HomeMy WebLinkAbout0554 STRAWBERRY HILL ROAD - Health IN
554 STRAWBERRY.HILL R_ D., HYANNIS
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'PION �Sy Sit�c✓��2<L% ��� /l �a � SEWAGE#2004-3C%
GE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NOAc� 7- .S'od ,5- e 3d2
SEPTIC TANK CAPACITY / S`e,6 �s����s✓
LEACHING FACILITY:(type) 3 �?�,�'per yam,/r�.;,b,0e) `x Q /Je �
NO.OF BEDROOMS
OWNER +` aj X 41'S'0 tee/
PERMIT DATE: / p 6 COMPLIANCE DATE: _
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNH ED��
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-LOCATION ASP/ J�Tk Awl ,¢2Y f�l�`� �D SEWAGE# 2-066— 3 ,
VILLAGE C ASSESSOR'S MAP&PARCEL fb
INSTALLERS NAME&PHONE NO. AP-cam/ l my-7 ea
SEPTIC TANK CAPACITY r-s'o D C s 7/<.✓
LEACHING FACILITY: (ty e 313os�1.,.���r2 0?0 �J (size)Z,;aC (1 'C ;1-
NO. OF BEDROOMS OWNER tztt-.t, //n�
e.d1 So.✓I
PERMIT DATE: O 6111 COMPLIANCE DATE: D
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
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TOWN OF BARNSTABLE
LOCATION S�� w �� SEWAGE #
VII: ..AGE' i d S SSO 'SMIAP &LOT ,_ %to
INSTALLER'S NAME&PHO
SEPTIC TANK CAPACITY CXX3 i9',
LEACHING FACILITY: (type) i (size) k 0m
NO.OF BEDROOMS V
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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) I Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 f et of leachi g facility) . Feet
Furnished by
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RECEIVED P"/
TROY WILLIAMS
SEPTIC INSPECTIONS
AUG 1 12003
Certified by MA Department of Environmental Protection L
OWN OF BARNSTABLE (508) 385-1300
HEALTH DEPT.
19 Hummel Drive
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Propert% Address: 554 Strawberry Hill Road (4 VIAO
_rPntPrvllle MA _ /
Owner's Name: Mary Booth &/ 30 d&
Owner's Address: 554 Strawberry Hill Road /
Centerville,MA 02632
Date of Inspection:. August 6,2003
Name of Inspector: . Troy M.Williams
Company Name:. Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
CERTIFICATION STATEMENT
1 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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000.). The system,
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: �� Date: $ /6 /d 3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection.certification is not to be construed as a guarantee of future working condition
of system,piping or components. This Inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. phis inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 . pace I of I I
y
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
554 Strawberry Hill Road
Owner: Centerville,MA
Date of Inspection: Mary Booth
August 6,2003
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 to 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 b replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board f Health,will pass.
Answer yes. no or not determined(Y,N,ND)in the__- for the following statements f"not determined"please
explain.
The septic tank is metal and over 20 years old" or the septic tank(wh ter metaj or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is i inent. Svstem will pass inspection if the
existing tank is replaced with a complying septic tank as approved by t Board of Health.
•A metal septic tank will pass inspection if it is structurally sound, t 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 igh static water level in the distribution boa due to broken or
obstructed pipe(s)or due to a broken,settled or ven distribution box.System will pass inspection if(with
approval of Board of Health):
broke ipe(s)are replaced
ob ction is removed
stribution box is leveled or replaced
ND explain:
The system requi d pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(w' approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
I
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART A
CERTIFICATION(continued)
Property Address:
554 Strawberry Hill Road
Owner: Centerville,MA
Date of frtspection: Mary Booth
August 6,2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to deterntiiie if the system
is failing to protect public health. safety or the environment.
1. System "ill pass unless Board of Health determines in accordance with 310 CMR 15.3030)(b) hat the
system is not functioning in a manner which will protect public health,safety and the envir ment:
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 mars
2. System will fail unless the Board of Health(and Public Water Su lier,if any)determines that the
system is functioning in a manner that protects the public health, ety and environment:
_ The system has a septic tank and soil absorption syste SAS)and the SAS is within 100 feet of a
surface %%ater supple or tributary to a surface water supp
The system has a septic tank and SAS and th AS is within a Zone I of a public water supply.
v
The System has a septic tank and SAS d the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank an AS and the SAS is less than 100 feet but 50 feet or snore front a
private water supply well". Met d used to determine distance
"This system passes if the ell water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile or is compounds indicates that the well is free from pollution from that facility and
the presence of am is nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria ar iggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 554 Strawberry Hill Road
Centerville,MA
Owner: Mary Booth
Date of Inspection: August 6,2003
D. System Failure Criteria applicable to all systems:
You mus 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
PLIt 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 NQT 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.
Not 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 thepresence 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.)
Nv (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described.in 310 CMR 15.303. therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design 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 ab e)
yes no
the system is within 400 feet of a surface drinking w r supply
the system is within 200 feet of a tributary to urface drinking water supply
the system is located in a nitrogen sen ' ive area(Interim Wellhead Protection Area—I WPA)or a mapped
Zone ll of a public water supply
If you have answered"yes"to any tioii in Section E the system is considered a significant threat,or answered
"yes"in Section D above the lar system has failed.The owner or operator of any large system considered a
significant threat under Secti or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owne ould contact the appropriate regional office of the Department.
4
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Page 5 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
554 Strawberry Hill Road
Owner: Centervifle,MA
Date of Inspection: Mary Booth
August 6,2003
Check if the following have been done. You must indicate"yes"or"no"as to each of the followine:
Yes No
information was provided by the owner. occupant,or BOW of I lealth
✓ Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period '?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
_ N/,9 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 link inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ __ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on.the site has been determined based on:
Yes no
— Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)(310 CMR 15.302(3)(b))
5
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Page 6 of l l
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
554 Strawberry Hill Road
Owner: Centerville,MA
Date of inspection: Mary Booth
RESIDENTIAL August 6,2003 FLOW CONDITIONS
Number of bedrooms(design): 2- Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): a 2,0
Number of current residents:_I
Does residence have a garbage grinder(yes or no): N�
Is laundo on a separate sewage system(yes or njIl Nv (if yes separate inspection required)
Laundry system inspected(yes or no): //,q
Seasonal use:(yes or no): /a
Water meter readings,if available(last 2 yearslrsage(gpd)): o,;L - Z 3 6&u u 30,000
Sump pump(yes or no):
Last date of occupancy: aLL,:, ; „t
COMMERCIA VINDUSTRIA L
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 syster �cs or no):
Water meter readings, if available: —
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Wass stem um ed asdan of th s coon Y P P P P � (Yes or nu): �u
lfyes, volume pumped: gallons-- How was yuautity pumped determined?
Reason for pumping: ,
TYPE OF SYSTEM
-ZSeptic 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:
Were sewage odors detected.when arriving at the site(yes or no): Am
6 _
Page 7 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
554 Strawberry Hill Road
Owner: Centerville,MA
Date of Inspection: Mary Booth
August 6,2003
BUILDING SEWER(locate on site plan)
Depth belu%� grade: 1 4
Materials of construction: _cast iron ,/40 PVC ✓other(explain):
Dkiance fron, pri%ate water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: ✓(locate on site plan)
Depth below grade: g"
Material of construction: -- concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of
certificate) .
Dimensions:
Sludge depth_
Distance from top of sludge to bottom of outlet tee or battle: oZ ' 2
Scum thickness: 3', — —
Distance from top of scum to top of outlet tee or baffle: 4 '1_
Distance from bottom of scum to bottom of outlet tee or bafl`le: /9
How were dimensions determined: 81A. _.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
<�Ah L✓y�-��._.9.✓�Ls-(• I.tL Wc..l drti c-... /vim
I'e Ly.�w .�.�Cal. /��o t✓r c9-.e.., t o l ._.le-d-, 41. n✓ �.F.-
_�-_ Hd
cX
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polye ene_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 affle:
Date of last pumping:
Comments(on pumping recommendations,in and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of le e,etc.):
7
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Page 8 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
554 Strawberry Hill Road
Owner: Centerville,MA
Date of Inspection:Mary Booth
August 6,2003
TIGHT or HOLDING TANK: (tank must be pumpZlimeoftion)(locate on site plan)
Depth below grade:
Material of construction: concrete metal_ fibylene other(explain):
Dimensions: - --
Capacity: gallons
Design Flog►. __ _gallons/day
Alarm present(yes or no):
Alarm level: Alarm in workin rder(yes or no):
Date of last pumping:
Comments(condition of alarm a float switches,etc.):
DISTRIBUTION BOX: A(,A (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.):
"Ole �1�✓ � �WY c y� �
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 pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
554 Strawberry Hill Road
Owner: Centerville,MA
Date of Inspection: Mary Booth
August 6,2003
SOIL ABSORPTION SYSTEM (SAS):y�(locate on site plan,excavation not required)
If SAS not located explain wh).
Type
_Zleaching pits,number: "x 'L co.•.1., P,f ,,,,7( I `S 1�„�
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length: _
leaching fields,number,dimensions: _
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of ve-etation,
etc.):
J-': L3a ,..;fl 2'
' �✓cr.� p V� �.s � � �ti L./w f'�r LtJ w,� �o L�L�t— �` �"_S�� ✓G{.aJ t.L
Lq �ti �-3 ,✓..� sl ..�.c wr �(1, — {i.., � off' ii.s��''�icsc�
CESSPOOLS: (cesspool must be pumped as part of inspection)(lo to on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: _
Depth of solids layer: —
Depth of scum la\er.
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or n
Comments(note condition of soil,sign f 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 hydraul' ailure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 554 Strawberry Hill Road
Centerville,MA
Owner: Mary.Booth
Date of Inspection: August 6,2003
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.
13,
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Page I I of I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
554 Strawberry Hill Road
Owner: Centerville,MA
Date of Inspection: Mary Booth
August 6,2003
SITE EXAM
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water 3• feet Adjusted high ground water elevation 2°•Y feet
Please indicate(check)all methods used to determine the high ground eater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
_Observed site(abutting property/observation hole within 150 feet of SAS) -
Checked with local Board of I lealth-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: /tl. L'j Ly z 0ti6� O t,
You must describe how/!you established the high ground water elevat'on:
In-t- �.� �-Y.� I-0sLy�—Gt�y'.'f-•e,.r � � ��—._—_7+�.:..L...-.i_ _ —S L.� fr d�..3 3_y 'I
N..t
G rod+.
w.�ojs.n. 1-4 6 L.�t_ -
- 3• L
This report has been prepared-and the system inspected as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly In the future. There have been no warranties or
guarantees,either expressed,written or Implied, relating to the system,the Inspection and/or this report,
11
210
TROY WILLIAMS
r_ N�Qvll
Ei�lVE0
SEPTIC INSPECTIONS 3 0—�e^^ y
Certified by MA Department of Environmental Protection i4NOFMASSACHU§E17S
t°roe�,Au (508) 385-1300
OFALIHGEp7
19 Hummel Drive �
South Dennis, MA 02660
COMMONWEALTH
EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE s
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CE CATI
554 Strawberry Hill R
Property Address: /oc
Owner's Name:
Joan Mather
Addr
Owner's Addres,: 554 Strawberry Hil Road
Centerville,MA 02
Date of Inspection: November 28,2000 O
Name of Inspector: Troy M. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
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
approN ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The svttem•
Passes
Conditionall%- Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature ^,, ;t� (� Date: >i /29 /od
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I leal(h 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. phis inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 611 V?000 nanP t
f
. Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
554 Strawberry Hill Road
Property Address: Centerville,MA
Joan Mather
Owner: November 28,2000
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
V/ 1 have not found any information which indicates that any of the failure criteria described in 310 C\4R
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. -
Comments:
B. System Conditionally Passes: A114
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. Svstem 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
indicatine that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2 .
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 554 Strawberry Hill Road
Centerville,MA
Owner: Joan Mather
Date of fnspection: November 28, 2000
C. Further Evaluation is Required by the Board of Health: A1119 .
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 I of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private ater supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:.
3
I
Page 4 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
554 Strawberry Hill Road
Property Address: Centerville,MA
Joan Mather
Owner: November 28, 2000
Date of Inspection:
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 primping 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.
_ p/a 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 forma
No (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as
dc,crihed 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: A1119
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 554 Strawberry Hill Road
Centerville,MA
Owner: Joan Mather
Date of Inspection: November 28,2000
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ l',:;;;ping information was provided by the owner. occupant, or Board of I Icalth
Were any of the system components pumped out in the previous two weeks?
_ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
— Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site '?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_ Existing information. For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
I
Page 6 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 554 Strawberry Hill Road
Centerville,MA
Owner: Joan Mather
Date of inspection: November 28, 2000
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): A Number of bedrooms(actual): �
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): a,20
Number of current residents: )
Does residence have a garbage grinder(yes or no): nio
Is laundn_ on a separate sewage system (yes or no):ND_ (if yes separate inspection required)
Laundry system inspected(yes or no): Al/9
Seasonal use: (yes or no): Nv
Water meter readings, if available(last 2 years)tsage(gpd)):
Sump pump(yes or no): AIJ
Last date of occupancy:
COMMERCIAL/INDUSTRIAL All,,
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
SuLtrCC of information: ivo��
Was system pumped as part of the inspection(yes or no): .v o
If yes, volume pumped: gallons- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_ZSeptic tank,diatribntkm-b",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:
�r� c, • n 1 �v �Jv.,c hL in Iy78 .
Were sewage odors detected when arriving at the site(yes or no):ivo
6
i
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 554 Strawberry Hill Road
Centerville,MA
Owner: Joan Mather
Date of Inspection: November 28,2000
BUILDING SEWER(locate on site plan)
Depth below grade: I ' f
Materials of construction:_cast iron Z40 PVC /other(explain):
Dktancr From private water supply well or suction line: Ai/1
Comments(on condition of joints,venting,evidence ul leakage, etc.): 1
A N N TD G.l e—, y t '/-1/+ 7et/YM i...
SEPTIC TANK: ✓(locate on site plan)
Depth below grade: "
Material of construction:_zconcrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: .S" k q ,e 6
Sludge depth: Y"
Distance from top of sludge to bottom of outlet tee or baffle: o?
Scum thickness: Novi
Distance from top of scum to top of outlet tee or baffle: ,y.
Distance from bottom of scum to bottom of outlet tee or baffle: /vu S,.
How were dimensions determined: (�rmeG
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Ccn,c , *na T� c ..y W r i 6'✓cLc✓. /y
U a. i a l i.+ /✓o .� �t�. r C 7 �y cs, a, t o c— of c�r..w c ✓�.s �i, ...d
/+ i
W tiff Y+�� r in Ncc J O J� Pv
GREASE TRAP:,cZLXlocate 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.):
7.
Page 8 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address554 Strawberry Hill Road
Centerville,MA
Owner: Joan Mather
Date of Inspectiont4oveniber 28, 2000
TIGHT or HOLDING TANK:'�A(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 Flo\ : 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:AtIq (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.):
All 0--0o,. 4, •• -A .„ ' i ias nc '0 CAI t��..,1�� ( w �C r.o d Soy
PUMP CHAMBER:NIA (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
I
Page 9 of 1.1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 554 Strawberry Hill Road
Centerville,MA
Owner: Joan Mather
Date of inspection: November 28, 2000
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain w•h)
T� _
leaching pits,number: I - C 'X6 ' L.4a✓l j-1:4 w;-eL,
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.):
NS L' L U W i s
�i 71
�✓cJ-��✓ wv !'. /A A/O ZUvl-at.l0.1[ tJ, J7 a'c'v C 7"/�f j --`-n d✓ pW:a��sMS 14t
W -"a J L1 't -I" ^s ?; M c o '- :
CESSPOOLS:NJ�2_(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 infloNv(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY:A114(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9 .
Page 10 of t 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
554 Strawberry Hill Road
Property Address: Centerville, MA
Joan Mather
Owner: November 28, 2000
Date of Inspection:
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.
0wc�k .
I
I
Al
[.K
z � �
�6
:3
10
Page 11 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 554 Strawberry Hill Road
Centerville,MA
Owner: Joan Mather
Date of Inspection: November 28, 2000
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 0 f [feet
Please indicate(check)all methods used to determine the high ground �sater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
VAccessed USGS database-explain: M z
You must describe how you established the high ground water elevation:
7w♦ � [h [a .A
T— 7
� J
L
11
\ CO.MNIONWEALTH OF M-%SSACHL'SETTS
ExECUTIVE OFFICE OF EIN-VIRONME\TAL AFF!JRS
I: DEPARTMENT OF EN`-IRONtiIE\TAL PROTECTION i •;,`
ONE WINTER STREET. BOSTON. NIA 021C�b
2
7RLMY CG
kILLIAV. F.WELD 1,998 ?=
)
Gfls•c:nc'
D'A 'ID B STRC1
ARGEO PALL CELLL'CCI ' ` ' - -
Lt.Govcrnor� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM�j.• Cornrissiarc
ApifZ� PART A
9 CERTIFI TI N
Property Address; � "�\�'`'�� RC ddress of Owner: hAQ�14 -
S ' vSt�1IC7
Date of Inspection: ��Eo\fig±.
If different)
Name of Inspector- Na rt'o E��C�� 1..\" ' -,"I
I am a DEP approved system inspector pursuant to Section 13.340 of Title 5 (310 CMR 13.000)
Company Name: I o her'c L-f-01 br"r'ef7a 0" P M 4-.—1
Mailing Address: -pO jjc);K C-3?_�4 H � (L H /T O 2-C41C1
Telephone Number: r5-e����-
CERTIFICATION STATEMF�%T
I cenih that I have pe•sonall\ rr.spec:ed the sev,aee d s;osat system- a: this address and tha: the information reported be:o, Is true. accurate
and comolete a: of the time of Inspec ,o-.. The Inspecion %%as penormed Ease--' on my training and experience In th.e proper funcicn and
r.amtenance o-' on-sae sewaee d,sposa• systems. The sys:err,:
Pastes
_ Concit,ona:ty Passes
_ ♦eec: Funhe- Evaruat,or• he Local Approving Autnorm
InsYector's Signat�r�Y %s,��X �t , = ;_... Date:
Sys:e-- lns•Jeci o• sham' submi: a copy of this inspec,on reocr, to the Aporoving Authority within thim.. (301 days of completing this
ins^ec',cr,. It the ssstem Is a share_ system a, ha- a des,gn floe of 10.000 gx or greater, the Inspecor and the sys:em owner shall submit
t-.e repc- tc the aporoprlate reg oval o nce of the Depa-merlt of Envircnmenta' Frotec;ror.. The crlg-na! should be sent to the system oNne
and copies .--I: to the buyer, ii applicable. and the ap--roving authority
INSPECTION SUMMARY: Check A, E, C, or D
AJ SYSTEM PASSES.
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 C.MR 15.303
Any failure criteria not evaluated are Indicated below.
COMMENTS:
B] SYSTEM COtiDITIONALLY PASSES:
_ One or more system components as described in the 'Conditional Pass- section need to be replaced or repairr-2. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
India:e yes• ne• or not determined (Y, N, or NDt. Describe basis of determination in all instances. If'not determined', explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: Or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratton, or tan%
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.
Paq• 1 of 10
SUBSURFACE 5EWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION; (continued)
Property Adduos:
0%ner:
Date of Inspection:
B1 SYSTEM CONDITIONALLY PASSES tconunj,�d
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(Wi,h approval of the
Board of Health). Describe observations:.
broken p)pefs) 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 pats
inspection ii tw•ith approval of the Board of Health):
broken pipets) are replaCL-
obstructor. is removed
Cj FURTHER B'ALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require iurthe• evaluation by the Board of Health in order to determine if the system is failing to prote the
public heath, saie-,-and the environment.
1) SYSTEM "'ILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH 'HILL PROTECT THE PUBLIC HEALTH AND SAF—ETY AND THE ENVIRONMENT.
Cesspool or prn\-� is within SO fee: of a surface water
Cesspoo! or pri%- is w ithin 50 feet of a bordering vegetated wetland or a salt marsh.
�! SYSTEM "'ILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONINC N A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFFE Y AND THE
ENVIRONMENT:
_ The systern has a septic tank and soil absorption system (SAS) and the 5A< is within 100 fey: to a surface water supply or
tributam- to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supnry well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the W is less thar. 100 fees but 50 fee! or more from a
private water supply well, unless a we!I water analysis for coliform bacteria and volatile organic compounds indicates thaz
the well is fre-- from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (a.ppro:irnation not valid).
3) _ OTHER
(revised 01;75/7') page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properts Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either "Yes" or 'rvo' as to each of the following
I have determined that the s�s:em violates one or more of the following failure criteria as defined in 310 CMR 15.303 The oasis
for this determination is identified below-. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facilit\, or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
S,a:ic !loud levei in the distribution boa 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 1/2 day ilov.
Rebuired pumping more than, 4 times in the last year NOT due to clogged or obstructeo pipes .
s,umoer o;times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Am ponion o.a cesspool or pr,v\ is w ithin 100 feet of a surface water suppw or tributar to a surtace water supply
And portion of a cesspoo' or privN. is within a Zone 1 of a public well.
An% po'tio- o;a cesspool or pristi• is within 50 feet of a private water suppl% well
An\ pon-or. ol-a cesspool or prey is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water qualit\ analysis li the well has been analyzed to be acceptable, attach cop% of well water analysis for
cohiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
1 ou must indicate either '•1'es' or "No'• as to each of the following:
The ioliow;r.g criteria aopi% to large systems in addition to the criteria above:
The system serves a iacilitm with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and safe[) and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking
_ the system is located in a nitrogen sensitive area (Interim Wellhead P :c_t o- Arca - 'V, ^.: or a rnapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6 00. Please consult the local regional office of the Department for further information.
(revised 04/25/9') Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propert,. Address: _> > 1111�4 rl+:�r::ri . ..... 'i,,
Owner: !!
Date of In ection: S l'v ki
U
Check if the following have been done. You must Indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ hone of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this Inspection
}( As built plans have bee^ ootamed and exarr•ined. Note if they are not available with NIA
The fac:lt:v or d%%elling was inspected for signs o;sewage back-up.
Tne systern does not receive non-sanitary or industrial waste flow.
The site v,as inspected for signs of breakout
_ All s\sterr. co^nponenu. e\cluding the Soil Aosorption System, have been located on the site
The septic tank rnantiole` were uncovered. opened. and the interior of the septic tank was Inspected for cond,tion of
babies or tees. matena' 0' c0n^ lructl0n dlme'sion�, depth of liqu,d depth ci sludge, depth of scum
—T he we hand I_-1\0\% o the Sal AbsOrt:i
On t -a t", �t'ri n!
The IaC-I_ O��ne• �anC OCCllDantS. It UI'b � ' : Ir;ui r»�.nt•i were [% i� ;n1Uri7iaUi r. the prOpe' mamtenanCe of
Sub-Surface Disposal Svsterr.
Nil It Existing information. Ex Plan at B O H
De,ermined In the field .i any of the failure criteria related to Pan C is at Issue, approximation of distance is
unacceatab,e (15.302.31:bi1
I
(revimed 04/25/5''i page 4 of 10
o `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR..{
PART C
SYSTEM INFORMATION
t
Properis Address: < , Ll �tryRj.,i ^fin 4. I ii I
r II,
.
Owner: `1. 15T-B 0
Date of Ihspection: ,:-`'t
FLOW CONDITIONS
RESIDENTIAL:
Design iiov% `=12 r o.d./bedroom for c.y'c
.umber of be--rooms (' ,-
NumLx,r c current resiaents
Carbage g•. der (yes or no,
Laundry co- e-aed to system (yes or no`
Seasonal use [yes or no•�j
Water me!er readings. if available (last r o i2 year usage tgDd[.
Sump Pump (ves or nod 4�
Lz,: da:e c' eccupanc�
CO•-MMERC�AUINDUSTRIAL:
Type of es;abhshmen;
DeSq:n fi0,. eahcns.'da%
Crease tray present jvej or no_
Incus:r a! V.aste Holding Tani, Dresen; %e5 or no_
w25te d,scnargeC to the T!tie 5 sys;ern o es or no_
%'%z:er me!er readings r available
Lzs:ra:e c: c, ez-c•
OTHER: .De.-cribe
1.2s; ca:e c eccu�an;•
GENERAL INFORtitATION
PUMPING RECO_ S and sour of Aniorma;ror. t
S.stem p mpec as par, ei rnspec;ton. tees or no
li yes, volume pumped ¢allons
Reason, for pumping
--f�'/� Septic tank,rchstrrbvr,on-be,,-,'soil absorption system
Single cesspool
O vertlow cesspool
Pin}
Shared system (yes or not (if yes, attach previous inspection records, if any) _.
I/A Technologv etc. Copy of up to date contract? _
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected -hen arriving at the site. tyes or no).1'J` _ ....
(r..•i..d c4/:s/9') D.q. 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
P.opert. Address: �7r S (K►�b�7V:t�'. _ti 'I l'h I
ff
Owner:r (
Date of Impect'on:
t i�Ir
BUILDIN''G SEWER:
(Locate on site plan) „•� I
Depth below grade.
Material of construction. cast iron _ 40 PVC _ other texplain'
Distance from private water supply well or suction Ire
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:��
occate cn sue p•
e ��
Depth beio.+ grade t
G construci.c- oncre:e _meta _Froe•g:ass _Poivethvlene _othertexplam
me;a;. Irs: age i; age confumec o. Cei.,ica:e c: Compuance _(l es,'vo
D�si,;nce trorn top o: s'•ucge to bor,o-n o: ou:;e; we o• ba�•e C
Scum t)ickness" t `l tl
Distance from top o' scum to top o' outlet tee or ba-,e I 1 _ , ,,
— —
Distance from bc;tom o' scu-•• to bo-e-: o; outte: tee c• bar:•c r
Ho-., dimensions "ere determrnec
Commen:s
trecom,mendation for pumping conda-on o- rn;et and 9utlet tees or baffles. depth of liquid level in reiation to outlet invert, structural '
rnte_rrrN..�.rdence of leafage, etc r
f
GREASE TRAP: E;�v'
(locate on site plan:
Depth below grade.
material of construction. _concrete _metal Fiberglass _Polyethylene _other(explarn)
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 baffie
Date of last pumping. -
Comments:
(recommendation for pumping, condmor, of rtlet and outlet te-, or baffles. depth of liquid level in relauon to outlet invert, structural —
cntegnty, evidence of leakage, etc.;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �• `� � f���{�_i �-� �, I
Owner: S -Ci
Date of Inspection:;
SOIL ABSORPTION SYSTEM (SAS): ..,
(locate on site_plan, if possible, exca-Ation not required. but may be approximated by non-intrusive methods,
If not determined to be present, explain.
Type
leaching pits. number its.S I k A > M
leaching chambers, number:
leaching galleries, number.
leaching trenches, number,length
leaching fieids, number, ci.-ensro^
0,erfIoN cesspool, numpe-
Alternative system
!game of Technolog\
Comments
,note condition -'so;i. sg r.s of hydra,, rc failure. I Lei of pond n , condrtt n of ve tat(on, a .) till
KIM
bz�-rain-ihh IL
CESSPOOLS: 1
(locate on site plae
Number and cory g ra:.o-
Depth-top of liquid to inlet inver,
Depth of solids Jaye,
Depth of scum laver
Dimensions of cesspool
Materials of construction
Indication of ground`,ate-
inflow tcesspool must oe pumper as par, of tnspection�
Comments:
(note condition of soil, signs of hydraulic failure, level of pondtng, condition of vegetation, etc.)
PRIVY: I
(locate on site plan)
Materials of construction: Dimensionsy
Depth of solids:
Comments
(note condition of soil, signs of hvdraulic failure, level of pondtng, condition of vegetation, etc.)
(revised 04/25/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued
Property Address:
Owner: CC<,1C ►
Date of In,pection:
SKETCH OF SEWAGE DISPOSAL SYSTEM.
include ties to at least n.o permanent references landmarks or benchmarks
locate all v%e!!s within 100 (locate where public water supply comes into house!
I
5S1A
(.-Pviaa: 04125!5') Page 9 o: 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert% Ad-dres—
Owner:
Date of Inspection:
Depth to Groundwate2C' Feet
Please indicate a!I the methods used to determine Nigh Groundwater Elevation:
_ Obtaine'.7 iron Design Plans on record
Observation v Site (Abutting propert). observauor, hole, basement sump etc.)
Determine it from local conditions
Cneck witr. loco 5,ard o• nea!,r
Cher F E-,1A macs
Chec', _o re m^n ' r
a.
Chec� leca' exca.ato•s installe,s
A_ l_se SCS Da
Describe r•, ,o �.,- „o o` r.o., so:: e_:abLshed the e^ Groundwater Elevation. must be completed
, � c
(A
P&g• 10 of 10
..
............................
Od.....
Fsa ....
THE COMMONWEALTH OF MASSACHUSETTS
i BOARD OF HEALTH
'4e Iluo _.. . .... ...... ......OF....................
AVVIiration furitiuttl Works TYui#rurttonrru1it
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Se a e Disposal
ystem a
....... .. - --- - -`-� C .. N
Isaca Addr�s� --------••-------•---•---or Lot No.
Owner Address
W
I nstaller Address
Q Type of Building Size Lot... --... a �-_�3q. feet
Dwelling—No. of Bedrooms-------2 ...........................Expansion Attic ( ) Garbage Grinder
aOther—Type
of Building ............................ No. of persons.............•.............. Showers ( ) — Cafeteria ( )
QOther fixtures -•---- ---------------------------------------------------- -----------------------------------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow.........9-�;- -A......................gallons.
WSeptic Tank—Liquid capacitv._/ bns Length................ Width......._.._..--. Diameter........._..... Depth----.._......_-
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter-.-..-....--.-...... Depth below inlet-..--..-----------.- Total leaching area..._.._...-..--.-sq. ft.
a
Z Other Distribution box (�) Dosing tank Percolation Test Results Performed by---------------- .........................................................
Date---•-•---------------------.......
l 117
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water----- J
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-..-... ..__..__.
O Description of Soil-----------
----•- ••---... .------- •------•--•-•--•.•--•---------•-•---•-----•----•---•••-----•---•-•----------------------••--•-----
fj,t ----------------•--------------------
x r ------------------
. �
W _
x -_----------------------
:----------------------------------------
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 Article XI of the State Sanitary de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has lbeiss e by the boar of health. / c�
Signed. --------------
Date
ApplicationApproved By......... •-- ---- ---------------------------------------------------------------------------
Date
Application Disapproved for the following reasons:---•---•---•------•-----------------------------------•------------•--..--•-------•--•-------------••-----------
-------------------------••--•--•---._...-------•------•------...----••-•--•-••--------•-•-•••--..-•-------•----•-•••---..-...----'•--------------..----•----------•-----------•- --------------
Date
Permit No------- Issued.-- .................................................
Date
., i. 6;
, G
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... . .._ ._ ... ..................OF..................................... ..................................................
Applirtttiun -for M.ipniittl Norkii Totuitrnrtinn Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
1 1XV.1?
Inca o -Add or Lot No.
IC
------ ..........
W Owner Address
� -•-----••--------•-•-•---•-•--
Installer Address
UType of Building Size Lot_.__1:�-- v �.__�`q. feet
., Dwelling—No. of Bedrooms---------------------------------------------Expansion Attic ( ) Garbage Grinder (�
aOther—Type of Building ............................ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- -
W Design Flow--------------------------------------------gallons per person per day. Total daily flow..........-............................----gallons.
WSeptic Tank—Liquid capacity--- ns Length_•--.----_---•_- Width................ Diameter-----_-------._ Depth.----------_---
x Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area---------------------sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet__-__-____-_.._.---- Total leaching area.._...__---_--_---sq. ft.
z Other Distribution box ('�) Dosing tank ( )
aPercolation Test Results Performed by------ -----------------•-------------------------•------•---- •-•-••... Date---...-.-----------•-----------------...
Test Pit No. l----------------minutes per inch Depth of Test Pit_..-._---___-.____-. Depth to ground water........................
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_.-.---.-----.._--_-
9 ----------------------------------------------------------------------•--•-•-•........."--"--'--".........................................................
Descriptionof Soil F '----------------•-----•-------•-•-- ---(----------------------------•-------•--•---•-------------------------------------------------
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------------------.
------------------------------••-.---------------------------------•-------•---.-------------------------------------.--•-•-----•--•-----------------------------------------------------------•-----..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary C,de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has 7issie by the boar of health.
Signed ------- ----------------------------------------- b o��..
Date
Application Approved BY Da
------------------------•--
Date
Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------
-----------------------------•-•-----••------•--••---------------•-•-••-------------•-------------•------.-_----------------------------------•--------------•--------•---••--------------------.-----
gw' � -) ✓—7-7 Date
Permit No.------- ----- ------------------------------- Issued..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................... .........OF......., f9/rF..rT���r.L.........................:.................
x1rdifirtttr of 01.1,11lnplittnr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( i) or Repaired ( )
i /,I ,, ,L/ / , , I /.
by....... _--------------------------------•--'......------------. --- ---------------------------------------------------- ----------------- ..' .----'---•-
j{� Installer /
• at.................... .! =---------' f• //pr1 /�I ii f / / ..L..�..._�.........._._.......
-------------------_--.....- ---------•-- -----••-----.- - -
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
'.. application for Disposal Works Construction Permit No---------;,,7/-.Vic................... dated...._..___.... - ... l
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. '
DATE---------L. _ �- -. ----------- Inspector. w
...............................................................
-F
THE COMMONWEALTH OF MASSACHUSETTS y{•i� , k ,.
BOARD OF HEALTH k
...'.... ........._...OF.......... ja/,. - TL+/y/c-
................ ..------...............................
No......................... FEE........................
�i��n>�ttl, ttrk,� �ttn�trnrtinn rrtttit
Permission is hereby granted-------------!'_.'.................. /1 - .'u'`
-•--------=•--------------------...................................................
to Construct or Repair ( ) an Individual Sewage Disposal System
at No---------------Z---" r f�•-•--•-----'--'---' • %.f' �.t. ... - �O �``- ;. --•.---
------------------- ---------
Street _ _
as shown on the application for Disposal Works Construction Permit No------ Dated---.__%_- L.__..!._�..._...__..
�1 t
DATE - 2 `. •--�-� Board of Health'
----------------------------'-------. /1 1
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r
y
s�-ip,"v rz* A<
vks
C- �r f r ,
OF
p WEL1A,M rG�.
C'
C. — I
N Y E y , C1=QT11=lED PL&,p No. 19334 � 7 �f
�9ryO1 SUM LOCATIOI,4
�-1 / fl �! ►J 15 ,
scnt_t �`� Via' vATI= , 24.>�
I CMSZTtF-f T"AT' THE �"-v��}a �[�Ut,� 51-law►J Pt-A►I1 REEM—zat.1GE.
Wt-iZEm" GOAAPLVS W tTtA TWG 5irrrr:_LI►ram C,
AWL> SET$ACk VC—QUIcZEMEWTS OF TNe
"To W U Op STA.l" - .C , C Zit
2Q » � �
DATE �
B,b�XTEtZ � ►AYE t�.1G_
REGIS�L-ZED L.Ai.1p SV2VcYorZ.S
T141S DLAW IS tJOT BA-SEY7 OW AN O5TEfZVtLLE o A4ASS.
(tJSf'i?cJMEt.tT SUtzVcY � THE pP�,��"S �iF-IOWI-D APPt_f GAtJT r---.
K1bT 6E tJSCC> To UC:TE2Mit4 LO-r i IwaS