HomeMy WebLinkAbout0007 BAYBERRY LANE - Health 7 Bayberry Lane,Centerville
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UPC 12534
No. 2-153LOR ;'-tOi4A
HASTINGS, MN
Commonweafth of Massachusetts
Executive Office of Environmental Affairs
Department of P
Environmental Protection
Mllulaer F.WSW < r Thrdr Cote ::
Atges F11ul CWuoal DwW B.-Stivhe
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SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTIFICATLON
7 Bayberry Lane
Properly Address: Cent e�jv 1/�, Address of Owner. T h o r a Sharp
Date of Inspection: �j;C�5 —� (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
CERTMCA77ON STATEMENT
I certify that I haw 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 aewaBe disposal systems. The system:
P/asses
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspeotor's Signature: !lo y ( 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:
Al PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 16.303.
Arp 611ue criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
Ons or mo m,re system components seed to be replaced or repaired. The syste upon completion of the replacement or repair,posses
Indicate ,no,or not determined(Y, N, or ND). Describe basis of determination is all instances. If"not determined",explain wby root)
The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or e:Sltration,.or tank failure is
imminent. The system will peas inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
by the Board of Health.
(re'is 11/03/9S) 1
One VAnter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)2 -5=
i�Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oonNnued)
propotyAddrem 7 Bayberry Lane Centerville
OwnsDa"of Inspadow Thor"- Sharp
21 SYSTEM CONDITIONALLY PASSES(continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obsttvdad pipe(a)
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
C1 FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
exist which require ftuther evaluation by the Board of Health in order to determine if the system is failing to protect the
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.
9) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES 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 leas than 100 feet but 50 feet or more hom a private water
supply well,ualew 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.
S) OTHER
(rwiasd 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
PevpestyAddress: 7 Bayberry Lane Centerville
wnest ,ho$ rp
Do"of Ioapaotioo:
DI FAHA:
lave dawrmined 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 water 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 ceespool.
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 tunes 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 analysed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARD SYSTEM FAILS:
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 Well Protection Area(IWPA)or a mapped Zone U of a public
water supply well)
The or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
to of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information►•.
3
(revised 11/03/95)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
pf,sputsAddmm 7 Bayberry Lane Centerville
owoen �i ho r a S a rp
Dab of hmpesdow �'•-� —
cls.cit it th. h been done:
`' ave information was requested of the owner,occupant,and Board of Health.
_alone of the system components have been pumped for at least two weeks and the system has been receiving normal Sow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
�N built plans have been obtained and examined. Note if they are not available with N/A.
facility or dwelling was inspected for signs of sewage back-up.
_The system does not receive non-sanitary or industrial waste flow
site was inspected for signs of breakout.
1/A11 system components,excluding the Soil Absorption System,have been located on the site.
_v4he septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of bailles or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
I/The site 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
f -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7 Bayberry Lane Centerville
owner. Thora Sharp
Date of Iospeotim 8—2 8—9 6
FLOW CONDITIONS
RESIDENTIAtt
Desip Lw:
Number of bedroom.:3
Number of eerre",esid.nts:Garbage grinds Vex or no): E O
Laundry connected to system(yes or no): 7
Seasonal we(yes or no): y
Water meter readings,if available: 19 9 A —
Let data of ooaupancy:�
COMMERCL LANDUSTwAL:
Type of establishment:
Design flow: p1lonalday
Cranes trap present:,(yes or no)_,
Industrial Waste Holding Tank present: (Yea or no)_
Non.witary waste discharged to the Title 6 system: (yea or no)_
Water meter readings,if available:
Last date of oocupaucT
OT9ER.(Describe)
Lad date of occupancy:_
GENERAL INFORMATION
PUMPING RECORDS and-sourog
�jawso�f
4f information:
Systempupinspection: (yes or no)_
If yes,volume pumped: ¢allons
Reason for pumping:
TYPB OF SYSTEM
Septic tankMbtrtbation bm*il absorption system
cesspool
C;Z O cesspool
Privy
Shared syswm(yes or no) (if yes,attach previous inspection records,if&AY)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: 1 ('
&W&V odors detected when arriving at the site: (_yes or no) /v 0
5
(revised 11/03/95)
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 Bayberry Lane Centervile
Owner. Thora Sharp
Date of Inspection:
SEMZt*
(loaf.
� _
Matern:_concrete_metal_FRP—Other(explain)
Dimensions:
Shdge depth:
Distance 5om top sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance$om to of earn to top of outlet tee or baffle:
Distance 6om m of scum to bottom of outlet tee or baffle:
Comments:
(rsconunendation pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet insert,structural integrity,
evidence of
CRUSE _
(bats on site p )
Depth below
Material of _concrete_metal_FRP_other(eaplm)
Dimensions:
Scum thickness:
Distance i3om to of scum to top of outlet tee or baffle:
Distance 5om of scum to bottom of outlet tee or baffle:
Comments:
(recommendation or pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,sbucdull icy,
evidence of ,etc.)
(revised 11/03/95) 6
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropettyAddress: 7 Bayberry Lane Centerville
Owsmr. Thora harp
Date of%weaum —�$—�j' G
TI OR HOLDING TANK.-_
(boats sits plan)
Depth Pads:
Material construction ooncrste_metal_FRP otheAsuplain)
G gallons
Design eallonslday
Alarm
( of inlet tee,condition of alarm and float switches,etc.)
D ON BOX-_
(boats an ON
Depth of level above outlet invert: O
Comments:
(note if and distribution is equal,evidence of solids carryover,evidence of leakage into or out of boa,etc.)
PUMP CR II—
(locate an plan)
Pumps working order(yes or no) oft.)
(note of pump chamber,condition of pumps and appurtenances,e
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PrepatyAddrem 7 Bayberry Lane Centerville
Owns. Thora -S arp
Date of IaspecUom
90EL AMORPTION SYSTEM(SAS)..
(locate on site plan.it poesible;many ion not required,but may be approximated by non-intnwkve methods)
It not determined to be present,szplain:
leaching pits,number:
hwhinF chamber,,number:_
leaching galleries,number.
leaching tenches,number,length:
lesching fields,number,dimensions:
overflow cesspool,number:
Comments:-(noteconditio n of soil,signs of hydraulic fail{j�r� level ponding,condition of vegetation,etc.)
1 �R G� G IJ S I � �L7 .L L Y •� G _ ��
d
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: °7
Depth of solids layer. G -/b
Depth of scum layer: I _
Dimensions of cwpool: A 4 '
Materials of construction: d3 I e c X,.5 C ► pi
Indication of groundwater: 1 6` )=7
inflow(cesspool must be pumped as part of inspection) Y S
1 / GC
ems:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
tofssite plan)
of construction: Dimensions:
olids:
(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 11/03/95) S
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
7Addmm 7 Bayberry Lane Centerville
Owner. r 1bora Sharp
Date of Inapeotioo:
SEMB OF SEWAGE DISPOSAL SYSTEM:
include ties to at Mast two permanent references kaadmark*or benchmark*
locate all wells within 100'
Cf`" I�
V
� 1
' 3
i
DEPTH TO GROUNDWATER
Depth to groundwater_L:E _fest D
method of&wmination or approximation:
(revised 11/03/95) 9
No.(75i.............. .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at,
Address
taller Address
Otherfixtures ..................................................................--------------............. ......-------- ---.--------
Dcaigo Flow... ---_------------_----------gallons per person per day. Total daily 8mv-----.--.-_------gallons.
Septic Tank—Liquid capacity------------gallons Length---------------- Widbb------ Diameter---'-' Depth--- ------------
Disposal Trench—No -------------------- Width-------- Iotal Length-------------------- Total leaching area---- --------------.sq. ft.
'Seepage Pit Nu ----------.-------- .. Depth below inlet.................... Total leaching area------- ------- ..vg.it.
Other Distribution box ( ) Dosing tank ( )
~~ Percolation Test Results Performed by--------------------- -------------- ---------.........--- ...... Date...............-----------------'
- Teo Pb No. l----_------minutes per inch Depth of Test Pit... -_ ------- Depth to ground water-------'
Tos Pit No per inch Depth of Test Pit.............. Depth to ground wutcr---.-----
. �� __-_'._-- ---------
----------
. ----------------------------------------------------
--_-'_'_'-._-_--__--
`� Dcacr�t�nnofSo�----_-.----_'_-----.-_---__--__--'_----____--------------- ------------ ----------------
----'-'---'''----''---'- ...........................----------- ...............................------------ --'--------
The undersigned agrees to install the aforcdeocribcd Individual Sewage Disposal System in accordance wi th
the provisions of Article }CI of the State Sanitary Code -The undersigned further ugrcco not to place the ayoueu in
operation until u Certificate of Compliance buo lu ucd by the board �
��.
Date
`
....... ...............� ---------_------_' �
Date
. �
Date
Date
06
No.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
..........OF&M.-&I. ........... ------------------..............................
Appliration -for Dispviial Works Tonstrurtion Vrruift
Application is hereby made for a Permit to Construct or Repair '7an'-Individual Sewage Disposal
System at
e. .i ----------- ...... .. ........... ...... ............................................................
�calion-Z5 or Lot No.
cation ddress
Address
--- ----------- ?e ..................... ..................................................................................................
nstaller Address
Type of Building Size Lot............................Sq. -feet-
Dwelling No. of Bedrooms................................... ____.Ex ansion Attic Garbage_Grinder
-
Other—Type of Building ---------------------------- No. of persons.---------------------------- Showers a-
0.1 Cafet&i
Other fixtures ---------------------------------------------------------------------
----------------------------------------------- -- ---- ------- ------------
Design Flow............................................gallons pgr person per day., Total daily flow-L'......*_---------------------
'k� ....z,, .gallons.
Septic Tunk Liqtlid,cajkwit Length________________ Width.._......------- Dia eter---------------:Depth----------------
Disposal-Trench, Nb�_._
- ---------------- Width.. ----------- Total Length. ..............._.. Total 1e,Jching area--._. ----_. ._ ---sq. f t.
Seepage Pit No.................. Dianker-------------------- Depth bel'6w inlet------------------_ Total lQt-iiing area-_-_7------------sq. it.
Other Distribution box .Dosing-tank
Dosingtank
Percolation Test Results Performed by == ........................................................... Date----------------------- ---- ---------
Test Pit No. I................minutes per inch Depth,-.of Test-Pit_.-_.........._..___ Depth to ground water-_------------------
Test Pit No. 2----------------minutes per inch Depth of'T-est Pit:_:..__..........__. Depth to ground water__._--_____--______--_.........................................................................................................
0 Description of Soil.......................................................................................................................................................................
x
-------------------------------------------------------------------------------------------------------------- .........---------------------------------------------------------
U
------------------------------------------------------------------------------------------------------------- - ---------- -----I Z------ --- -- ------ ----------------
4 t=v�, ns�er " ii -S-0.
go !�--- -----------------
- ---------- .... ---- ------------------------------
U •
Na re of Repairs_or Uera A �*lwn applicabl ......... ----------------------
X21re-of Repairs
-.1 C .... ------- -
----
/Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the pfovisions 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 j)el5n)issued by the boar of he t *.-.%
...............
Date
ApplicationApproved By-------------------------------------------------------------------------------------------------- -----------------------------------------
Date
Application Disapproved for the fo!jpwing reasons:...
........................................................ ............ .......................................
............................................................................................ -------------------------------------------------------------------------_-*1......... ........
Date
r.
Permit No------------------------------- .......... ........ a Issued_.. ..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
It
. .................OF.............6,jc:j� .. ............... .......................
101TWrtifirate offflUNImpliana
THIS Ai0,&RT1F.Y hat the dividu Sewage Disposal System constructed or Repaired
. .........................An,--------_--- .................................................
y .............. lee
t-------- ---- -- -- ---- A at.............................. -------------------------------------------------
=------------------ ----1�---4��------------ t has been installed in ance with the prov4i ns of A d ;t!n: a c o r Ins f e State Sanitary Code as described in he
05 �_ -X '? -:� - Z/- 747
. ... ..TI'o Th
application for Disposal Works Construction Permit N ----------------J---------- dated................ ...............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A.WRANTEE THAT THE
SYSTEM WILL FUNCTION-SATISFACTORY.
DATE----------- iris---------- ......... pector....... ...................... ...... . ...........
THE COMMONWEALTH OF MASSACHUSETTS
41
BOARD '0 �_H E L H
.......... ...
....... ...&U/h..........0 F ........ .........................
N 0.�4)............ FEE..q.................
R-rupolial Mrkiijaillito. ul/lin ram,
Permission is hereby grant4�...4--- -- ... ---- ---ffA .............. ......................
y e'n-y'--1------------—
2or R 01 an Individual $ewage i4sD6Q, S s�
a air % -
to Construcr� 4 ret' _;__/1
................... ------ .......... .................at No--------- .....C ........
Street
/as s6"w'-n on the 4,pplication for Disposal Works Construction it No ated-----------------------------------------
%,it..No..
....... --- ----- -------
...................
7r Board of Health
DATE.......;Z- ---------------------------------------------...................
FORM 1255 H0813S & WARREN. 'INC.. PUBLISHERS
4
LOCATION : 5EW&C4E PERMIT MO,
1hJSTaLLER'S U&NlE ADDRESS
C-As Al
BUILDERS Q L VAF- ADDRESS
DATE PER"IT 15SUED
O ATE COMPLI W ACE ISSUED : -�a uJ
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