HomeMy WebLinkAbout0331 WHITE OAK TRAIL - Health 331 WHITE OAK TRAIL, CENTERVILLE
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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
Property Address: 331 White Oak Trail, Centerville, MA Name of Owner: Marylyn Williams
Address of Owner:
Date of Inspection: September 30, 2000
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Osterville, MA 02655-0049 Map.
Telephone Number: (508)862-9400 Parcel.
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:
✓ Passes
Conditionally Passes
_ Needs Further Evaluat By the Local Approving Authority
_ ils
Inspector's Signature: Date: October 1, 2000
The System Inspector shall submit 4py of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days
of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable,and the approving authority.
NOTES AND COMMENTS
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revised 9/2/98 Page 1of11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 331 White Oak Trail, Centerville, MA
P Y
Owner: Marylyn Williams
Date of Inspection: September 30, 2000
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
_ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
—Sewage l ackup or breakout or high static water level observed in the distribution box is due to.broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if.(with approval of the Board of
Health)
broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 331 White Oak Trail, Centerville, MA
Owner: Marylyn Williams
Date of Inspection: September 30, 2000
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 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 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 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 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
CERTIFICATION (continued]
Property Address: 331 White Oak Trail, Centerville, MA
Owner: Marylyn Williams
Date of Inspection: September 30, 2000
D. SYSTEM FAILS:
You must indicate either"Yes" or No" as to each of the following:
_ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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.
''Anyportion 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 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. 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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 331 White Oak Trail, Centerville, MA
Owner: Marylyn Williams
Date of Inspection: September 30, 2000
Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following:
Yes No
✓ — Pumping information was provided by the owner,occupant,or Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ As built plans have been obtained and examined. Note if they are not available with 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,excluding the Soil Absorption System,have been located on the site.
✓ — The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles
or tees, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:,,
✓ Existing information. For example,Plan at B:O:H:
✓ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)].
✓ — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 331 White Oak Trail, Centerville, MA
Owner: Marylyn Williams
Date of Inspection: September 30, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 4
Total DESIGN flow n/a
Number of current residents: 3
Garbage grinder(yes or no): No J
Laundry(separate system)(yes or no): No; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two year's usage(gpd): Unavailable
Sump Pump(yes or no): .No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd Based on 15.203)
Basis of design flow
Grease trap present: (yes or no) _
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER: (Describe) _
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Unavailable
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE-AGE of all components,date installed(if known)and source of-information: _Approx. 1992-per owner.
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 331 White Oak Trail, Centerville, MA
Owner: Marylyn Williams
Date of Inspection: September 30, 2000
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (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 Certificate of Compliance_(Yes/No)
Dimensions: 1000 gal.
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
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: 7"
How dimensions were determined: Measuring stick
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.) The tee and baffle were present. The liquid level was even with the outlet invert. There were no 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:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,.etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 331 White Oak Trail, Centerville, MA
Owner: Marylyn Williams
Date of Inspection: September 30, 2000 f
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day '
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The D-box was level. There
were signs of solids in the D box There were no signs of leakage
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.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 331 White Oak Trail, Centerville, AM
Owner: Marylyn Williams
Date of Inspection: September 30, 2000
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits, number: I-4'x 6'
leaching chambers, number:
leaching galleries,number:
leaching trenches, number, length:
leaching fields, number,dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
The pit had 1'6"of water on the bottom The scum line was at the same level. There were no signs of failure. The bottom to grade was
approximately 9'
CESSPOOLS: None
(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: 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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 331 White Oak Trail, Centerville, MA
Owner: Marylyn Williams
Date of Inspection: September 30, 2000
Map:
Parcel:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 331 White Oak Trail, Centerville, MA
Owner: Marylyn Williams
Date of Inspection: September 30, 2000
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 30+/- Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
✓ Determined from local conditions
Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
The bottom of the pit to grade was approximately 9'. Using the USGS topographic map and Cape Cod Commission water
contours map, the maps were showing approximately 30' +/-to groundwater 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.
revised 9/2/98 Page 11of11
TOWN OF BARNSTABLE
LOCQiMON 331 W�►�G 04 �(i4►� SEWAGE #
VILLAGE W-R-(V' AI ASSESSOR'S MAP & LOT/942 O 3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Jown G,0
LEACHING FACILITY: (type) P T (size)
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NO. OF BEDROOMS l
BUILDER OR,OWNER-IY74CI& I W, I I t-QMS
PERMITDATE: COMPLIANCE DATE:
L
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Conunonwealth of Massachusetts
Executive Office of Environmental Affairs
° Dept. of Environmental Protection
ad
One winter Street'Boston,Ma. 02108 John G1epti
D.E.P. Title V Septic Inspector
P.O
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WILLIAM F.WELD8)564-6813 '
Governor REM E0
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM m NOV 1 3 1998
PART A
CERTIFICATION
TOWN OFBARNSTABI,E
lq �j - 4 3U L I %1P HEALTH DEFT.
Property Address: 331 WHITE OAK TRAIL CENTERVILLE Address of Owner:
Date of Inspection: 10/26/98 (If different) 10
Name of Inspector: JOHN GRACI JODY PROUTY;16 DUTCHLAND DR.YARMOU T 0 6 5
1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
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 This Inspection Is based on criteria defined In Title V
Conditionally Passes code 310 CMR 16.303.My findings are of how the system Is
performing at the time of the inspection.My inspection does
Nee rther Evaluation By the Local Approving Authority not imply any warranty or guarantee or the longevity of the
Fail septic system and any of Its components useful life.
Inspector's Signature: Date: 1113198
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection, or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised(MV97)
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 331 WHITE OAK TRAIL CENTERVILLE
Owner: JODY PROUTY;16 DUTCHLAND DR.YARMOUTHPORT MA.02675
Date of Inspection:10126195
_ Sewaae backup or.breakout or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to 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:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
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 in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to tho iurfnce,of the ground or stirfoco waters clue,to on ovcirlonde-rl or 1:Iog�Prl
cesspool.
SAS is in hydraulic failure.
(revised 04127)97►
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 331 WHITE OAK TRAIL CENTERVILLE
Owner: JODY PROUTY;16 DUTCHLAND DR.YARMOUTHPORT MA.02675
Date of Inspection:10f26199
D]SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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. 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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall 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 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 331 WHITE OAK TRAIL CENTERVILLE
Owner: JODY PROUTY;16 DUTCHLAND DR.YARMOUTHPORT MA.02675
Date of Inspection:10126/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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, excluding 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.
X — The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
X Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)j
(revised ORM97)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 331 WHITE OAK TRAIL CENTERVILLE
Owner: JODY PROUTY;16 DUTCHLAND DR.YARMOUTHPORT MA.02675
Date of Inspection:10126199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 g•p•d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy:JULY98
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:o gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: nta
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
NONE
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: rda
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions 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 information:
1990
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127/97)
f -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 331 WHITE OAK TRAIL CENTERVILLE
Owner: JODY PROUTY;10 DUTCHLAND DR.YARMOUTHPORT MA.02675
Date of Inspection:10126/98
SEPTIC TANK: x
(locate on site plan)
Depth below grade: V
Material of construction: concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age n1a . Is age confirmed by Certificate of Compliance_No (Yes/No)
Dimensions: Le•6^H5'7^w4.10"
Sludge depth:5"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness:4"
Distance from top of scum to top of outlet tee or baffle:2'
Distance form bottom of scum to bottom of outlet tee or baffle: Na
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rda
Scum thickness:r-da
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: rya
Date of last pumping;,l,
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.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: vw-
Material of construction:_cast iron x 40 PVC—other.(explain)
Distance from private water supply well or suction line:TOWN
Diameter: No
Q,mments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION (continued)
Property Address: 331 WHITE OAK TRAIL CENTERVILLE
Owner: JODY PROUTY;16 DUTCHLAND DR.YARMOUTHPORT MA.02675
Date of Inspection:10126199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rva
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nra
Capacity: rda gallons
Design flow: rva gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nra
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: LIQUID LEVEL wnN80770MOFPIPE
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Ye:
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
Na
(revised 04127197)
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 331 WHITE OAK TRAIL CENTERVILLE
Owner: JODY PROUTY;16 DUTCHLAND OR.YARMOUTHPORT MA.Q675
Date of Inspection:10126195
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:
rda
Type:
leaching pits, number: 1000 GALLON LEACH PIT
leaching chambers,number:rda
leaching galleries,number: nla
leaching trenches,number,length: nfa
Teaching fields, number, dimensions:rda
overflow cesspool,number:rda
Alternate system: rda Name of Technology:_rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.
CESSPOOLS:_
(locate on site plan)
Number and configuration: rda
Depth-top of liquid to inlet invert: rda
Depth of solids layer: rda
Depth of scum layer: rda
Dimensions of cesspool: nla
Materials of construction: rda
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
PRIVY:
(locate on site plan)
Materials of construction: da Dimensions: ma
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.),
rda
(revised 04127)97)
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
331 WHITE OAK TRAIL CENTERVILLE
JODY PROUTY;18 DUTCHLAND DR.YARMOUTHPORT MA.02675
10/26/98
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)
D
� rG�
Aq I�
� 23
(revised04rz7197) Page f of x0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
331 WHITE OAK TRAIL CENTERVILLE
JODY PROUTY;16 DUTCHLAND DR.YARMOUTHPORT MA.02675
10126198
Depth of groundwater 12,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
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
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS MAPS AND CHARTS
(revle"04127197) Pape 10 of 10
. J TOWN OF�B—A,RNSTABLE
LOCATION �`1���( �K— ���EWAGE #
VILLAGE ASSESSOR'S MAP &LOTda s JNL%
INSTALLER'S NAME&PHONE NO. /
SEPTIC TANK CAPACITY /C�O� (
LEACHING FACILITY: (ty �� , (size) ��
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE D TE: ISAW
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands ekList
within 300 feet of leaching facility �n Feet
Furnished by Ott
All
wC
No =?-E
LOClTION _ ��� Lde � 5� EWAGE # 90'il f
VILLAGE Cfv)b 6(l111`c ASSESSOR'S MAP 6z LOT
Q INSTALLER'S NAME Cz PHONE NO. 114 ',r'
SEPTIC TANK CAPACITY ��
+ 41
LEACHING FACILITY:(type) (size) ��'�
NO. OF BEDROOMS j PRIVATE`WELL OR PUBLIC WATERZbI-
i d
BUILDER OR OWNER l,!� �rO6,✓J- ft
DATE PERMIT ISSUED: �' / go
DATE COMPLIANCE ISSUED: 3- D
a
VARIANCE GRANTED: Yes No
y..
�� � ..�
%i'�
��fr � � ��
� � �� -�-
�-
� � r
� ��
� �_
No, ...1.....C` t FEs.�`' .`°�....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
g
............. °�.AS/......OF....7 e -;k!t��,-------
ApplirFa#ion for Elhgp sal Works Towitrurtiun "truth
Application is hereb made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Lo ion•Address r Lot N ea
a ro F✓
--------------•-Dst.�L ....... ............................................... ' -.. . ...... .......................................wner Addr ,
W
Installer Address
Type of Building ,, Size Lot.. -----Sq. feet
a
4 rram�Dwelling—No. of Bedrooms_.........'....._._��i�.a.............. Attic ( ) Garbage Grinder ( )
Other—T e of Building .__..__. No. of persons............................ Showers
a YP g ............................ No.
( ) — Cafeteria ( )
Other fixtures ... ----- --- ------- --------- --- - -- ----- -------------
-•--•-------------
--
Design Flow.................................. gallons per person per day. Total daily flow___ ��._.._._.._..____._..._....gallons.
W Septic Tank—Liquid capacity/".A-.gallons LengthJ''� _�.._... Width �'��'Diameter---- Depth g�e.....
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....../........... Diameter.... ....... Depth below inlet_. :. ....... Total leaching area.F�------sq. ft.
Z Other Distribution box ( ✓f Dosing tank ( )
'-' Percolation Test Results Performed b _� 4— *���_ � '' ._ Date...3.m-'_-._ .
W Y � �'---------------
Test Pit No. 1-----•__ ._._minutes per inch Depth of Test Pit.._ .-��__.. Depth to ground water........................
44 Test Pit No. 2........ ._minutes per inch Depth of Test Pit.... Depth to ground water....:...................
Q'
0 Description of Soil--
v --------------------------------------
•--------------------------------------
•----------------------
•-•-----------------•-----------------------------------------------------•------------------------
W
VNature 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 TTL ,
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has fekissue b the boaLdoif h th. S.�_ 9O
Signed------ ----------- .....
Date
Application Approved BY-'--•--- ------•- - -
Date
Application Disapproved for the following reasons:................... ----I
.....•-'----•----------'---•-------------•-•-••......------------•---......
.-• ------'•----------'-••------'--'---------•'--•-'-•---•-------'-----'--•••'--•-------•----•------•-•---------------••---•---•••-----•-----•'•--•-•
yy / -_Date
Permit No.---. '. k.. ...................... Issued. --._--
`�nl'r' a
,1 Dot„
Jl
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Disposal Works Tunstrnrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair { } an Individual Sewage Disposal
System at:
k - ...... k 4. ..Iza.................... ..................3 ...... ................................................
Loc ion- ddress Lo N
wner � Add
4.
Installer Address
Type of Building Size Lot__Z_;- ....Sq. feet
a Dwelling—No. of Bedrooms...........................__.._..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .---••••••• ------.••----•••••••-•-•••-•--•--•----------------•--••-•............................................
Design Flow....................................:.`.._gallons per person per day. Total daily flow----�'.?:_: 1..........................gallons.
WSeptic Tank—Liquid*capacity4»�..gallons Length._`'__:....._. Width.;_-=` '..'Diameter-_--_-
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 ( )
Percolation Test Results Performed by._fz%:. _=`�?' ...............................
='::.: ___f_:.- �:.............. Date---�.:..=
,� .
Test Pit No. 1......_=__....minutes-per inch Depth of Test Pit.--- .�_%>._.. Depth to ground water......'—___-____---
f� Test Pit No. 2............. per inch Depth of Test Pit...... Depth to ground water......_— __•-..._.
----------------------------------------------•-•••........---•••......•.-•-•----•......------....--------------------------------------------------•-
Descri Description of Soil.... . ................. ... J,?!%,.: c�, .i r( .. _..,c <,- ��,�... ,.! f w
x P - �.. 1 .._...--•••---
q
W
---------------------------•--•---•-------•-••••-••-•••••--••••••••••-•-------•---•••----•--•••••---••-•••••--•••--•--.....---••-----•----•••••••-•-----•-•-••••••••-•••-----••••......-••-•------•••-
U 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,L I .;.
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation.until a Certificate of Compliance-has e issued the boa d of IIth.
Signed._
Date
Application Approved By.. ... ! f_w-= z ..[ .__._I
" -- J
Application Disapproved for the following reasons:............................. ___....__.__...__._.........._.........._._
......---..Date--------------
---------------------------------•-------•--•---...--•-------...-----------------•------.......----------•••--•------••--••............---•............................................................
Date
PermitNo.... =- _ -7------------------------ Issued................................ •------------
LF._..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................$..L:!tier.m.......OF........ ............................................
(Entif irate of TontpliFanre
THIS IS TO CARS FY, That the Individual Sewage Disposal System constructed Y ) or Repaired ( )
by - /1 -------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at................
' •"""`mod�- .._..._._..
has been installed in accordance with the provisions of TIT E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ _....... dated...... _. _...
r ./ '
THE ISSUANCE OF THIS CERTIFICATE SHALLNOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 .✓.. .....I......OF........- � �° �
No�l .......:// FEE%
Disposal Works Tonotrnrtion trout
Permission is hereby granted....... .......--.---...-----•------------------------------------------------------------------------•------•--.
to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem
an ------ ------ - ; ------------------------
$rreet
as shown on the application for Disposal Works Construction Permit No0- / Dated.,% _., .._ ,�/7........
........................................................................................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
Made 3-9-90
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