 2" BELOW GRADE, PIT DRY, WALLS ARE CLEAN-LIKE NEW. CESSPOOLS: N/A (locate on site plan) Number and configuration: Depth-top of Liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:: (note condition of soil, signs of hydraulic failure, , level of ponding, condition of vegetation, etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Valle Brook Road Centerville P Y Y , Owner: Evangelista, Raphael Date of Inspection: April 28, 1998 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) I 0 o (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Valley Brook Road, Centerville Owner: Evangelista, Raphael Date of Inspection: April 28, 1998 Depth to no groundwater 13 feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained fro Design Plans on record X Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) NOTE: HAND DUG TEST HOLE 13' NO WATER, TEST HOLE 4' BELOW BOTTOM OF PIT. TEST HOLE NOTED ON PAGE 9. I (revised 04/25/97) Page 10 of 10 LOCATION SEtIAGE PERMIT DO• VILLAGE INSTA LLER'S NAME b ADDRESS GUILDER 0R 0t1p ER DATE PERMIT ISSUED DAT E C 0 M P L I A N C E ISSUED �� � .Ate, eLA� C� a i .................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..............._0F.............t �.r.. .c��o�� Appliration for Uigpnaa1 Workii Tomitrurtinn thrmit Application is hereby made for a Permit to Construct (v ) or Repair ( ) an Individual Sewage Disposal System at a\1 e c d©� ..a 3® ---- -Location-Address_ o Lot No. ....................... ............................................. O caner Qddrcss Installer Address UType of Building ? Size Lot-_-\ � _T........Sq. feet Dwelling—No. of Bedrooms.............,?.._._......................Expansion Attic (IJO) Garbage Grinder (MO) Other—Type e of Building .............. No. of ersons........_._.........._....__ Showers P.i YP g ------•------- P ( ) — Cafeteria ( ) a Other fixtures ..--•••-•-••••. •••-•-.....•. . . W Design Flow............. .......................gallons per person per day. Total daily flow............._3.3©--.............._..gallons. WSeptic. Tank—Liquid capacityiT ..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing-tank ( ) aPercolation Test Results Performed by-------3-(:U4.lLA........ �J ............... Date......:_...._._ __._._...--__... �.� �'2— Test Pit No. 1................minutes per inch Depth of Test Pit............_....... Depth to ground water........................ 4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil....O"•�'••-•--..LQ ry\..----.k•----...S_Q)Q.S_4:�-- ------------------•--------- --------•------•--------------. -- v ..................................._... ......... ................ - - 1 .......................... W •••••-••••-•......................Ul`._� ............... .............. Q n. c1 UNature of Repairs or Alterations—Answer when applicable........................................................................................... •••-••••••••--•-----••-•--•••---•--•••••-••-•••-••-•••••••-•••••••-••-••-•-•---•---••-•---•........-••_...••-•••------------••••---•-••-•••••-••••••••••--•-----....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with e provisions of iITA U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed------- F- `---- .:._._- - C'^ '� ---•----•-•--- �2— �C Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons----------------................................................................................................. •--••-•••......................•-•.........•-•--•---••-•••-••••••-•-••-••--•--•-•--------...••••••-•-•-...--••••--••--••••-••--••-••-••••••••••••....••••-••----•--••-•-•-•-----••••••-••-••••---•-.-••-- Date Permit No......................................................... Issued---•----------••-----------•--•-----••-••----•......... th . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .---- Appliratiou for Uiipusal 10orbi Tomiitrurtiun Permit Application is hereby made for a Permit to Construct (v ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address o Lot No. P �r... \1 \ .-,Owner ddress •----------------------•--•-•---•--.._.._..-----------.. ...---•-•-=•---== ......_...----••-- _ .. S feet Installer Address Type of Building Size Lot....�... ........_ q. Dwelling—No. of Bedrooms............._..:...........................Expansion Attic (0,3) Garbage Grinder (00) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................................................... W Design Flow............. .........................gallons per person per day. Total daily flow.............. .................... _____gallons. WSeptic Tank—Liquid capacity�`� _-gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) + Percolation Test Results Performed by........ .........Y..._Q _ _______________ Date_____ ' + tO� I f a ......._ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil----` >........ CA �•..... ................>� _ ..a -----------------------••-----........................................................... - U . UW ` ------------------ "e ................. Nature of Repairs or Alterations—Answer when applicable................................................................................................ •------------------------------•-------------------------------------....-----------.......__-----•----...-------•--•-------•--••----------------------•---------------------------•---........_...---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions.of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed........ ...... :.........�--� q � Z_ •------------- ------------D __......_...._ Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons:---•--------------------•--------•-•---...-----._.........-•-----•-•---------------•-------••--•---------_••-- •.....................•----...........__...--------------•--------------••-------•••-•---------•-•----------•-••-------••-------------•----•--•----•--•-------------•-----•---•-----.....--•••---•----- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ^............OF.......... C�} ::� ........................................................ Trrtifiratr of TompliFaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (� or Repaired ( ) by .......` ...............................y ................ 4 �(� r� ( ^ c`� 0...�..�• �j ..�� �. Installer CA(\1 �1 `C__ at " == .�� --=----------------•-------•-•-------•----------•---------------------•---------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit ................ dated_--...-_-_._--______......_..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A UARANTEE THAT THE SYSTEM WI OCTION SATISFACTORY. DATE--_��'- •--......----•---•--•------••---------•............. Inspector,--- . . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��Q J_-----•-31. : FEE........5.'.......... Roposal Workii Toup#r Milan Permit Permission is hereby granted........v C'.�'C ,n to Construct ( Jf or Repair ( ) an Individual Sewa e Disposal S stem ---------------------------------•--•-------------------------........ Street o as shown on the application for Disposal Works Construction Permit No..................... Dated........................................... .�'' s DATE. L2i� o�.ia of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 611.16LE— FAMIL.Y - :5 BEORooM dJ WO GAIZBAGE- DA1Ly FLOW c 110X 5x B306.PR SEPT IA = 33Ox15O'/- —�9/r" G.R 0 p��G TtiK u5E- 100o GA%-. i 015Po5A► P17 u5E l o 00 GAL. 51 DF-WALL AZS,& = 15o s,F �`7�4�7� VCO 150 5.F X BOTTOM AREA= 5� 5•F, � p � N . �' 5cl s.F X. 1• o z 5o G.Pc� �.J %P ArZAsx � °9 _TOTA.L p>rs1GN = 25 G.P M O 1Fir LP, mLOT 7oTAI.. DA 1 LS( FL-ov.! i PE2c.0LA7r10u 2ATE: 1"JMN 2MIN Zit. 32 tiSM OE ALAN. S "BAXTER i 0N. 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