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Home My WebLink About0054 ANSEL HOWLAND ROAD - Health 54 Ansel Howland, Centerville A= I � UPC 12534 ' No.2_ 153LOR HASTINGS, MN { d 3 a ai Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ansell Howland Roads\�/ Property Address Laura Hilf Owner Owner's Name information is g required for Centerville MA 02632 August 7, 2008 ' every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. _ Company Name � 189 Cammett Road t _ Company Address _ Marstons Mills MA 02648 rerun City/Town State-iyP Code 'I 508-428-1779 SI12855 ) _ Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ August 7, 2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. 08-209 Hilf R.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ansell Howland Road Property Address Laura Hilf Owner Owner's Name information is required for Centerville MA 02632 August 7, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank was pumped following inspection leaching pit has 20-24" of effective leaching 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 08-209 Hilf R.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ansell Howland Road Property Address Laura Hilf Owner Owner's Name information is required for Centerville MA 02632 August 7, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. 08-209 Hilf R.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of s 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ansell Howland Road Property Address Laura Hilf Owner Owner's Name information is Centerville required for MA 02632 August 7, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (Cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_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. 08-209 Hilf R.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 ..�Qlul of Massachusetts Title 5� o W e Official icia► Ins • �° Subsurface Sewage Inspection F ge Disposal System Form . Dram 54 Ansell Howland Not for Voluntar Property Address Road y Assessments Owner Laura Hilf information is Owner's Name required for Centerville every page City/Town MA 02632 _u g 2008 State Zip Code A ust 7, Date of Inspection — B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ® 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 from a private water supply well with no acceptable water quality analysis. fehs system passes if the well water analysis, performed at a DEP certifie i laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 20009pd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 08-209 Hilf R.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 5 of 15 Title 5 Of Massachusetts Offi . Subsurface Official Inspection o Sewage Disposal System Form - on Form Not for Voluntary 54 Ansel/Howland Road Pro e Assessments p rty Address Owner Laura Hilf information is Owner's Name required for Centerville every page. Cityfrown MA 02632 State Zip Code August 7, 2008 Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, oc❑ cupant, 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 t this inspection?. he system recently or as part of ❑ ® 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: ❑ ® Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 08-209 Hilf R.doc•08/06 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 6 of 15 commonwealth of Massachusetts . Title 5 Official Inspection A 6 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Ansell Howland Road Property Address Owner Laura Hilf _ information is Owner's Name required for Centerville _ every page. City/Town MA 02632 August 7, 2008 State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 3 Number of bedrooms (actual): _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 57,000 gal. _ 78 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): -- - 08-209 Hit(R.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 54 Ansell Howland Road Property Address Laura Hilf Owner Owner's Name information is Centerville _MA 02632 August 7, 2008 required for -- every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped 2-3 years ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-.209 Hilf R.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ansell Howland Road Property Address Laura Hilf Owner Owner's Name information is Centerville MA 02632 August 7, 2008 required for even page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 8.5' long x 5.2'wide- 1000 gal. - Dimensions: 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 27" 2 Scum thickness 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12" Measured How were dimensions determined? 08-209 Hilf R.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments k!"M 54 Ansell Howland Road Property Address Laura Hilf Owner Owner's Name information is Centerville MA 02632 August 7, 2008 required for ever/page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank was scheduled ofr pumping following inspection. Recommend annual pumping with use of garbage grinder. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 08;209 Hilf R.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ansell Howland Road Property Address Laura Hilf Owner Owner's Name information is Centerville MA 02632 August 7, 2008 required for ever. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): 011 Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Liquid level was found at bottom of single outlet pipe. Structural condition of box is marginal, no evidence of exfiltration was observed. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08 209 Hilf R.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ansell Howland Road _ Property Address Laura Hilf Owner Owner's Name information is Centerville MA 02632 August 7, 2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ 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.): Liquid level in pit was 20-24" below inlet pipe with no high stains or other evidence of surcharge. 08-209 Hilf R.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 54 Ansell Howland Road Property Address Laura Hilf Owner Owner's Name information is Centerville MA 02632 August 7, 2008 required for event page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. 08-209 Hilf R.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 / (e\, Commonwealth of Massachusetts Title ~~ Official Inspection Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 54AnseU Howland Road ,mperty*dd'es^ LaurmHi|f _........... _- .... ..... _ .... --___ nwne, Owner's Name information is MA 02832 August 7 2008 Cen\nwiUa required for ------------' ----'' ---- State — Zip Code Date o'mnpemion evnp page. `^'~—� D. System Information (cont.) - Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal oyoh*m including ties 0osd least two permanent reference landmarks orbenchmarks. Locate all wells within 100feet. Locate where public water supply enters the building. ^� &��omx�^�� nxx��x xx��mxo�..~= ou~�u�ww � � . . � / ' | / Water Service 00. 4", N % N N N N N N N N N N 32 30 21 ' 47 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments k"W „ 54 Ansell Howland Road Property Address Laura Hilf Owner Owner's Name information is Centerville MA 02632 August 7, 2008 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 15+ Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 35 and topo map shows property at el. 50. 08=209 Hilf R.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 f tHE j Town of Barnstable Op ay_ Regulatory Services snxxsrnBLe Thomas F. Geiler, Director 9� M6 1 `fig A,f639. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within-this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTICTisclaimer Private Septic Inspections.DOC TOWN OF BA ST BLE _ LOCATION � � �� 1� C ��i SEWAGE# 3 05P VILLAGE ` (V O AU- ASSESSOR'S MAP&PARCEL f 'S NAME&PHONE NO. f IC nJ*t 1 1-1 8-1-0 SEPTIC TANK CAPACITY /1X30 LEACHING FACILITY:(type) (size) /®Ue NO. OF BEDROOMS �J OWNER. (—cvrq PERMIT DATE: ATE: 'n5( G O� 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 Ansell Howland Road Water Service 32 a 30 35 2 axa 21 47 TOWN OF BARNNS`TABLE q?LO _TION, S A �� 1 CN. SEWAGE# r VILLAGE • iEKI,w,,N\�C ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. t�T SEPTIC TANK CAPACITY �(= !rA LEACHING FACILITY: (type) Qnc�) a y4 (size) (a NO.OF BEDROOMS BUILDER OR OWNER I& E PER MffDATE: cq"1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility } a Q Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) iN�14 Feet Edge of Wetland and Leaching Facility(If any wetlands exist N within 300 f et of leaching facility) ` Feet Furnished by -g - � 4� J .D . Cho GO 00 w Commonwealth of Massachusetts Executive of Environmental Affairs. Q �� DEP MAR 2 J96 Department of �;�Environmental Protection 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 54 Ansel Road - Centerville Ma. Address of Owner: Bob Chase (if different) P.o Box 442. Centerville Ma 02632 Date of Inspection: 03/18/96 Name of Inspector: Michael D eD ecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel .- (508) 4771420 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 ---- Fail; Inspector ' s Signature.,, Dater 03/19/96 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Ansel Holland Road - Centerville Ma. Owners : Bob Chase Date of Inspection : 03/18/96 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 as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below 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 determinate (Y,N, or ND). Describe basis of determination in all instances. If "not determinated", explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration , or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- 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 ---- 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : 54 Ansel Holland Road - Centerville Ma. Owner : Bob Chase Date of Inspection : 03/18/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 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 of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING 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 water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: - I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. ---- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Ansel Holland Road - Centerville Ma. Owner: Bob Chase Date of Inspection : 03/18196 D) SYSTEM FAILS (continued) --- 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 over- loaded or clogged SAS or cesspool. --- Liquid depth in cesspool is less than b" 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). number of times pumped --- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I of a public well. --- Any portion of a cesspool or privy is within 50 feet of a private water supply well --- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality ana- lysis. 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. 1- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Ansel Holland Road - Centerville M a Owner: Bob Chase Date of Inspection : 03/18/96 E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above ' The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist --- the system is within 400 feet of a surface drinking water supply --- 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 compli- ance 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 Ansel H olland R oad - Centerville M a. Owner: Bob Chase Date of Inspection: 03}1 B/Sb Check if the following have been done -x 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 system has been receiving normal flow rates during the 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 sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, 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 deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 54 Ansel Holland Road - Centerville M a. Owner: Bob Chase Date of Inspection: 03/18/96 RESIDENTIAL: Design flow : 33d gallons Number of bedrooms : o 3 Number of current residents: v Garbage grinder (yes or no) : 06 Laundry connected to system (yes or no): yC.S Seasonal use (yes or no) : v% Water meter readings, if available: Last date of occupancy : COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow : gallons/day Grease trap present: (yes or no) Industrial waste holding tank present (yes or no) : Non-sanitary waste discharged to the Title 5 system (yes or no) : Water meter readings, if available : Last date of occupancy : Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information : 41�:..t�l1!%�►v.1 pit ............. System pumped as part of inspection (yes or no) :...... ......... if yes, volume pomped : .................... gallons Reasonfor pumping :............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Ansel Holland Road - Centerville Ma Owner: Bob Chase Date of inspection: 03/18/96 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) --- Other (explain)........................................................................................... APPROXIMATE AGE of all components, date installed (if known and source of information ............................................................... ................................ Sewage odors detected when arriving at the site : (yes or no).............. SEPTIC TANK : ...LAO..... (locate on site plan) Depth below grade: ..3...... Material of construction.- A. concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: Sludge depth :...off..`........ Distance from top of sludge to bottom of outlet tee or baffle:.......3.2.��................ Scum thickness :....L)............... Distance from top of scum to top of outlet tee or baffle: ...........I.0.1'*..................... Distance from bottom of scum to bottom of outlet tee or baffle :....1.�`.`............... Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet tert, structural integrity, evidence of leakage, etc.)................ rN.IR,$ .-�)�.��...� �.!!�...!t.�:..lj�.l.�cx:.. . :C.►4..a'�..�..Q.��<B:P�.�t�ru�-;(�..�a..a1t.�...r..�.j.�Vf.l.�!!�4�-. ................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Ansel Holland Road - Centerville Ma Owner: Bob Chase Date of inspection: 03/1 B196 GREASE TRAP : ......IIU�..... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... .......................................................................................................................................... Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... 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.)........................ ................................................................................................................................................ TIGHT OR HOLDING T 06 (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Ansel Holland Chase - Centerville Ma Owner: Bob Chase Date of inspection: 03/1 BI9b DISTRIBUTION BOX:.g6 (locate on site plan) Depth of liquid level above outlet invert:...ak...O.0; � Comment: (note if level and distribution equal evidence of solids carryover, evidencq of leakage into �c.)..�-. ?>.... ...`�.e ...x .� �.�� or out of box, e � c� L .. ................................................................................................................................................ PUMP CHAMBER:....r-�)..... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):.... ........ (locate on site plan, if possible, excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ Type.............................................. ...................................................................................... leaching pits, number: ....I............. leaching chambers, number:........ leaching galleries, number:........... leaching trenches, number , length:..................... leaching fields, number,dimensions:................... overflow cesspool, number:.......... Comments: (Hoke c ndikion of soil ; ns.of hydrau1ic ;le1 of ponding, condition of veekakion, g?.n? ....V" v -GjC..rr�-� kfl (UO . ......................... f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 54 Ansel Holland Road - Centerville Ma Owner: Bob Chase Date of inspection: 03/1 BIBS CESSPOOLS:..1A.0..... (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: ..................... Indicator of ground water: .................... 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 : ....NC)...... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . ..................................... .......................................................................................................... ................................................................................................................................................ SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 54 Ansel Holland Road - Centerville Ma Owner: Bob Chase Date of inspection: 03/1 BI96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. I Viz, 4g p t} S h a DEPTH TO GROUNDWATER: Depth to groundwater: .10'ZQ.feet Method of determination or approximative: ...5q.cvc ..,...In 11 ..,.., ►�rsr��rT u...J 1t5...+ .A.►...�d�.2....�s ................................................................................................................................................ ZQ QXWSEG C,� v Yr S E RMIT NO. LOCATIONLe VILLAGE INSTA LLER'S NAME i ADDRESS 11UILDEIt OR OWNER DA T E PERMIT ISSUED 3 as DAT E COMPLIANCE ISSUED -0 -3� �,1 ILL c `T'AN,�� PI-7- Fxs..3J......... .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® 9F H EA T .......... ... .............O F......-..... ................... Appliratiun for Uiiputittl Worko Tunitrnriiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat* �.... -------• -------- ................................ ------ -�� on-----•••-- oc . :Addre • ---•--:r�Lot 3d caner - Address a -------------- '......... ------ Installer Address Type of Building Size Lot._._ _f_!3rP.Sq. feet U Dwelling—No. of Bedrooms__--_-_-•-___• -•-__••.____.---•-•-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures d W Design Flow........... '��'.................gallons per person per day. Total daily flow.......... . . ............gallons. WSeptic Tank—Liquid*capacity. .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........4-1&&. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--___-_____•_••_-__--__. i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------•-------........................................................................................................................ 0 Description of Soil..............................................•-•--------------------------------------------......--------------------•-•----------•------------------•--•-----•-•--••- U ---------------------------------------------------------------------..................................................... ----------•----•-------•------•----•---•----------.._......_....•----...... 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 LJITH . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the -•• b od of health. Si ed-•--• 3 - � tApplication Approved --- -- ='•------•-•-----••-•--•--•..................•----•-•-------••--•._•-•--- �--• --....-L-------- - Date Application Disap v or a following reasons:--•••-•••••-••-•-•----•-••••-----••--••••---•------ ............................................................ ........................... •----•------------•-----------•--.....-•-•--------•--......----•.._.._•-••-•••.---- Date PermitNo._..._.. ......................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................ .............OF.......................................................................................... Appliration for Uhipoii al Workii Tontxnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_................................................................................ ....................................................-••-.......................................... Location-Address or Lot No. ....-•----•--.........................•----•-----•--•--•--.....-•-••-..................----•_._.. ..........-•...................................................................................... Owner Address W Installer Address d Type of Building Size Lot............................Sq. feet v Dwelling—No. of Bedrooms.............................. .. .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P1 Other fixtures ...................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid'capacity............gallons Length................ Width................ Diameter-__--___--__-- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... ( Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•--------------------------------------------------•---•-----•-----•--•.........._....--••---•--......................................................... ODescription of Soil........................................................................................................................................................................ W •----•---•------------------••------....-•--•--••--------•---------•-----------....---------•-•---•-----------•--•••-••--•-••......-----••---•------•--•---............................................ UNature 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 TIT1,;�. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ate Application Approved l= * ;f?_!`�..f<.' . ......................... Date Application Disa ro f for following reasons--------------•-••-------•-------•--•-------------------------------•---•-•--•-------•--••-••----------.....---- f Date Permit114-0......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE L c2i_Zz�. ,...-................OF r'k':............. ... ................................................... Trrtif iratr of Toutpliatta TH I CE Y, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by-- ------.... -- .... .. •-- -- . = g at.._ _. . f � Ins ler ............ ............"..,......... ................... has been installed in accordance with the provisions of TIT:F' 5 o Pe State Sanitary Cod as�l i�d in the application for Disposal Works Construction Permit No.. .... ._..`,��.................. da.ted_......•..._.. ............................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............................R—.r................................. Inspector.............)- ................................................ THE COMMONWEALTH OF MASSACHUSETTS BOA OF H A. H �C .........................O F. ...........C :.... ............................................... NO...!&.....l... .. FE X............... Bilivo n k Tnnatrnrtion Uvrrmft Permission wQeby granted.....:.. .:..... -- •------------- to Construct Fr air ( ,.fin Ind' dual ewageIspoyst at No.. -- C� - ` --•----••------•-------- --- .... W Street as shown on the application for Disposal Works Construction Permit N*2-7, -32---- Date ...... ........... Q y � S�/b`4 Board of Health DATE .-•................................... FORM 1?55 HOBBS & WARREN. INC.. 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