HomeMy WebLinkAbout0055 WOODVALE LANE - Health 55 Woodvale Lane
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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PARCEL
LOT
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 55 Woodvale Lane
Centerville, MA 02632
Owner's Name: Vytautas Rupinskas
Owner's Address:
Date of Inspection: February 10, 2004
Name of Inspector: (Please Print) James M. Ford RECEIVED Company Name: James M. Ford �®
Mailing Address: P.O. Box 49
Osterville, MA 02655-0049 FEB 2 6 2004
Telephone Number: (508) 862-9400
LEF
CERTIFICATION STATEMENT TOWN O BARNSTAB
HEALTH RNS
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fa'
Inspector's Signatur\Sub
Date: February 14, 2004
The system inspector st 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
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 55 Woodvale Lane
Centerville, MA
Owner: Vytautas Rupinskas
Date of Inspection: February 10, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes, no or not determined(Y,N,ND)in the for the following statements. if"not determined", please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 55 Woodvale Lane
Centerville, MA
Owner: Vytautas Rupinskas
Date of Inspection: February 10, 2004
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:
3
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Page 4 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 55 Woodvale Lane
Centerville, MA
Owner: Vytautas Rupinskas
Date of Inspection: February 10, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 55 Woodvale Lane
Centerville, AM
Owner: Vytautas Rupinskas
Date of Inspection: February 10, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner, occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period ?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(if they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up
✓ Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: SS Woodvale Lane
_ Centerville. MA
Owner: Vytautas Rupinskas
Date of Inspection: February 10, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:__Never pumped-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 612194-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: SS Woodvale Lane
Centerville, MA
Owner: Vvtautas Rupinskas
Date of Inspection: February 10, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: S"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: SS Woodvale Lane
Centerville, MA
Owner: Vytautas Rupinskas
Date of Inspection: February 10, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
I
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 55 Woodvale Lane
Centerville, MA
Owner: Vytautas Rupinskas
Date of Inspection: February 10, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -6'x 6'w/2'stone(per as built card)
leaching chambers, number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
The pit had Y of water on the bottom. The scum line was at the same level There did not appear to be any signs offudure
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool-
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: SS Woodvale Lane
Centerville, MA
Owner: Vytautas Rupinskas
Date of Inspection: February 10, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page 1 I of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: SS Woodvale Lane
Centerville. MA
Owner: Vytautas Rupinskas
Date of Inspection: February 10, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and water contours map the maps were showing approximately 25'+/-to ground water
at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
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TOWN OFBARNSTABLE
LOCATION S� IAJ(JD�V4 it- lAAk SEWAGE # 194/" OVS'
VILLAGE CQ,+Tt fyd k. ASSESSOR'S MAP& LOT /90 /7 '
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (XG� P, (size) 1414 641
NO.OF BEDROOMS 3
BUILDER OR OWNER "-r VAS ?(PPI S kAS
PERM TDATE: - COMPLIANCE DATE:
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 lea4ing facility) Feet
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COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS _
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632 t Gj 0
Name of Owner PHILIP NEAGLE
Address of Owner: 55 WOODVALE AV CENTERVILLE,MA 02632
Date of Inspection: 8/22/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 508-664-6813 FAX 608-664-7270
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
Inspector's Signature: Date:8/22/00
The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department 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
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner PHILIP NEAGLE
Date of Inspection: 8/22/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X 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.
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.
nta 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.
n1a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due
to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction is removed
_distribution box is levelled or replaced
n/e 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 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner PHILIP NEAGLE
Date of Inspection: 8/22100
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 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:
k _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 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 nLa (approximation not valid).
3) OTHER
n/a
6 '
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner PHILIP NEAGLE
Date of Inspection: 8/22/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist 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
X Backup of sewage into facility or system component due to an 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 1/2 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 Q.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 I 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,
ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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
- X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner: PHILIP NEAGLE
Date of Inspection: 8/22/00
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,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.The size and location of the Soil Absorption System on the site has been
determined based on:
X _ . Existing information,For example,Plan at B4O,H,
X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b))
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems. t
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner PHILIP NEAGLE
Date of Inspection: 8/22/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 2 Number of bedrooms(actual):n/a
Total DESIGN flow: 220 gpd
Number of current residents:2
Garbage grinder(yes or no):NO
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): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
816100 TANK ONLY BY ACE
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n/a
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.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1972
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner PHILIP NEAGLE
Date of Inspection: 8/22/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 18" "=
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER.
SEPTIC TANK:' X
(locate on site plan)
Depth below grade: 12"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 6'7"W 4'10
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or°baffle: 33"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How 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.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
Comments:
(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.)
n/a
^'r.
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner PHILIP NEAGLE
Date of Inspection: 8122/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and Float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
t 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): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
n
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner PHILIP NEAGLE
Date of Inspection: 8/22/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(1)1000 GAL 6'X 6'
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT WAS 1/2 FULL AT THE TIME OF THE INSPECTION.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2198 Page 9 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner PHILIP NEAGLE
Date of Inspection: 8/22/00
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)
A � �
VT
g
. I, AO
P t3
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 WOODVALE AV CENTERVILLE, MA 02632
Name of Owner PHILIP NEAGLE
Date of Inspection: 8122/00
NRCSReportname: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow—..Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 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
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
I
TOWN OFBARNSTABLE
OCATION t.I7 SEWAGE #
VILLAGE Lx ASSESSOR'S MAP & LO 0 ro py
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: 1
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
i
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EA
CAZ 8,b
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TOWN OF BARNSTABLE
pN ( ��0(_)() yz-,Ce nAR SEWAGE #� d JO
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-VILLAGE �.� �j'� ASSESSOR'S MAP & LOT ,-
INSTALLER'S NAME `PHONE NO. rTjuA 2
"SEPTIC TANK CAPACITY cy t�
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
r
BUILDER OR OWNER �WN'oWc&ci
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED
VARIANCE GRANTED: Yes No !�
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• TOWN OF BARNSTABLE
OCATION SEWAGE #
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VILLAGE ASSESSOR'S ASSESSOR'S MAP & LOT tom/
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY j ee)0 Z.
, LEACHING FACILITY:(type) /_ OBc' 4, f (size)
NO. OF BEDROOMS P RIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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II
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I � 16
1 CIO -- d ,Y TN
No...9. ��'�''".��� '' �j Fi$.J o..: ..
� z�RVv=i! THE COMMONWEALTH OF MASSACHUSETTS
6 " BOARD OF HEALTH
Onto TOWN OF BARNSTABLE
Appliration for Uhnp ml Work.6 Tomitrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair k/ an Individual Sewage Disposal
System at:
.. . --.._ _.... ----
1 �4 Locati n-Address or Lot No.
caner d oss
a - --------------------------------------- ..... i�
Installer Address
Type of Building Size Lot............................Sq. feet
.. Dwelling— No. of Bedrooms._-___3--------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures ------------------------------------------------------
---•---•--------
W Design Flow............................................gallons per person per day. Total daily flow_----_.---_--_..............................gallons.
WSeptic Tank—Liquid capacity/p -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 ( )
� Percolation Test Results Performed by........ ----------------•------•--•-•••----------------------••--••----_. Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit---------_-_----- _. Depth to ground water........................
(Z Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___-----_---__---------.
W ----------------------------•-------......................................._------------•.....------.........................................................
0 Description of Soil........................................................................................................................................................................
x
U ---------•-----------------••-••---------•-•----•--------••-----•-••-•------------------------•---------•••-•-------...-------------•••-------------...--•--••--••-•---••--•-•-•.....---•----------••-•
x ------------------ ----------------------------------------•---------•-----..._....-•------------------•--- --- �-- ----------...................
je............_..........
jj -
U Nature of Repairs or Alterations—Answe when ap licable... !1
(A-----------�-('�"sX'��X c L... _�Q?� fox �'�---._..inn...-A-4-S- ---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by-die board of health. /
Signed ... .... ................................... ................... .��-./... .. ...
Date
Application Approved By ......... - .. ........... ... ....�:......1..... .CL �-..
ate
Application Disapproved for the following rearonr: ------------------------------------------ ------- ----------------------------------------------------------------------------
11
... ............................................... ... ... ..... ........................................
n L?ate
Permit No. _.jt_v.........�, $ -------- ---------- Issued ........................_ ............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer#ifirate of Complianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( L
b -------------C. `� �,/............................................................... ------------------------------------------.....................................................
at .. ..... ....... ..... . --- .. �.. -Cr c �- .... Lc� ---- -t------------------------------------------ ---- ---------------------------------------.--------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -- .../.. ......;.-.s--- t..... dated __--------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...... .. ...161..... ....... Inspector ...................... .-1 ����
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c TOWN OF BARNSTABLE
No...;.. .: :..� .).. FEE.......
�i��ns�t1 �rk� �un�#��s#i�n remit
Permissionis hereby granted -- -- ------------•----------------------------------------•--------------------------------------------.----------•---
to Construct ( ) or Repair. ( an Individual Sewage Disposal.System
at Nora-- C�n(�v , 1-.�. ............... ----------------
Street
as shown on the application for Disposal Works Construction Permit ..............................
o Board of Health
DATE.................. / j..............------------.......
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
\I
GO -- I
No...._/...........- a...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD' OF HEALTH
/ 9X
TOWN OF BARNSTABLE
firation for Di,a mm II 1 onti.� i t�r Cn rurtintt ramit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at
. S ,J O vc .
..... ....._..-- �- O --------------- ...... = ............
,.Loocalion- Address C or Lot No.
Owner d css
l`� .-------------------------------------------------------- -----�--z`f----..c..M ..1 . t�
a .
Installer Address
UType of Building ^� Size Lot............................Sq. feet
Dwelling— No. of Bedrooms___..... ............................Expansion Attic ( ) Garbage Grinder ( )
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��4�..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.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit-__----_----____-_ Depth to ground water........................
P+ ----•--••-••----------------•••••-•---•••-•--•--••-••-------••--•----•-•-••--••--•-•-•-.....................................................................
0 Description of Soil........................................................................................................................................................................
x
U •---•••--•---•-•.....---•••--•••-••---•-•••••-••-•-••-•••-------------•---•-------•-••••-••--•---••--•••-••---------------••------•----••-•••-••-•--•--•------•-•------•-•••--••••----•-•-•...-•-•--•--
x •--•••-----------------------•---•••....••-•----------•--•----------•---•.----------•--------------•---••--- q 1 -- ...............
Nature of Repairs or Alterations when applicable---l�V ------_ ��C -lAlv_!�a_ __
U P _ r
---...•....<.c�2 5 ^ �---------k-----�-�Z-�--- �cx�^ PS-E w!"'s� .S+ci _..
Agreement: J
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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 ........ ...4.. --------------------------------------------- ��./...�../-...�.... .....
. L/�p`r�3y� Dare
ApplicationApproved By ........ .4 a-y .. .mot �n: - -------------------------------------------------------------------------------- ----�/...,......(.....'��.-4...
Date
Application Disapproved for the following reasons- -------------- --------------------------------- - - --------- - .. ..............................
C...` .......................................
Date
.................................................................._....-..._ ,........ ......
PermitNo. ....1...../.......... ..` " .......... ..... Issued ................................................
Date