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HomeMy WebLinkAbout0009 JOYCE ANNE ROAD - Health 9 JOYCE ANNE RD. CENTERVILLE A = 209 111 — 21 rc No. 42101/3 ORA 1000 ® A p p IN o �� N 0 �. � - �I�I i it �j�, I 4 r DOMESTIC SEPTIC DESIGN, INC. 804 Main Street, Suite B Osterville, MA 02655 Tel : (508) 420 - 1904 Fax: (508) 420 - 9316 Daniel B. Johnson, R. S. ,C. S.E. May 16, 2002 �FCEIN/ED Tom McKean Board of Health VOVVNOFBA1.NSTABLE 200 Main Street HEALTHDEPT• Hyannis, MA 02601 RE: Title V Inspection 9 Joyce Anne Road, Centerville Dear Mr. McKean: Per the request of the Board of Health, a follow up Title V inspection at the above referenced site to determine the present status of the septic system was performed on May 16, 2002 . The inspection within the inlet manhole of the septic tank, which is the only means of inspecting the septic system, indicated that the septic system conditionally passes . The septic tank was pumped during this inspection . Because the house was not occupied during the follow up inspection, it is recommended that the septic system be re-evaluated after 30 days of the new homeowners occupancy. I thank you in advance for your attention to this matter. If you have any further questions, please do not hesitate to call . Sincereryours, Daniel B. /ohnson, R. S . , C. S. E. Page 1 of 11 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9 JOYCE ANNE RD,CENTERVILLE Owner's Name: CHARLES CROVO RECEIVED Owner's Address: 9 JOYCE ANNE RD,CENTERVILLE Date of Inspection: 11/17/00 MAY 1 7 2002 TOWN OF BARNSTABLE Name of Inspector. (please print) DANIEL B.JOHNSON HEALTH DEPT. Company Name: DOMESTIC SEPTIC DESIGN,INC. Mailing Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE Telephone Number: (508)420-1904 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 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 X Inds Further Evaluation by the Local Approving Authority _ Fails Inspector's Signature: Date: 11 ;L,s 0,0 The system inspector shall submit a copy o 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. THE OUTLET COVER OF THE SEPTIC TANK IS LOCATED UNDER THE SLAB OF THE GARAGE FLOOR. AS A RESULT, THE IS NO MEANS TO ACCESS THE OUTLET TEE TO DETERMINE THE LOCATION OR THE FUNCTION OF THE SAS. NOTE THAT THE SEPTIC TANK WAS PUMPED DURING THE INSPECTION TO DETERMINE IF BACK FLOW EXISTS. THE RESULT OF PUMPING THE SEPTIC TANK SHOWED NO SIGNS OF BACK FLOW. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 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: Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: 9 JOYCE ANNE ROAD, CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 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. JOYCE 7+NNE P- 0 40 ED S"1 DiZ��1Ew11`i 'v �.� ro TENT IA L )Ie�LEACOW6- PIT J CA WN /u v►�A I � J h 3 �'y.url�vb m SEll7'Ic TanMk 3 Cove& Ar&-#aE SE 00 SfAIILS Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 C. Further Evaluation is Required by the Board of Health: X 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. THERE IS NO MEANS TO ACCESS THE OUTLET COVER OF THE SEPTIC TANK TO DETERMINE THE FUNCTION OF THE SAS,OR IF A DISTRIBUTION BOX,IF IT EXISTS. THE REAR OF THE SEPTIC TANK IS LOCATED APPROXIMATELY 3 FEET BELOW THE CONCRETE SLAB OF THE GARAGE. AS A RESULT,THERE WAS NO MEANS TO INSPECT THE SAS OR D-BOX (IF IT EXISTS). Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for a 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 NDj 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.] _(Yes/No)The system fal1t.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply _ — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:9 JOYCE ANNE ROAD,CENTERVILLE Owner:CHARLES CROVO Date of Inspection: 11/17/00 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X _ Have large volumes of water been introduced to the system recently or as part of this inspection? _ X Were as built plans of the system obtained and examined?(If they were not available note as N/A) I X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X Were all system components, excluding the SAS,located on site? X _ 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? *EXCEPT THE OUTLET COVER(SEE PAGE 1) _ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION Property Address:9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no): NO Last date of occupancy: PRESENT 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: ACCORDING TO THE HOMEOWNER,THE SEPTIC TANK WAS LAST PUMPED APPROXIMATELY 2 YEARS AGO. Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 1000- 1500 gallons--How was quantity pumped determined? ESTIMATED Reason for pumping: TO DETERMINE IF BACK FLOW EXISTED,AS TO DETERMINE BY THE ONLY MEANS AVAILABLE, SINCE NO ACCESS TO THE OUTLET COVER IS FEASABLE DURING THE INSPECTION. TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system*NOT VERIFIED(ASSUMED) _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:ACCORDING TO THE HOMEOWNER,THE SEPTIC SYSTEM WAS INSTALLED IN 1978. Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 BUILDING SEWER(locate on site plan) Depth below grade: 4'(EST.) Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): NO SIGNS OF LEAKS SEPTIC TANK: X (locate on site plan) Depth below grade: 3' Material of construction: X concrete_metal_f iberglass_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: 10'L(EST.)X 5'W X 50"H(EFFECTIVE) Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: SEPTIC MEASURING POLE Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): *NO ACCESS TO OUTLET COVER(BELOW CONCRETE SLAB OF GARAGE). INLET PVC TEE IN GOOD CONDITION. CONCRETE OUTLET TEE APPEARS TO BE IN GOOD CONDITION. SEPTIC TANK WAS PUMPED TO DETERMINE IF BACK FLOW EXISTS. LIQUID LEVEL APPEARS TO BE AT OUTLET INVERT(LIQUID LEVEL AT APPROXIMATELY 2"BELOW INLET INVERT). NO SIGNS OF LEAKS. TANK APPEARS TO BE GOOD CONDITION. GREASE TRAP:_ (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner:'CHARLES CROVO Date of Inspection: 11/17/00 TIGHT or HOLDING TANK:_ (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass__polyethylene other(explain): Dimensions: Capacity: Qallons 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) 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.): *UNDETERMINED(NO ACCESS TO OUTLET COVER OF SEPTIC TANK) PUMP CHAMBER:_ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I_ Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:9 JOYCE ANNE ROAD,CENTERVILLE Owner:CHARLES CROVO Date of Inspection: 11/17/00 SOIL ABSORPTION SYSTEM(SAS):YES (locate on site plan,excavation not required) If SAS not located explain why: Type - X leaching pits,number: *NOT VERIFIED/ASSUMED — 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.): *NO ACCESS TO OUTLET COVER OF SEPTIC TANK CESSPOOLS:_ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer.- Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 1 o of l i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: 9 JOYCE ANNE ROAD, CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 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. J OYCE 74NN E R 04 o pi4-4 fb I'1 DR.,q L Uj A� ti .��10 Po rENTIA L EEA(eIA4 PIT ..� CEITiMAre o� ww ' o A WN �► � J t /3kv FX�sr�Nb h 5C0r,4 7-4,0< StarR-S V1 �fo�SE 3 EN Ar 6e4OE 8 El'ova S rA of-S 61LICA— p RTio Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner. CHARLES CROVO Date of Inspection: 11/17/00 SITE EXAM Slope VARIES(20%TO LEVEL) Surface water N/A Check cellar DRY/NO SUMP PUMP Shallow wells N/A Estimated depth to ground water>10 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: X Observed site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain: _ Checked with local excavators,installers-(attach documentation) _ Accessed USGS database-explain: You must describe how you established the high ground water elevation: NO SUMP PUMP EXISTS. SAS APPEARS TO BE LOCATED ON SIDE OF A HILL,DESIGNATED BY THE SCS MAPS AS CdC(CARVER COARSE SAND). THE PROPERTY DROPS OVER 10-20 FEET ALONG JOYCE ANNE ROAD TO THE INTERSECTION OF MAIN STREET. BASED ON THE ABOVE IT APPEARS THAT THE HIGH GW IS GREATER THAN 10 FEET BELOW GRADE. BOTTOM OF SAS IS ESTIMATED AT 7- 8 FEET BELOW GRADE(BASED ON SITE OBSERVATIONS) NOTE THAT THE ONLY ACCURATE MEANS TO DETERMINE HIGH GW IS TO PERFORM A SOIL TEST ON THE PROPERTY BY AN APPROVED SOIL EVALUATOR. Q izi PvA K1 os, Page 1 of 11 3. vi IS, TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS `' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9 JOYCE ANNE RD,CENTERVILLE RECEIVE® Owner's Name: CHARLES CROVO Owner's Address: 9 JOYCE ANNE RD,CENTERVILLE D E C 1 5 2000 Date of Inspection: 11/17/00 TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector:(please print) DANIEL B.JOHNSON �L Company Name: DOMESTIC SEPTIC DESIGN,INC. Mailing Address: 63 CAPTAIN ALDENS LANTE,OSTERVILLE t Telephone Number: (508)420-1904 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 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 X Needs Further Evaluation by the Local Approving Authority _ Fails ` Inspector's Signature: rN=;4 Date: 11 13 00 The system inspector shall submit a copy o 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. THE OUTLET COVER OF THE SEPTIC TANK IS LOCATED UNDER THE SLAB OF THE GARAGE FLOOR. AS A RESULT, THE IS NO MEANS TO ACCESS THE OUTLET TEE TO DETERMINE THE LOCATION OR THE FUNCTION OF THE SAS. NOTE THAT THE SEPTIC TANK WAS PUMPED DURING THE INSPECTION TO DETERMINE IF BACK FLOW EXISTS. THE RESULT OF PUMPING THE SEPTIC TANK SHOWED NO SIGNS OF BACK FLOW. \,V' +7b-P-s Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 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. ATD 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).They system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 C. Further Evaluation is Required by the Board of Health: X 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: THERE IS NO MEANS TO ACCESS THE OUTLET COVER OF THE SEPTIC TANK TO DETERMINE THE FUNCTION OF THE SAS,OR IF A DISTRIBUTION BOX,IF IT EXISTS. THE REAR OF THE SEPTIC TANK IS LOCATED APPROXIMATELY 3 FEET BELOW THE CONCRETE SLAB OF THE GARAGE. AS A RESULT,THERE WAS NO MEANS TO INSPECT THE SAS OR D-BOX (IF IT EXISTS). Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for a[l 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.] _(Yes/No)The system&&I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered.a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered`yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. I. .. .. .. ... _.. ... ... ..._ . .. ... Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:9 JOYCE ANNE ROAD,CENTERVILLE Owner:CHARLES CROVO Date of Inspection: 11/17/00 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X _ Have large volumes of water been introduced to the system recently or as part of this inspection? _ X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? _ X Were all system components,excluding the SAS,located on site? X _ 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? *EXCEPT THE OUTLET COVER(SEE PAGE 1) _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION Property Address:9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or n6): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no): NO Last date of occupancy: PRESENT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 9nd 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: ACCORDING TO THE HOMEOWNER,THE SEPTIC TANK WAS LAST PUMPED APPROXIMATELY 2 YEARS AGO. Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 1000- 1500 gallons--How was quantity pumped determined? ESTIMATED Reason for pumping: TO DETERMINE IF BACK FLOW EXISTED,AS TO DETERMINE BY THE ONLY MEANS AVAILABLE, SINCE NO ACCESS TO THE OUTLET COVER IS FEASABLE DURING THE INSPECTION. TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system*NOT VERIFIED(ASSUMED) _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: ACCORDING TO THE HOMEOWNER,THE SEPTIC SYSTEM WAS INSTALLED IN 1978. Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 BUILDING SEWER(locate on site plan) Depth below grade: 4' (EST.) Materials of construction:_cast iron X 40 PVC_other(explain): Distance-from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): NO SIGNS OF LEAKS SEPTIC TANK: X (locate on site plan) Depth below grade:3' Material of construction: X concrete_metal_f iberglass_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: 10'L(EST.)X 5'W X 50"H(EFFECTIVE) Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I" Distance from top of scum to top of outlet tee or bade: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: SEPTIC MEASURING POLE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): *NO ACCESS TO OUTLET COVER(BELOW CONCRETE SLAB OF GARAGE). INLET PVC TEE IN GOOD CONDITION. CONCRETE OUTLET TEE APPEARS TO BE IN GOOD CONDITION. SEPTIC TANK WAS PUMPED TO DETERMINE IF BACK FLOW EXISTS. LIQUID LEVEL APPEARS TO BE AT OUTLET INVERT(LIQUID LEVEL AT APPROXIMATELY 2"BELOW INLET INVERT). NO SIGNS OF LEAKS. TANK APPEARS TO BE GOOD CONDITION. GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 JOYCE ANNE ROAD,CENTERVILLE Owner:'CHARLES CROVO Date of Inspection: 11/17/00 TIGHT or HOLDING TANK:_ (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_.polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: * (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc,): *UNDETERMINED(NO ACCESS TO OUTLET COVER OF SEPTIC TANK) PUMP CHAMBER:_ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:9 JOYCE ANNE ROAD,CENTERVILLE Owner:CRARLES CROVO Date of Inspection: 11/17/00 SOIL ABSORPTION SYSTEM(SAS):YES (locate on site plan,excavation not required) If SAS not located explain why: Type - X leaching pits,number: *NOT VERIFIED/ASSUMED _ 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.): *NO ACCESS TO OUTLET COVER OF SEPTIC TANK CESSPOOLS:_ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_ (locate on site plan) Materials of construction: { Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:9 JOYCE ANNE ROAD,CENTERVILLE Owner: CHARLES CROVO Date of Inspection: 11/17/00 SITE EXAM Slope VARIES(20%TO LEVEL) Surface water N/A Check cellar DRY/NO SUMP PUMP Shallow wells N/A Estimated depth to ground water>10 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: X Observed site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain: _ Checked with local excavators,installers-(attach documentation) _ Accessed USGS database-explain: You must describe how you established the high ground water elevation: NO SUMP PUMP EXISTS. SAS APPEARS TO BE LOCATED ON SIDE OF A HILL,DESIGNATED BY THE SCS MAPS AS CdC(CARVER COARSE SAND). THE PROPERTY DROPS OVER 10-20 FEET ALONG JOYCE ANNE ROAD TO THE INTERSECTION OF MAIN STREET. BASED ON THE ABOVE IT APPEARS THAT THE HIGH GW IS GREATER THAN 10 FEET BELOW GRADE. BOTTOM OF SAS IS ESTIMATED AT 7- 8 FEET BELOW GRADE(BASED ON SITE OBSERVATIONS) NOTE THAT THE ONLY ACCURATE MEANS TO DETERMINE HIGH GW IS TO PERFORM A SOIL TEST ON THE PROPERTY BY AN APPROVED SOIL EVALUATOR , t 1 Ft�kl�1 Gi�81- 209111 y „ 209111 V fi:, " 001291 0000000 - LOT 12A .35 HANSEN,KIM K&CORINNA F n f 1 00003220 �PP0, 242 MAIN ST " 00 CENTERVILLE MA 02632 00-0000-000 4 HANSEN,KIM K&CORINNA F 1093 R • 8852/087 k � � � _ 000237100 b 0000000000 r � Q 9 JOYCE ANNE ROAD 0811 0080 �" ` CO ",< MAIN STREET(CENT.) 0950 0206 f "�xs •- �l Rl 9A k,, � k�yn �jnt'r'�+' WQ ujj ''4 �-.. V, ��� •t���i h .��y'•�, `rJ.•I, pp �3c