HomeMy WebLinkAbout0067 NORTH PRECINCT ROAD - Health �6 North Precinct Road
Marstons Mills -
IA=148-133
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TOWN OF B TABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP &_LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY-:-(type) (size)
NO. OF BEDROOMS �
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")- Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
t,
_ �No. i
� ON � �I
'•'�� Fee /
00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftphration for Mispo8al 6pstrm Construction Permit
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.6,7 AbI Tin lPf?C IkXt Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel r Ll S (3 3
Installer's Name,Address,end Tel.No. Designer's Name,Address,and Tel.No.
L :D 0) ( n
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A[ gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ���p�C,� P 50 —1-�C C)to
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �Loiy^ I Date Issued
0 -ECG, oN I
t No. _. _ _ Fee / �V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH pIVISI.ON -TOWN OF BARNSTABLE, MASSACHUSETTS
01pphi Lion for Disposal 6pstem'Construction Vermit
Application for a Permit to Construct(, ) Repair(V)/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.(,7 Aky T1%-pi VC 10C t �� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel ( H 1 3 3 vl ' l'rc< M 1,,
Installer's Name,Addre s,1Wd Tel.No. Designer's Name,Address,and Tel.No.
L Do
Type of Building: '
Dwelling No.of Bedrooms /V Lot Size sq.fr. Garbage Grinder( ) . I
Other Type of Building No.of Persons + Showers( ) Cafeteria( )
Other Fixtures
Design Flow min.required) A ' d Design flow,provided j` "' d
� g (min. q ) /v gP g "� P ..: gP
Plan Date Number of sheets .- }:�`� ''Revision Date
Title t�
Size of Septic Tank Type of S.A.S.
.Description of Soil
Nature of Repairs or Alterations(Answer when applicable)k.e y\GC to 0
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. aop- I Date Issued
THE COMMONWEALTH OF MASSACHUSETTS 'P'j oo�l((,� ON \
BARNSTABLE,MASSACHUSETTS I
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( -I,/ Upgraded( )
Abandoned( )by N xl G gA 31 ra-ij L,3 T Ax
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 901 Lf- 17 q dated 5'}�'f 7
Installer!:a�, �4 A _T3 rw W ry Designer
#bedrooms Approved designXow ;,, gp
i r d
The issuance of this perm' shall rat be construed as a guarantee that the system w•.I nct on l esigned.
Date_ {✓j Inspector %/ /I i "/! m ��;i. (�','
---------------------------------------------------------------------------------------------------------------------------------------
No. THE COMMONWEALTH OF MASSACHUSETTS Fee I
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem -onstruction Permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at Co-T Q)M�+��at-, r t
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction mu t be completed within three years of the date of this permit. `
Date ''2��l Approved by
fa
SHE down ®f Barnstable Barnstable
� l�
Regulatory Services Department AHMahmCft
BAMSTABLFi 6 M Public Health Division
16 f59. 200 Main Street, Hyannis MA 02601 2Q07
Office: 508-862-4644 Richard V. Scali Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7012 1010 0000 2851 3566
May 14, 2014
Heather Eldridge
67 North Precinct Road
Centerville, MA 02362
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 67 North Precinct Road, Marstons Mills, MA,was last
inspected on 4/23/2014, by Matthew Gilfoy, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
The-distribution box needs to be replaced.
® The septic tank is H-10 septic system and partially under driveway. Must be
relocated or replaced with H-20 component(see enclosed policy).
You are ordered to repair or replace the distribution box within sixty (60) days from the
date you receive this notification. You have two (2) years to correct the problem with
the H-10 component.
Failure to repair/replace the septic system with the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
` `=I'hor�i"as cKean, R.S. CHO
Agent of the Board of Health
Encl: Public and Environmental Health Program under 310 CMR 15.301, State
Environmental Code, Title 5
Q:\SEPTIC\Sample Conditionally Passes\67 North Precinct Rd Cent May 2014.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
67 North Precinct Rd
Property Address
Heather Eldridge
Owner, Owner's Name - ..
information is Centerville Ma. 02632 4-23-14
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results 11 must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end.of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Matthew F. Gilfoy
use the return
key. Name of Inspector
- B&B Excavation
Company Name
14 Teaberry Lane
Company Address
rew;,
. Sandwich Ma.:. 02644
City/Town State Zip Code
(508)477-0653 S131640
Telephone Number License.Number
B. Certification
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 15000). The system:
❑ Passes Z Conditionally Passes ❑ Fails
Needs Further Evaluation by the Local Approving:Authority
ejow A/- I
4-23-14
Inspector's Sig ture - .. Date
The,system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The originafshould be sent to the system owner
and copies sent to the buyer,.if.applicable, and the approving.authority.._
***.This report only describes conditions at the time.of inspection and under the conditions of use
at that time. This inspection does not address how the system.will perform in the future under
the same or different:conditions of use.
t5ins•3It3- Title 5 OMlnspcm:Subsurface Sewage isposal System Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is required for every Centerville Ma. 02632 4-23-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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.
Check the box for"yes", "no" or"not determined"(Y, N, ND)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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 4-23-14
page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
D-box in poor condition and must be replaced.
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 67 North Precinct Rd
M
Property Address
Heather Eldridge
Owner Owner's Name
information is required for every Centerville Ma. 02632 4-23-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
cesspool
Liquid depth in is less than 6" below invert or available volume is less
El 0 q p
than h day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is required for every Centerville Ma. 02632 4-23-14
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is Centerville Ma. 02632 4-23-14
required for every
page. CitylTown - State Zip Code Date ofTnspection
C. Checklist
Check if the following have been done..You must indicate"yes" or"no":as to each of the following:
Yes No
El ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were.any of the:system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows:in the previous two week period?
El ® 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
El
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site? .
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption. System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
EJ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System.Information
Residential.Flow Conditions:
Number:of bedrooms (design): 3- Number;of bedrooms(actual.):: 2
DESIGN flow based.on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): _ 330
t5ins•T13.: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is required for every Centerville Ma. 02632 4-23-14
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
. Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 4-23-14
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is required for every Centerville Ma. 02632 4-23-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
7/31/02
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1'6"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal.
5"
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is required for every Centerville Ma. 02632 4-23-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
31"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appeared to be in working order,Tees present no sign of back-
up.Liquid level equal with outlet iT v_er_t:Tan --i- -10 and partially under driveway, Owner was going to
shorten drivewayas the ton hs ould be driven o .
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
f Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is required for every Centerville Ma. 02632 4-23-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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 per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
2 Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 4-23-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
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.):
D-box was is poor condition and needs to be replaced.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is required for every Centerville Ma. 02632 4-23-14
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2 6'X6'
❑ 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.):
At time of inspection leaching appears to be in working order, no sign of hydraulic failure.Water level
was 3' below invert in pit#1 at time of inspection and 2'6" below in pit#2.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is Centerville Ma. 02632 4-23-14
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Tithe 5 Official Inspection Form
Subsurface Sewage Disposal,System Form Not for Voluntary Assessments
67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is required for every Centerville Ma. 02632 4-23-14
page. Cityrrown State Zip Code Date of Inspection
D System Information (cont.)
Sketch Of Sewage Disposal'System: Provide a view of the sewage disposal system, including ties to
at least°awo permanent reference landmarks or benchmarks: Locate all wells within 100 feet. Locate
where public water supply enters the building. Check-one of the boxes below:
Z. hand-sketch in::the area below
Ej drawing attached separately
0
Z-101% i
l
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 4-23-14
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: no GW @ 12'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers -(attach documentation)
® Accessed USGS database-explain:
Usgs topo maps
You must describe how you established the high ground water elevation:
Taken from usgs topo maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 67 North Precinct Rd
Property Address
Heather Eldridge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 4-23-14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
M F
DEPARTMENT OF ENVIRONMENTAL PROTECTION
W
� , d
SJO��
TITLE 5
(11,'FICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 67 NORTH PRECINCT RD ERVI ,MA 02632
Owner's Namc: JOHN ROSE A4 Al
Owner's Adt':;ss: 67 NORTH PRECINCT RD GEN�LLE,MA 02632
Date of Inspect ion: 6/22/01 J
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA. 02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of 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:
X Passes
_ Conditionally Passes
_ Needs Further E al ation by the Local Approving Authority
Fails
Inspector's Si-nature: Date: 6/22/01
The system inspector shall submit a copy f this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If ie system is a shared system or has a design now 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
SYSTEM PASS1:5 TITLE V INSPECTION. RECOMMEND PUMPING SYS`�EMNOW AND EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE. D-BOX HAS SOME SOLIDS IN IT-RECOMMEND NOT DRIVING OVER
SYSTEM- IT IS 1110
****This report only describes conditions at the time of inspection and under the conditions of use at that time.This
inspection does not address how the system will perform in the future under the same or different conditions of use.
Title S Incnrrtitw harm 611 s0n00 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 67 NORTH PRECINCT,RD CENTERVILLE,MA 02632
Owner: JOHN ROSE
Date of Inspection: 6/22/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.SYSTEM HAS SOME SOLIDS IN IT AND RECOMENND
PUMPING NOW
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.
n,
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If not determined please explain.
k
n/a 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: n/a
i static water level in the n/a Observation of sewage backup or break out or high distribution box due to broken or obstructed s a t
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipd(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 67 NORTH PRECINCT RD CENTERVILLE,MA 02632
Owner: JOHN ROSE
Date of Inspection: 6/22/01
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the einvironmetit.
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,detennine distance n/a
"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.
v ;
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 67 NORTH PRECINCT RD CENTERVILLE,MA 02632
Owner: JOHN ROSE
Date of Inspection: 6/22/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped Wa.
X Any portion of the SAS, cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. (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
(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 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
t
F If you have answered"yes'wto any question in Section E the system is considered a significant threat,or answered
ill t*lion D above III@ 11rg�§ymelll lim,foiled:Tile omwr oi-Operator of any large§ymeIll comi(I@red it§igllificant 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 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 67 NORTH PRECINCT RD CENTERVILLE,MA 02632
Owner: 30HN ROSE
Date of Inspection: 6/22/01
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?
X _ 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)]
S
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 67 NORTH PRECINCT RD CENTERVILLE,MA 02632
Owner: JOHN ROSE
Date of Inspection: 6/22/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents:3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_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): n/a
Approximate age of all components,date installed(if known)and source of information:
1990
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: 67 NORTH PRECINCT RD CENTERVILLE,MA 02632
Owner: JOHN ROSE
Date of Inspection: 6/22/01
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
n/a
SEPTIC TANK: (locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L 10' 6" H 5' 6 ' W 5' 8""
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
Page 8 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 67 NORTH PRECINCT RD CENTERVILLE,MA 02632
Owner: JOHN ROSE
Date of Inspection: 6/22/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
DISTRIBUTION BOX IS STRUCTURALLY SOUND,SYSTEM APPEARS TO BE FUNCTIONING PROPERLY.
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
u
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 67 NORTH PRECINCT RD CENTERVILLE,MA 02632
Owner: JOHN ROSE
Date of Inspection: 6/22/01
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 2
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
K Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PITS APPEAR TO BE FUNCTIONING PROPERLY.DID NOT EXPOSE FIRST LEACH PIT-
SECOND LEACH PIT NEVER HAD MORE THAN ONE FOOT IN IT-SOME SOLIDS IN SYSTEM AND
RECOMMEND IT BE PUMPED OUT NOW
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
ilia
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 67 NORTH PRECINCT RD CENTERVILLE,MA 02632
Owner: JOHN ROSE
Date of Inspection: 6/22/01
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.
PO
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Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 67 NORTH PRECINCT RD CENTERVILLE,MA 02632
Owner: JOHN ROSE
Date of Inspection: 6/22/01
SITE EXAM
_Slope
_Surface water
Check cellar
_Shallow wells
Estimated depth to ground water 10+ feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
YES Checked with local excavators, installers-(attach documentation)
NO Accessed'USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUND WATER FOUND BY AUGER
� II
No.......
:Ll.....a..... a i ES'...........V .'
' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................0F................................`........................................................
Appliratiun for Diupuual Works Ton.iArnrtuan fIrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Dj osal
System at:
.. ............ „�1�1�?:.l'!! t ._�.� :1' !� c` ..............._
- - ..._..... ...................................................... ti._=_
Location-Address or Lot No.
........... .7-------..!ti',E). .. ........................................ ------------......................................................................................
wner Address
Installer Address
UType of Building .�_ Size Lot...........................S q. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (/ )
pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a
� Other fixtures -------- - ...... --- --------------------------.-----------------------------------------------------------------------........._..------•-----
Design Flow............. .`5. ✓.O
...gallons per person per day. Total daily flow..............2- ........._....--gallons.
W --
WSeptic Tank—Liquid*capacity_ d'gallons Length................ Width................ Diameter-..-..-------.-- Depth................
x Disposal Trench—No..................... Width........:........... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..SA 1---------- Diameter...... Depth below inlet......6.J--.t.. Total leaching area.._!/P.l.....sq. ft.
Z Other Distribution box (-( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water....U-,14.............
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..----..................
---••.............................•-----....-•--•----•-----------•--•---••-••••---•------•-••_......................................................
..........
0 Description of Soil......... --------------------------------------------•--•-------------------•----------------------------•---------------------------------•-----•-----•-----------..
v ................................................. G�luwi_.:.. '!Kje�•----r°--••= ......•----•......•-------
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 TL I'L 1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h;�s been issue y the board of health.
6
'gned.... - 7- 7�
-S��� Date
Applications 1Za.�'� ��' 7-------------•••-y P.7.....Y
Date
Application Disapproved for the following reasons: ......Al............ .......................
Permit No.---.... //-------------•----------------------- ssued � `2•�=�
� �
Date
7
%
No 01�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................0 F................................................................................
Appfiration for Uhipagal Works Tomitrurtion Permit,
uct or Repair an Individual Sewage Disposal
.,j;�tion is hereby made for a Permit to Construct
System at: P�f
................./ ........................................................................... ...............................................E;.Ka...........................................
Location-Address or 0
j IL
............................................... .................................................................................................
yq.caner Add At re,?
Installer Address
Type of Building Size Lot............................Sq. feet
i ,
Dwellin No. of Bedrooms............................................Expansion Attic Garbage Grinder
P4 Other Type of Building ............................ No. of persons__ .. ....._... Showers Cafeteria
Other fixture
Design Flow...... .___... 4 a0w gallon per person per day. Total daily flow...... . ......... S ......................._:__..........gallons.
1:4 Septic Tank—Liquid capacity./.'.? gallons Length................ Width__............._ Diameter__._.._..._..... Depth.....__.._._.__.
Disposal Trench—NJ . ........
A.. Width!.................... Total Length__................_. Total leaching area....................sq. f t.
.
Seepage Pit No .......... Diameter..... l(l_- Depth below inlet.....lo.�jC... Total leaching area---y�_�_._sq. ft.
Z Other Distribution box-04 Dosing tank
Percolation Test Results .Performed by....................................................:..................... Date........................................
Test Pit No. 1--------_-----minutes per inch Depth of Test Pit.................... Depth to ground water....0-/(------_----
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_...._..............___.
7----------------------- ----------------------11_1111-11-1------------
--------- ----------------------*--------------------
0 Description of Soil.........4 .....................................................I............................................................................................
.................................w�.;...............4_c111&61...... n........!P......
---------------------------------------------------------------
U
!;,�. -1 - .A , ; a
-----------------------I....... ......I-------------------------------AX.-,V
....................................................................................................................
U *Nature of Repairs or AlteiAtions—Answer when applicable--------------------------------------t................................ ......................
........... .............................-...................................................................................:...............t..................... ...................................
Agreement
The undersigned agrees to install the. aforedescribed Individual Sewage Disposal SystemAn accordance with
the provisions of TITLTZ 5','Of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certific4te kTCb In pfia'.fici��astbe&lils'sded,by-t'
he board of health.
igne d....... "/ .. ./..........
...... --------------------- ---
- Date
Application I-71 ......
Date
Application Disapproved for-.the .................................................................................................................
following reasons
............ ............................................................................................................................................
........77�----------------------------------- Date
PermitNo.......6 . . . Issued_._ . ... .. ... .
Date
-;44v 40' THE COMMONWEALTH OF MASSACHUSETTS 7,
BOARD OF HEALTH )e
........ .............................OF.........A.....................................................................
Trrtifirate of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by................. ........Z/!�r 2- ------------.........................................................................................................................................
' Installer
.....................................................................................................................................................................
..................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as dles"
crabed in the
--------------_------- .......................................
application for Disposal Works Cdfi fruction Perm� it No';r.'-;A-114,,_�,.1' dated....4, �6'- 177
5 ,, 7 1
THEASSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
.......................<--------------------------------------------------------- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF- HEALTH
...OF..................0 K....................... .........................................................................
N ............ FEE........................
Disposal Works Tonotrurtion P`rrmit
Permission is hereby granted...... ......... .................................................................................................
to Construct (-A) or Repair an Individual Sewage Disposal System
at No...................../V�.....414-1......... 7- W" t,11,e c
. .................................................................................................................................
Street
as shown on the application f`F"Disposal Works Construction. 7-7,P�
erio'mlii t N o...2 .......... Dated.._.41__�...........................
......... .......
DATE........................................................ .......... ...... Board of Health
FORM 1255 HOB13S 6.1WARREN. INC., PUBLISHERS
k
' SOIL LOG I
'1,s z
f I t +I e
I JJ
BOX 6 D
/ s�
i5ao Ivno '01 87,5Z
- Gr4 L o
MIN. GAL. i ' P� dK_ /
SEPTIC ( 40 nc� ✓.-,
..
/
TANK } (
�r' l-EAGK�N�i pIY ♦ i I s
f '
20' MINIMUM
FOUNDATION �-
r' WASHIU 5Tt3ME/ ! w.s rc 7 9.6Z
i f SCALE: I"= 4'
ELEVATION . SKETCH PERC. RATE
SCALE ! 4 TEST BY:TOWN INSPECTOR :
INSPECTOR : Pg.��- .,g✓a�-�✓
BACKHOE OPERATOR :
TEST MADE ON : Z
~7r �p
g n, 7
IL
'P ti1'S "P►T r: J
DIX
goo GAL
LE
Y
_?12
- 7 0
90
Cl
o
8 F� D
\NN
APPROVED. BY BOARD OF HEALTH $ 2'
DATE
Y �P�tH OF MSS
.RENWtCK13.
G '
s G' o !�� // " CJ / G9 ra ca HAPMAN
too:27654 Q
�G/STV0'c
fss/ONAI
ELEVATION SCHEDULE
PROPOSED SITE PLA
' I. INV. AT FOUNDATION
2. INV. INTO SEPTIC TANK _ � � 2� SEWAGE SYSTtM DESIGN
o/0
3. INV OUT OF SEPTIC TANK .1oT Alo�CZA/ /'Qt��-C//yG Y Cewo
C'esr/Tc.r i. .
4. INV. INTO DISTR!BU710N 9f GeX - g�•�Z• / oAI 05
SCALE I =moo ,7v.vE / 1977
5. INV, OUT OF D!STR BUTiON BOX 90• l5 •
-
6. INV INTO L1!AGµitNGy PIT _ °�O S� CAPE COD SURVEY CONSULTANTS
ROUTE 132
T, WTTCaM HYANNIS MASS
_y4
8. BaT-t'o� O�' vhii t-AY�t�"
f �