HomeMy WebLinkAbout0155 ANSEL HOWLAND ROAD - Health 155 Ansel Howland, Centerville
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UPC 12534
No.2_53LOR
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No. ! � � Fee 4 0 .0 0
THE COMMONWEALTH OF MASSACHUSETTS
1
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACH SETTS
0[ppYtcatton for Xh6pogai *pgtem Con5trurtton Vermtt
Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at:
Loi ' Address or1.of No. Owner's Name Address and Tel.No.
Ansel Howland Rd Norma Perry
Centerville MA
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Septic Sery
P.O. Box 1089
Type of Building:
Dwelling No.of Bedrooms 2 Garbage Grinder(noj
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil sand
(p install 3 #330 stonepacked
Na re -apcitylt in 1 trateorsen applicable)
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 Certifi-
cate of Compliance has been issued by this Board f Hp,alth,
Signed Date _!
Application Approved by
Application Disapproved for the following reasons
Permit No. �� d ��/ Date Issued '13 ` 94.
/Fee
40.00
No. / /
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DKISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for Mgogal *pgtem Congtruction Permit
Application is hereby made for a Permit to Construct( )or Repair(X )pan On-site Sewage Disposal System at:
Lo&ag�Address or.]_.ot I�Io. land Rd kOrma ebAAdddre s and Tel.No.
11 Ansel How y
¢entervill'e MA
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Septic Sery j
P.O. Box 1089
Type of Building: j
Dwelling No.of Bedrooms 2 Garbage Grinder(nc) f
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow, gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil Sand
i
Naga gn caapcityt in'Mtrators;applicable)
install 3 #330 stonepacked
l
Date last inspected: j
r
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 nd not to place the system in operation until a Certifi-
_. ' cate of Compliance has been issued'by this cYarr f')3 altht. j
Signed Date f "r
Application Approved by i
Application Disapproved for the following reasons
Permit No. 7(O .�-�/ Date Issued �.3 " :94+
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance - -
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(X)on
_ byy for Norma Perry
as 155 Ansei HoWland Rd Centervl=e has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions set forth below:
401,
ts�
No. �o�~•�/ Fee 40.00
THE COMMONWEALTH OF MASSACHUSETTS
Perry PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS
ligpogar *pgtem Congtruction Permit
Permission is hereby granted to
W.E. Robinson Septic Service
to construct( ))re air( X)an On-site Sewage System located at Ans Howland RD
Centerville
and as described in the above Application for Disposal System Construction'Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date: 6 �2 14 Approved by O—Al" ��Y
f
a '
L
.r
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANSI
hereby certify that the application for disposal works
construction permit signed by me dated /- 11—9 , concerning the
property located at 1,5 A-c-1 meets all of the
following criteria:
1
• There are no wetlands within 300 feet of the proposed septic system
,1
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED: rV 11 DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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r
do
TOWN OF BARNSTABLE
O,"ATION l,3'�/ /✓.�C'l �6C/L�iYD��'i,SEWAGE # �"'
VILLAGE /L1 o�r ASSESSOR'S MAP& LOT 7/-
INSTALLER'S NAME&PHONE NO. f=, A0,6/SSGIV 776-= e 7le
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS�ZL
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
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Commonweafth of MassachusettsIs - x
Executive Office of Environmental Affairs ✓U Rfcf�y�®
ANN
/V2 ®
Department of 19�8�
Environmental Protect
ion � ' g /
�.:
WUHam F.WeldGovamor �'•'�`3"� Trudy Cox*
4•
Arpao Paul Celluccl w... �Davi A Struhs
u.Gorsrnor
,,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A - r
CERTIFICATION •�-- i.
Property hAd Address: f�/'✓r/� Address of Owner.
Date of Inspection q' 7k (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5—8 7 7 6 ,
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
+� Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: e,'j 9 A 4,
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system',owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B,C,or D:
A] PASSES:
7I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 16.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
*) One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Ie yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiitration,-or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(r vised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 Is FAX(617)556-1049 a Telephone(617)M-M00
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /�i /y✓I��` 6r�//9!?�fl �C� C'e,7
Owner. rnft
Date of Inspection:
B]SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution bout is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] )TRIER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
ETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3)
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
�
Property Address: /v�� i�lL
Owner.
Date of Inspection: G ., f
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
Backup of sewage into facility 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.
Static liquid level in the distribution bog above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than&'below invert or available volume is less than 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
ooliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARD SYSTEM FAILS:
TLb following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owneZnof
operator of any such system shall bring the system and facility into AM compliance with the groundwater treatment program
requirem 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Anther information.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property ��e—
Aaasd:
re
Owner. lzle r"Ve"9- / �
Date of Inspeetlon: r t _g
Check if the following have been done:
_1,1�umping information was requested of the owner,occupant,and Board of Health.
__�Aone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
built plans have been obtained and examined. Note if they are not available with N/A.
_The facility or dwelling was inspected for signs of sewage back-up.
_ Ae system does not receive non-sanitary or industrial waste flow
he site was inspected for signs of breakout.
11 system components,excluding the Soil Absorption System, have been located on the site.
L.Ae septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of bales or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
1�The sise and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Addre /��j r u`e—� /t/9//�� �e�l �//�/��`
ss:'
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL.:
Design flow:3 3 o sallons
Number of bedrooms:
Number of current residents:
Garbage Winder(yes or no)•�O
Laundry connected to system(yes or no):_Y_
Seasonal use(yes or no): A-o /
Water meter readings,if available: 9 q
"5-
Last date of occupancy: ^� L*
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
A,' /iL
System pumped as part of inspection: (yes or no)_
If yes,volume pumped: gallons
Reason for pumping:
TYPE OFSYSTEM
t-fSeptk tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: A(, til c.t� � ttid�l�& .5
`
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM
S�INFORMATION(continued)
Property Address:
Owner. •/ 'o r wr A
Date of Inspection:
SEPTIC TANK
(locate on site plan)
Depth below grade:/0
Material of construction: l�6onceete_metal_FRP—other(explain)
11
Dimensions `7
Sludge depth: 3 1- .,
Distance from top of sludge to bottom of outlet tee or baffle: C) If
Scum thickness: ;?_,
Distance from top of scum to top of outlet tee or baffle: V
Distance from bottom of scum to bottom of outlet tee or baffle: �
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) <
d E TRAP:_
(locate o site plan)
Depth bel grade:
Material of ustruction:_concrete_metal_FRP--other(explain)
Dimensions•
Scummesa:
m top of scum to top of outlet tee or baffle:
Distance bottom of scum to bottom of outlet tee or baffle:
Commen
(recomme elation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence f leakage,etc.)
Wv
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
owner.
Date of Inspection: L _j c�,_9 Gy
TIG OR HOLDING TANK:_
(locate)ep:)
Depth
Materia n:_ooacrete_metal_FRP—other(explain) -
Dimens
Capacit ons
Design gallons/day
Alarm
Commea
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX_v
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP C ER:
(locate on site Ian)
Pumps in war ' order:(yes or no)
Comments:
(note oondi ' n of pump chamber,condition of pumps and appurtenances,etc.)
(revised 111131") 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,SYSTEM
INFORMATION(continued)
Property Address
Owner. /j�c,�"r+'►r9 y �/''�/
Date of Inspection: G_ q_ 14
SOIL ABSORPTION SYSTEM(SAS):_V
(locate on site plan,if possille;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number: .a c X�2
leaching chambers,number. 3 j 3 0 5 70 x.
leaching galleries,number:
leaching trenches, number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) r= ,o /d G .r4 9 A .S
CESSPOOLS:_
(locate on site plan)
Number d configuration:
Depth- of liquid to inlet invert:
Depth of lids layer-
Depth
of layer:
Dimensio of oesspool:
Materials construction:
Indication f groundwater:
ow(cesspool must be pumped as part of inspection)
Comme ts:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:
(locate on plan)
Materials of oonatniction: Dimensions:
Depth of solids•
Comme :(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
N,
(revised 11/03/95) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�SYSTEM INFORMATION(continued) -
Property Address: /•S �Jrls �"l� i9/%(� A'2
Owner.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
f y
7
1
DEPTH TO GROUNDWATER
Depth to groundwater. j :2'F feet
method of determination or approximation: i,l ti
(revised 11/03/95) 9
Commonwealth of Massachusetts Q
Executive Office of Environmental Affairs
MAY
Department of 1996
Environmental Protectio ,
Wllllarn F.Weld T 4,Y�<Coxe
Governor LCA
Argo*�Paul Celluccl 9 David B.Struhs
LL Commhdorw
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
1.5S— /qnSe,l Aekdl-nO RJ PART -
CewrtC,-ui Ili CERTIFICATION
d Property
Inspection:Address: Address of Owner. S r A'
Date
a7
—I (If different)
Name of Inspector. W.E. Robinson SR C>�-
Company Name,Address and Telephone Number. ( 5 0 8 )7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
,Needs Further Evaluation By the Local Approving Authority
✓ Fails
Inspector's Signature: e/ r f Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B,C,or D:
JM PASSES:
have not found any information which indicates that the system violates any of the failure criteriaas defined in 310 CMR 15.303.
ny failure criteria not evah>iated are indicated below.
M CONDITIONALLY PASSES:
ne or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection-
,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiitration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revis 11/03/95) 1
One Winter Street 9 Boston,Massachusetts 02108 s FAX(617)556-1049 • Telephone(617)292-SM
i Printed on Recycled Paper
J ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner. p/' �►'r r9 /` S�
Date of Inspection:
B]SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh.
Z) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
ETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
AFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution in that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3)
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) y
Property Address: e-1 + O�v��re
Owner.
Date of Inspection:
D) BY FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be neosssary to correct the
failure.
Backup of sewage into facility 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.
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 lase than U2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
_ Any portion of a 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El GE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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 H of a public
water supply well)
The or operator of any such system shall bring the system and facility into frill compliance with the groundwater treatment program
require nts.of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Rather information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
orty Address:
Date of Inspeadon:
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
_✓Done of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
_�:/As built plans have been obtained and examined. Note if they are not available with N/A.
✓The facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow
TThe site was inspected for signs of breakout.
✓All system components,excluding the Soil Absorption System, have been located on the site.
, /The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,®® //SYSTEM INFORMATION
Property Address: Wee,1n O Rd C2< A<
Owner. /7 6 r"i A- Ae r''
Date of Inspection: /
5 •,Z 9'
FLOW CONDITIONS
RESIDENTIAL
Design flow: ns
Number of bedrooms:-2=,:3
Number of current residents:
Garbage grinder(yes or no): ;`O
Laundry connected to system�or no):
Seasonal use(yes or no):,f:4
Water meter readings,if available: 9y LC� D` 0--
Zo S
Last date of occupancy: $"off•
COMMERCIALANDUSTRL4LU
Type of establishment:
Design flow:_ allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yea or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS annsourge of information:
//-q
System pumped as part of inspection: (yes or no)_
If yes,volume pumped: gallons
Reason for pumping-
TYPE OF SYSTEM
t/ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
i
APPROXIMATE AGE of all components,date installed(if known)and source of information: 2 0 �;i@ >d
Sewage odors detected when arriving at the site: (yes or no)�✓0
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION(oontinued)
Property Address:
Owner. 17 p P M/f A r^'y
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grade.
Material of construction: concrete_metal_FRP—other(explain)
Dimensions: S ? +
Sludge depth: ,
Distance from top of sludgeto bottom of outlet tee or baffle: 3
Scum thickness: C , ,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:_
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) A,&t /S G /i� ,�a✓e�
GREAS TRAP:
(k►cate on ite plan)
Depth below
Material of nstruction:_concrete_metal_FRP_other(explain)
!re.7
fro top of scum to top of outlet tee or baffle:
bottom of scum to bottom of outlet tee or baffle:
tionfor pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evdence leakage,eft.)
(revised 11/03/95) 6
I _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
` SYSTEM INFORMATION(continued)
Property Address: I S� ,9 p 4/l RS Ce raj Zv el
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate site plan)
Depth grade:
Material . n:_concrete_metal_FAP_other(esplain)
Dimensions:
Capacity: ons
Design flow: ons/day
Alarm level:
Commen
(condition f inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) C -e.,/i off$ l'w.>�V
O
PUMP C BER:_
(locate on a plan)
Pumps in wo king order:(yes or no)
Comments:
(note cc n of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /�6 i9hSe/ wd&//'9ko '/�o
Owner. Aey'-rneq- Arl— v
Date of Inspection: /
SOIL ABSORPTION SYSTEM(SAS):✓
(locate on site plat,if possible:excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number:_
leaching chambers,number:-12--
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
Overflow cesspool,number:
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
s k-- C 14A mk`lZ r .S d�ll r-7 C>v L 2 O v d J2 r
C LS:_
(locate O site plan)
Number an configuration:
Depth-top o to islet invert:
Depth of so' layer.
Depth of layer:
Dimensions of cesspool:
Materials of nstruction:
Indication of water:
(cesspool must be pumped as part of inspection)
Comments: ( condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
PRIVY:_
(locate on si plan)
Materials of n: Dimensions:
Depth of solid
Comments:(note n of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.
(revised 11/03/95) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) //
Property Address: I �c �ICfZ�/l`ghf� �� C� ?�'L/�r�lA,
Owner. O/ rn✓f
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent referenoes landmarks or benchmarks
locate all wells within 100'
V bG l�
v �
17L`y
DEPTH TO GROUNDWATER
Depth to Drnrnuidwater. I L} feet
method of determination or approximation: 0j 6
y
(revised 11/03/95) 9
�y U,
= P
No.....�........... FEa.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..OF.........................................................................................
,�l t �tPtt#i1�Yt for Uhipasal Workii Tonstrurtion Urrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System,� ���� G�J �
6.1�.......................... ......--�;r:d--------•------ --------•-----------------.�.......-. ....-------------••-•---.......--•-•---..
.... .
.L.....1n ddres ----------•--....or Lot No.
Ow pr Address
..
a ......................... .5.1_- ... ............................ ..........................
Installer Address
d Type of Building Size Lot_ f..l.�..Sq. feet
U Dwelling—No. of Bedrooms----------------------------- •Expansion Attic ( ) Garbage Grinder (� �
►�
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria
Pa Othe fixtures.................................
W Design Flow.............. _.............__...gallons per person per day. Total daily flow......:__ _ ..................gallons.
WSeptic Tank—Liquid capacity.. gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....._-.-f ........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.............._.........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
P4 --•-------•------•-••---•-•---••.................................................•-••••......••...........•••--•--•---••--•------....------••-••••••-•-------
0 Description of Soil........................................................................................................................................................................
W •-• •----------- --------•--•---•---••--------•--------•••••---------------•---•--••-------------•-•-•-----------------------------------------•---•---------------------------------------••--......---
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
------•-----•----...-•------------------------•----•---------••-------..............................----......--------•--------•--•----•-•----------•--------------•---•--------------.................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued b t e board of Health.
P P
Signv �;� ........................................... ....... ... .....
D
Application Approve -- ----• ..... . .. ......:............•-•--•-•--•-•-----..........-•-•-••-•.--•... _.._ .......��
Date
Application Disapprove po e f ollowing reasons:
.......................................................•----•------------•---------...•-•---------.............................._....-------•----....•-•--..............................................
Date
PermitNo......................................................... Issued-------••-•-----.......................................
No................3..6i.... Fl:a..............................
~ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ...................OF...............................I'll.......................................................
Aplrliration for Biipnsal Workii Cann.6trnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System --.........
- �. ........................................... ....... ............
Location-Address or Lot No.
......................—.......................................................................... .................................................................................................
Owner Address
W
Installer Address
Type of Building Size Lot.-. _ 4 ...Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )i�
•-------_____•- No. of persons............................ Showers — �/
Other—Type of Building _____________ p � ( ) Cafeteria
Q' Other fixturoa........................................................................................................................................................
W Design Flow..........
# ................................................•..._gallons per person per day. Total daily flow.......", _: __ .................gallons.
1:4 Septic Tank—Liquid capacity gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x ,`
Seepage Pit No.-____----I:�%--__-- Diameter.................... Depth below inlet.................... Total leaching area..................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.........................
Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------------------
-...........................
----....
.------------
............
-....
•----------------------
•-------------
-......
-•-••--.........
ODescription of Soil........................................................................................................................................................................
x
U ...-----••---....._•••...
W ----••--•-••---- -----------••-••••••-••-••-•••••••••---••-•-----------••-•-•---•---••-••••-••--••--•••-•••-•••----•--•-•••••---•••-•-•-••-•-•-••--•-•-•-•-•••••-•-••--•-•-......-•---•---....------•...
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-----------------------------------------------------------•----------------------------------_.....•--•-••.....••••--•--••-•••••---•••---•-----•••••-•••••--•----•••••••••-•-••-•-----••---••-•--......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued byte)loard of health.
Sign .. ........... .._. i ( ..............................
t Datre/�
ApplicationApproved y `- -------- ----tip... .............................................................. -•---
Date
Application Disapprove o e following reasons:-•-----••----------------------•----•-------------------------•••-••-----------••-•-•-•-•- .........
...................................... •--••••--...-•---••-----•--•---•--•••----•-•-•---•--•---•---•---•-••----•-----------•-----•--••••--•----------••--••------•----••--...•--•...........---.........
Date
PermitNo......................................................... Issued.-------•-•-•--------------•--..._.......------•---...:
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Tntifirate of Toutpliatta
IS IS TO CERTIFY, That the Individual Sewage Disposal rystem� onstructed (Uj or Repaired ( )
ler
at... = "2�� �!` '�� ' -----•------------------•-----........----------
_ - - - - = -- -•----------
has been installed in accordance with the provisions of TITLY, 5 9f State Sanitary C,ordA9,(
scr' the
application for Disposal Works Construction Permit No. �".-,tj� �l� dated-----`t� :_-: � ........
THE ISSUANCE QF THIS CERTIFICATE SHALL NOT BE CONSTR AS A GUARANTEE THAT THE
SYSTEM WILL FU TON SATISFACTORY.
DATE....�O �y- ........ Inspector... _.._G--------------------------------------------•------•------------.-------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTIrl
l .......OF......................................................................,..............
NO ....................... FEE........................
�i��aal nrk� Cn�un��rnr#ilan rrntt#
Permission is hepeVi granted....- t' ............ .........
to Construct r e air ( )an Indi ual� gage I� p sal 'ystem
at N
Street �i?
as shown/thelication for Disposal Works Construction Permit No...............DATE- •-----.....-•--••---......_. .... _ ,and of Health ........---•---•-••-----•----••--------
-
FORM 1255 A. M. SULKIN, INC., BOSTON
LOCATION _ SEWAGE PERMIT NO.
w` VILLAGE
I N S T A LLER'S NAME i ADDRESS
BUILDER OR OWNER
-RI A SSyK A 11 �
DATE PERMIT ISSUED &-&ILY
DAT E COMPLIANCE ISSUED � I
ck o�� �Uv su
' 31
�.� jq`
j ,�,J;JGL& FAMILY - ;3 BGOQooM i
GAIZBA(,E 6IzINDErz
0 1
I( DialLY FL0W z I10A PP �
!i SEPTIG TAB = 33Ox15o01- = '4976.P. o
j� use ► 000 GAL. . _ '
D1 SPoS�L PIT t-)5E too0 6A�._
i S Dr-WALL AQCIa = I j0 S.F / A2�A
gOTTOM AQE-A= .. 5
-ToTAI- �1✓SI614 = .425
-1 oTAL DA I
4o J, m
Ii PE2COLA-r,C)W RATE : I"IIJ 2MIN
Ii
q� 9
' S4-
OF Bf.4 1•�,tN OF I�._ AN L -•/
RICHARD tiG ALAN
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31 BAXTER u JONES '� V
No.2ti048Q p Nu 251co
t^QPST��� �i •r
i! �rYp SO'�yF'y
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FInLF 8/12f81 r. r/^Y
LOAM+ 1000 W�•
��IFShOIIi MST. INS o4t_.
2 BVx C EPTIC
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I GAL. 5Z
II SAIIb. LEA.C%4 INV. INV.
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-TrwN oF:--le- a241 "7TAr!W ANC IS
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FZ.E6 6r-'I,.AW D S u i-v El�oi�S
T%A15 PL&►J I S KART O►d AN OSTI✓2.VILLE - MASS
1w5TR-uMENT Sv2vey �- -rNE 01=F5E75 5uou,,D I
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BUILDER TIMOTHY GRAY JOB ADDRESS �' pATE REVISION DRAWN BY PAGE SCALE
DIANNE KUZMAROWIS DESIGN PROPOSED EXTENSION OF EXISTING KITCHEN AND SINGLE CAR GARAGE- Fo5
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ar!IS5 ANSEL HOWLAND ROAD
CENTERV ILLS MA. NOTE I PI ZASE%DRAM 1 LEAVES PLSLCHABgL RESPON6IBLE FOR COMPLWNCE MTH ALL 7 EXACT WE A.It..CEMQIT OF ALL CONCRETE FOOTINGS B ALL FOOTINGS SHALL EXTEND BELOW fROSTLD�VER FY DEPTH BOB)380980
LOCAL BUDDMG CODES ANp ORDSIANCES-J B DESIGNS MAT NDT BE 4ffLD RESPONBBLE MUST BE DETERMINED BY LOCAL SOD_CONDITIONS AND ACCEPTABLE 4 V i STRUCNRAL ELEMENTS
FOR S CONDITIONS OR FOR THE USE OF TNEBE DRAupNGS vtIi CONSTRUCTION. PRACTICES OF CONSTRUCTION.VERIFY Di WITH LOCAL ENf•n1EETL WITH LOCAL ENGINEER AND BIWDSIG OFF�LGLB. WEST BARNWTABLE MA 03668
ITE