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Home My WebLink About0048 AUDUBON CIRCLE - Health 48 Audubon Circle Centerville A= 191 180 014 a I S M EAD No.H163OR UPC 10259 smead.com • Made in USA JA Y 4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION W O1�f Syev� TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 48 Audubon Circle 0 l �� Centerville MA 02632 1 Owner's Name: Kershaw Owner's Address: Same Date of Inspection: May 17,2007 Job#07-119 3 r Name of Inspector: PATRICK M. O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. c ' - Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 w CERTIFICATION STATEMENT co rn I certify that I have personally inspected the sewage disposal system at this address and that the informati n reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Appr ing Authority Fails Inspector's Signature: Date: 5/17/07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching pit had 2' of standing water at time of inspection, recommend pumping tank. Recommend installing risers on tank and pit,also recommend replacing deteriorated outlet baffle in septic tank with a PVC tee. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: r Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: f Page 4 of l 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 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_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 _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 _No_(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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. . Page 5 of 1 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 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)] Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 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): Seasonal use: (yes or no): Unknown Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: Over .one year. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): god Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): _ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection (yes or no): No If yes,volume pumped: gallons-- How was quantity purnped determined? Reason for pumping: 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): Approximate age of all components, date installed (if known)and source of information: 1976 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: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction: _cast iron _X-40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition ofjoints, venting,evidence of leakage, etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: V Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8.5' long x 5.2' wide— 1000 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 3" 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: 10" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Liquid level at bottom of outlet invert outlet baffle is intact but deteriorating Recommend pumping tank and replacing outlet baffle. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete__metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: No (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits, number: One 6x6 pit. leaching chambers, number: _leaching galleries, number: _leaching trenches,number, length: leaching fields,number,dimensions: _overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Observed 2' of standinp_water and a hiEh stain line 18"above current level CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 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. 39 46 22 38 .. .. . ........... ater Service Audubon Circle Page 11 of 1 1' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Audubon Circle,Centerville Owner: Kershaw Date of Inspection: May 17,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water : More than 15 feet Please indicate(check)all methods used to determine the high ground water elevation: _Obtained from system design plans on record - If checked,date of design plan reviewed: _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) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.35 and topo map shows property at el.50. TOWN OFB""ARNSTABLE .!LOCATION 'lig Adybor) di(et� SEWAGE#-.-TV15P VILLAGE-&'X('Late ASSESSOR'S MAP&PARCEL M NAME&PHONE NO SEPTIC TANK CAPACITY `000 , LEACHING FACILITY.(type) �i (size) /600 flap NO.OF BEDROOMS 3 OWNER 42rSAe�, PERMIT DATE: CQ,1 &4AW"DATE: -5 1 6 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY a 39 46 2 - 8 i Water Service Audubon Circle COMMONWEALTH OF MASSACHUSETTS fD EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s 4 Vey TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_`IFF 14611(20 ba -eft 4 ty i - r Owner's Name t e Owner's Address: 1,57 ,rOle" f& Date of Inspei 7116 ( d� Name of Inspecto=Var(C se print) ,�tc6 a� Company Name: Mailing Address: C-�c - -6 Telephone Number: CERTIFICATION STATEMENT ' I certify that I have personally inspected the sewage disposal system at this address and that the information reported Z below is true,accurate and complete as of the time of the inspection.The inspection was performed basId on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: !i� �c� c4.� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 i Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: t� �( Owner vuskoio — Date of Inspection: D-ti 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 15.3 3.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"Condi ' nai Pass"section need to be replaced or repaired.The system,upon completion of the replacement or re ,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 2 ears old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltratio or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a com ying septic tank as approved by the Board of Health. *A metal septic tank will pass in tion if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less an 20 years old is available. ND explain: Observation o sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) due to a broken,settled or uneven distribution box.System will pass inspection if(with, approval of Boar of Health): broken pipe(s)are replaced obstruction is.zemoved distril ution box is leveled or replaced ND ex 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): in broken pipe(s)are replaced obstruction is removed ND explain: 2 f 'Page 3 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: � '4 Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to det ine 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 MR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, ety 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 tland or a salt marsh 2. System will fail unless the Board of Health(a Public Water Supplier,if any)determines that the system is functioning in a manner that protects a public health,safety and environment: _ The system has a septic tank and soi bsorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a s ace water supply. _ The system has a septic tank d SAS and the SAS is within a Zone I of a public water supply. — The system has a septic t and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a se p c tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply we #.Method used to determine distance "This system pass if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volat' a organic compounds indicates that the well is free from pollution from that facility and the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria a triggered. A copy of the analysis must be attached to this form. 3. Oth 3 Page 4 of l l OFFICIAL.INSPECTION FORM—NOT- FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE D OSAL-SYSTEM INSPECTION FORM PART.A, CERTIFICATION"(continued) Property Address: V' Owner: aclj _ Date of Inspection: / .. D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 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 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 f00 feet but greater than 50 feet from a private water T supply well with no acceptable water quality analysis.(This system passes if the well water..analysis, performed at a DEP certifiediaboratory;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.eguatto or less than 5.ppm,provided that no othec.failure criteria are triggered.A copy of the analysis must be attached to this form.] (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 facili h a design now of 1Q000 gpd to 15,000 gpd• ..s You must indicate either"yes"or"no"to each of the wing: (The following criteria apply to large systems in. ition to the criteria above) yes no the system is within 400 fe of a surface drinking water supply the system is within 0 feet of a tributary to a surface drinking water supply _ J the system is 1 ated in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of ublic water supply well If you have ans red"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Sec ' n D above the large system has failed.The owner or operator of any large system considered a. significant eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. a system owner should contact the appropriate regional office of the Department. A Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 0 Owner: J Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks? . T Has the system received normal flows in the previous two week period ` Have large volumes of water been introduced to the system recently or as part of this inspection? — Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? — Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper d—intenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7 U V v v Owner: &5 Date of Inspection: C6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): ,3 Number of bedrooms(actual):_ 3 DESIGN flow based on 310 C 15.203 (for example: 110 gpd x#of bedrooms):,,_-3 30 Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(y s or no): Seasonal use: (yes or no): Water meter readings; if av�a] ibie(last 2 years usage(gpd)): Sump pump(yes or no): /" Last date of occupancy: r COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15203): gpd Basis of design flow(seats/persons/sgft c.): Grease trap present(yes or no):_ Industrial waste holding tank pres t(yes or no):_ Non-sanitary waste discharged the Title 5 system(yes or no): Water meter readings, if avai ble: Last date of occupancy/us OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or 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 s _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all compone s;date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): � 6 '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: On 0eCp Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: cPO L' Materials of construction:_cast iron s 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) 42 c.r Depth below grade:I— Material of construction: a 'concrete_metal_fiberglass__polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: l Qv C'6z r' Sludge depth:_ i u Distance from top o sludfge to bottom of outlet tee or baffle: Scum thickness: ..z $1 Distance from top of scum to top of outlet tee or baffle: s� IreDistance from bottom of scum to bottom of outlet tee or baffpe: Cu d How were dimensions determined: / -ea,4 d`c`�cy Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): f c / ,� GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_meta _fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to to f outlet tee or baffle: Distance from bottom of scu to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumpi recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet ' ert,evidence of leakage,etc.): 7 r Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ` VLF Owner: 2 w Date of Inspection: —74 TIGHT or HOLDING TANK: (tank must be ped at time of inspection)(locate on site plan) Depth below grade: Material of construction: . concrete etal fiberglass polyethylene other(explain): Dimensions: Capacity: Ions Design Flow: gallons/day Alarm present(yes or no): Alarm level: Al in working order(yes or no): Date of last pumping: Comments(condition alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,et0 P t„[ PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of pump c ber,condition of pumps and appurtenances,etc.): 8 f Page 9 of]l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C nSYSTEM INFORMATION(continued) Property Address: -e v Owner: / Date of Inspection: t SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type K leaching pits,number: 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.): l L �a5 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inve . Depth of solids layer: Depth of scum layer: Dimensions of cesspo Materials of cons ion: Indication of gro dwater inflow(yes or no): Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate site plan) Materials of cons ction: Dimensions: Depth of soli Comments( ote condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): 9 Page 10 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Y SYSTEM INFORMATION(continued) Property Address: � S U ll3 Owner: revs i&") Date of Inspection: 7Ml b 6 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. s r Page l l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: v rC Owner: Date of Inspection: asp SITE EXAM Slope AEU. Surface water W Check cellar a 'rs Shallow wells tV0 Estimated depth to ground water r. W feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: 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) ,e�y Accessed USGS database-explain: You must describe how you established the high ground water ele tion: 11 THE COMMONWEALTH OF MASSACHUSETTS BOAR HEA OF..W .......... Application is hereby made for a Permit to C t uct or Repair an Individual Sewage Disposal C 4er�,nit o t--_,ns r System C /t St em ............ ----- ...... . .. ......e&. ------ . .................. -------------------- ess Location- or Lot No. ------------- Address Z Other Distribution box ( ) Dosing tank ( ) --------'--'--------------`-----`----------`----------`---``—'-----------`--- ^^grecozcot: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systern in accordance with the provisions of Article XIofthe State Sanitary Code— ]heomdersigned further agrees not to place the system in | operation until u Certificate of Compliance has been issued by the board ofhealth. | S -..-----.-- ................................ � Application Approved 8y- �_�Application Z Date i . d for the followingreasons:_—................................................................................................................ ------------------------------------------------------------------------------------------------------''—'---- --'--' No..;.3---�'°- ...... ............ �.--. THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE H -------------- Appliration for Ditipwial Workii C omitrurtiou Prrmit Application is hereby made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System,at, ' -t�-- ..L a.o A✓°i`.....ss �iF�� ----- -------- ..... Lot No. ...... !�'�.... .... 0.�.. Address.. mac.. d f/K taller Address IV Q Type of Building Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms._--___fir...................................Expansion Attic ( ) Garbage Grinder ( ).-. Other�T e of Building--.. p-, yp g-:. _-�f��23,_e...._ No. of Pei-soils........ ............... Showers ( ) — Cafeteria ( ) Pa Q Other fixtures l •------•------------------------------•-----------•---•---------------------------------------------------•----------'------------ W Design Flow............................. x _ � oh sPe person Per day. daily ----gallons. WSeptic Tank—Liquid ca acitX/�e ..gallons Length Width - --- Diameter----------------- Depth-- Disposal Trench—No. .................... Wi lth_____`__ — Tata ngth________ __._._--- Total leaching area_____;. ........Sq. ft. 3 Seepage Pit No...9_�--------------- Diamete01--e['�. ...... Depth below inlet...... Total leaching area.__ _.---�°"sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by......................................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit--___________-_-- _ Depth to ground water..-.__--._-.--..----.--. fsl Test Pit No. 2................minutes per in h Depth of Test Pit ............. Depth to ground water-_--_-___---_____-__.-_- ODescription of Soil : = t.= , -------------------------------------- -------------------------------------------------------------- V W ------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------ U Nature of Repairs or Alterations--Answer when applicable------------------------------------------------------------------------------------------------ q -•---------••-•------•-------•••--------------------••--••-•.....-•--•-•-•••--•••-•--•-•----•••-•••--•••-••-------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to- install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. f Sigged..............I...........................................••--•------------•-•-••- ................................ /at.e Application Approved BY t Application Disapproved for the following reasons-------------------•--. --------------•-------•------•---•----------------------------------------------------- -•-•-•-•-•---•-----•-•--••-••...-•---•------•------=••••-----•---•-•-- •-•-----••------- Date d PermitNo...................................••-......---•-•-_.... Issued-----x�� -------------- - -ate THE COMMOINWEALTH OF MASSACHUSETTS BOARD OF HEALTH 44— `'..........OF.... ... .� � r,.. sr..t.................... 1 pn if iratr of ('I'uutphatirr THIS IS TO CE: TIFI-;That-the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ... ..... •. ... -------------------------------- Installer3Y�� at--•---.°.4-d• � U sf"t_�el..._ -�trF° � g ;/Fa,� L+k, � , �a°'' h� -=6 w G ti has been installed in accordance vwith the provisions of A tic'le XI of The State Sanitary Cgde as de r' ,d in the application for Disposal Works Construction Permit No_________________ ___ _ ____�a _ dated..._ "'w-_. .. .................... THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F NCTI N SATISFACTORY. DATE '-r-------------------------------------- Inspector.. ... �= - '--- ---- `f-- •,THE COMMONWEALTH OF MASSACHUSETTS BOARD r OF HEALTH ........OF--. .. No... ° ................. Permissto :hereby, granted-•_.. - --------••- = ' .. to Constrluct ) rVRepat> ) anndivlduaR$ewa 'I�tsposa] System Street i as shown on the application for Disposal Works Construction Peyn t No----- '�,f"?___ ! ted__ ` _____..__ ._____________ �1 � Board of Health DATE. , --- -------- ............................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �\, 1� I � -q LOCUTION : oT SEWo.GE PERMIT Uo. VILLAGE — ��ltJ7'F"�('U�LGC INSTALLER S 1 &ME ADDRESS BUILDER 5 Q &"F- �. ADDRESS Db\TE PERKA T ISSUED D ATE COMPLI &KiCE ISSUED : — r love, 7Ae- %R,u1e (. 4 � r�0 G/1.11 No.......� ' a-a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H A H OF ..� .. . _.......... Appliratiuu -fur 13hipauttl Works Cnutuitrurtiou Vrrul t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal LIitys.l tem at:' - ......... de/�G'! K-r-��( we �+ Locatio -Addres + ( r Lot ' ......5tC...�.•�-•-•2 — ......••1...�!`��```•►•..... I-L.---•--•-•--•••...............•-•-•-- �, Own . X__s•_:.5.................. ............ly ,. Installer Address Type of Building Size Lot...... -----Sq. feet Dwellings No. of Bedrooms------------ �_______________Expansion`AJttic � Garbage Grinder `4 Other—Type of Building No. of persons_---__--L4.............. Showers ('� ) — Cafeteria ( )g -- - o .---•-•- d Other fixtures ------------- w Design Flow f l......................gallons per person per day.. Total daily flow._______.--__-____--.-----....gallons. WSeptic Tank—Liquid capacity->!0*11ons Length.......... Width.--_ ' ._.. Diameter................ Depth.......... x Disposal Trench—No. .................... Width-------------------- Total Length_-_-______-.._----.. Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Tota e clt' area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) — V -S'- 7 �" 0�� Percolation Test Results Performed by-------- ----------------------•--•------------..._..........-•-......_.__ Date--.------------------------------------ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water------------------------ riq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_..-_--------.----.- ix ........... ---- O x �o � �- ------- -••• r_ Description of Soil--------�---�--�-�----_�------ -----� ---- -------------------�- -----------------a---------9--rG-� U -------------- ��--"•-.... �------ ..---s ----------------------------------------------------------------------------..-------------- w U Nature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------------------------------------------. - ------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation.until a Certificate of Compliance has been issued by the board of health. igned . -----•-- Application Approved B v Date" y .. -7-G------------ Date Application Disapproved for the following reasons----------------------------------------------------............................................................. -------•-•••-••--------•-•--••--•---------•--•-----•---------••-•-----------••---•-----•--••------------------------•••---------------------------•-------•-•_-----------------------------------.-•--- Date PermitNo.............•......................................... Issued.::'-.................................................. Date THE COMMONWEALTH OF MASSACHUSETTS Finc Le. BOARD OF H A • . H ApplirFatinaa -fur Diiipwial Works Tonfitrurtioaa Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .._ Location.Address�//� ^ S j/��Qr Lot ;Q% - Owner Address -----•-------- r ..................................... Installer Address UType of Building* Size Lot.... _.�-v__._Sq. feet Dwelling�l o. of Bedrooms............... _________ ----- Attic (N i Garbage Grinder OI V P-I Other—Type of Building _A!R_!'��-�,_____ No. of persons---------- ............. Showers O ) — Cafeteria ( ) Pa Other fixtures ------------------------------------- - W Design Flow�`�... ..........................gallons per person per day. Total daily flow....._....Z_ 72---------------------gallons. WSeptic Tank—Liquid capacity.-I. gallons Length__._-_-_-_(,t__ Width----?'' -_-- Diameter................ Depth.......... x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------_----------- Diameter---..._____-_____--_ Depth below inlet.................... Total},eachiiig area------------.-----sq. ft. z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by----------------`-------------------------------------------------------- Date---••---------------•-------•----.-----. Test Pit No. 1................minutes per inch Depth of Test Pit_----------------- Depth to ground water..._____-___.__.__._..-. f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---__._.____.__.____---. ------------•-•--- - ---------------•--- ----•----....._..............'.............................................................. O Description of Soil-------- l].." t.•... f �- . >� �m W r�l ------------------ ------------ ----------------------------••----------------------•---------------------•----------------••------•----------------•---••---•---••---------------------------------- U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- ----•----•---•----------------------•-----------------------------•-------••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. j / %' '✓ Date Application Approved By-------` ............... -- 7.�d Date Application Disapproved for the following reasons________________________________ ......••... ------------------------------------------------------------------ --...-••---••.-•-•••--------•---------------------------•••-----------•-------------•-•••----•------•-•-•--•---------• ------------------------------------------------ -------------- --------•--•----• Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 101.1rrtifirate of 101.1,11mpha urr v THIS-IS TO CERJJIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ----- -U........ ......-•----•-- ------•-•---------------------- rInstaller - at has been installed in accordance with the provisions of Ar �e�XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-:- %_____3 :__`/......... dated...___'n..-:. �..-------r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE7 �------~-� Inspector•----- ----------- -- ------- —......•. I� THE COMMONWEALTH OF MASSACHUSETTS /?, J BOARD O HEALTH a�> y , ............O F...............«- - ` - ----------------------- No..... -----••------•--- FEE :f Bi_nVaiiaa1_f rrrkg n mitrurtion Vrrmit Permission }s_hereby granted )�I! 1 to Constr t ( ,) or Repair`() an Individual Sewage Disposal System / at No.-Zktji/ . r�''f _.1�__ .............._.. ---------••---- Street / n .y ,/ PPDisposal �--- .-f - -----�--- Dated__�`. �''_'---�-._/..--t---------------- �-/ ass own on the application or Worts Construction Perm, . ._.!:-__ Board of Health _ DATE............................. ------------------------_---------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS /9J J U o • f vjkv Ol r• . Y A ` Jr 20 pot- ~~ 2 ES FrZ vE {* .�.?>Y' jar L,O i'i•'d5•C�e7 i ! � LioCa prT S11-L fL-E.K Ff�T 4eoV,6 PO.dD PLOT PZAIV LOCA7"/O!v SCALD .._DLJT� 8 =76 — PLAN 2EFL-�eENC4 : Ii'ElN6 GAT J4 As 6�VO,wn✓ !n/ PG 4A/.600,- 272 r„Pq`+4e '.1F��4d PAGE SO: ✓�. .,... yn gip. I NEQESY C,6V '/FYl'T,4A T 7'/�E EXIST /,,VG FOUNDA T/ON LOC.417"1On/ /S COOZE wq 45 6NIOWAI AND pa CO,,t/FOL� JK�/7N 754E - / 1 SU LD NG S�T E..qI1f,E'4-4MEitl7, OF T7-OWN O � - SZ"•At3L E B GfJ/GLOM/ .` yA/�'M.,OcrT3/f'Y�QT MA,