Loading...
HomeMy WebLinkAbout0010 BELDAN LANE - Health 0 BELDAN LANE, CENTERVILLE A= i UPC 12634 No.2`R ,�;,e HASTING119 pN. -.:..._.�.......�...r ,�...._..__ ,�....,.. ...._. .. ..y.a. ....�........ tee,.. ,� - - Commonwealth of Massochusetts Executive Office of Environmental Affairs John Grad Department o� D.E.P. Title v Septic Inspector P.O. Box 2119 ' Environmental Protection Teaticket, MA 02536 (508) 564-6813 VMI&m F.Weld Trudy Coxe 8ecnl.,Y.EOEA David B. Struhs r' "14 Cormm�wionet SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMPART ACERTIFICATION � � Property Address: ,� tC��.� �-Et'(�` � ,(�e��Q Address of Owner: ,,� Date of Inspection: (if different) t 5 221a� Name of Inspector: Company Name, Address and Telephone Number: Ile CERTIFICATION STATEMENT I certify that.I have personally inspected the sewage disposal system at this address and that the information reported below rs1rue, 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: �sses - Conditionally Passes Needs.Further Ev uation By the local Approving Authority Fails ' S1Zz Inspector's Signature: Date: � CI 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 cope_ sell; 10 tnr buyer, if applicable and the approving authority. INSPECTION SUMMARY: Chec" , C, or D: Ai. SYSTEM PASSES; �� not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303, Any failure criteria not evaluated are indicated below. Bi SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or rtepiair, passes inspection. , Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. 1("not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, 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. lzevised 8/15/95) One Wltnter Street • Boston,Massachusetts 02108 • FAX(617),U&1049 • Telsphone(617)2924M P.J Pnnted on Qocichd Pow SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 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] FURTHER EVALUATION 15 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. 1) 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 ENVIRONNEN'T: ine s%s!pm nay a Sept iL tdnh anu bun dbwrption syitrn, snd ii fee', iG a s ilacc Lvatc, sL;p jn'ruu:ar) tv i surface water supply. The s�s!eo ha, 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 thet the well is. free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to.O Less than 5 ppm D) SYSTEM FAILS: 1 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 necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the.ground or surface waters due to an overloaded or clogged 5A5 or cesspool. (revised 8/15/95) Z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: \^ Owner: Date of Inspection: D)SYSTEM FAILS (continued): 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 flew. _ 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 LARGE SYSTEM FAILS: The following-criteria apply to large systems in addition to the criteria above: The design floe• of system is 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 II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6/15/95) 3 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION, FORM PART B CHECKLIST Property Address: Owner: Date of Ins p ett k 5�Zz1G1V Check if the following have been done: gimping information was requested of the owner, occupant, and Board of Health. one 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. __� a facility or dwelling was inspected for signs of sewage back-up. _L�-fhe system does not receive non-sanitary or industrial waste flow L-I'te site was inspected for signs of breakout. III 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. `- he 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 faciht, o.. ^4 ^-c,.mantc if diNP/Pnt frnm owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of InspecN n C FLOW CONDITIONS RESIDENTIAL Design flow: )��Qallons Number of bedrooms: Number of current residents: Garbage grinder (yes or no):Zi�j Laundry connected to syste (yes or no): 'IS Seasonal use (yes or no). Z Water meter readings, if avai able: Last date of occupancy:-Ma' COMM ERCIAUINDUSTRIAL:(A I \ 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 RE2,RDS and so rceof infor anon: System pumped as pan of inspection: (yes or no)_ If yes, volume primped gallons , Reason for pumping: TYPE OF STEM Septic tank/distribution box/so.il 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: t I U Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr : 10 \dQ[\ �—�t,1L, Owner: Date of Inspection: �7`ZZ.1 Glp SEPTIC TANK: (locate on site plan) Depth below grade--L3'I Material of construction: _ oncrete _metal FRP—other(explain) Dimensions: Sludge depth: S't Distance from top Qf tJudge to bottom of outlet tee or baffle: a r i Scum thickness: Distance from top of scum to top of outlet tee or baffle: `t Distance from bottom of scum to bottom of outlet tee or baffle:—LL Comments: (recommendation for pumping, condition f inlet and outlet tees or les, cl pth of liquid level in relation to outlet invert, structural integri , evide ce of leakage, etc.) C?�\ C G{r C. C L GREASE TRAP:.CW (locate on site plan) Depth below grade: Material of construction: _concrete _metal _,FRP—other(explain) Dimensions: Scum thicknr». Distance from top of scum to top of outlet tee or baffle: Distance frorn bottom ni r gym t^ hottom of outlet tee or bahle 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.) (revised 8/.5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) p ����ICLf, Prorty Address:a � f - Owner: Date of Inspection: TIGHT OR HOLDING TAN (locate on site plan) Depth below grade: Material of construction: _concrete ,_metal _FRP,_,other(explain) Dimensions: Capacity: gallons Design flow: eallons/day Alarm level: 'Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:1e--� (locate on site plan) 1 d �� ` � ��,,11�� Von Depth of liquid level above outlet invert: U ��e�l��`\��""' �t Comments: (note ii evei and distri` rwn 0 r udl, e .d�rice of sulid-, carr)o:er, e%idence of leakage into or out of box, etc.) [�X PUMP CHAMBEt (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:. ` Q Owner: ction:�f. _ Date of InspeZ SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: �Q� P►� •. _ umber: leaching pits, n (`�� leaching chambers, num r._� leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: p� Com s: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etcJ �i 'J cS CESSPOOLS: �\(� (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 ground,.a:c-. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Dimensions:. Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 8 (revised B/15/95) V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: f� `���\ „ R Owner: Date of Inspection: uhzZ SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � B 44 �7 AC 75 bc ►�� DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: >C 6 3 (�C �- (revised 8/15/95) 9 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108(617)292-5500 i' TRUDY CORE Secretary DAVID B.STRUHS ARGEO PAUL CELLUCCI Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � R PARTA CERTIFICATION i Property Address: #10 Beldan Lane,Centerville,MA Name of owner: Richard Pears04-4XV,1 Date of Inspection: 7/14/00 Address of owner: Same y to Z Name of Inspector:(Please Print) Mr.Carmen E.Shav lk10 6' F�� 0 I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) �oFs�'- �(J Company Name: CARmENE. SHAY-Environmental Services. Inc. Mailing Address: 34 Thatchers Lane,East Falmouth,MA 02536i Telephone Number:508-548-0796 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: XX Passes OFAp Conditionally Passes Needs Further Evaluation By the Local Approving Authority CARME s� E. Fails v Inspector's Signature: Date: 7/14/00 FS►N5 " f;e'w The System Inspector shall submit a co of this inspection report to the Approving Authority Board of Health or DEP within thirt 30da s of Y P PY P p PP 9 Y( ) Y( ) Y 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 or-Environmental'Protection.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 Certification of this septic system is for the inspection performed of the system on this date only and implies no warranty of future performance under different loadings. a revised 9/2/98 Pagel of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Beldan Lane,Centerville, MA Owner: Mr.Richard Pearson Date of Inspection: 7/14100 INSPECTION SUMMARY: Check A,B.C,01 D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate 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,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or ex-filtration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 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 wilt pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping-more than four times a year-due to broken or abstracted pipe(s).The system will pass inspection if(with approval of the Board of Health); broken pipe(s)are replaced obstruction is removed revised 9/2/98 page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Beldan Lane,Centerville, MA Owner: Mr.Richard Pearson Date of Inspection: 7/14/00 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE HITH310 CMR 15.303 11Kb)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 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(MS)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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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.Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Beldan Lane,Centerville, MA Owner: Mr.Richard Pearson Date of Inspection: 7/14/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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 necessary to correct the failure Yes No Backup of sewage into the facility or system components 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 less than 112 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. E. LARGE SYSTEM FAILS: 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: 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: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for further information. revised 9/2/98 page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTB CHECKLIST Property Address: 10 Beldan Lane,Centerville, MA Owner: Mr.Richard Pearson Date of Inspection: 7114/00 Check if the following have been done:You must indicate either"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 _ None 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. X _ As built plans have been obtained and examined.Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ 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.The size and location of the Soil Absorption System on-the site has be determined based on: X _ Existing information. For example. Plan at B.0. H. X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)(15.302(3)(b) X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal S revised 9/2/98 page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC SYSTEM INFORMATION Property Address: 10 Beldan Lane,Centerville, MA Owner: Mr.Richard Pearson Date of Inspection: 7114/00 FLOW CONDITIONS RESIDENTTAL: Design flow: 110_g.p.d./bedroom. Number of bedrooms(design): 3 Number of bedrooms(actual): 3 Total DESIGN flow 330 pad Number of current residents: 1 Garbage grinder(yes or no): No Laundry(separate system) (yes or no): No ; If yes,separate inspection required Laundry system inspected(yes or no) N/A Seasonal use(yes or no): No Water meter readings, if available(last two year's usage(gpd): Sump Pump(yes or no): No Last date of occupancy: Currently Unoccupied COMMERCIALANDUSTRIAL: Type of establishment: Design flow: gpdd(Based on 15.203) Basis of design flow: 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: PUMPING RECORDS and source of information:_ No Pumnine Records on File System pumped as part of inspection:(yes or no) No If yes,volume pumped: gallons 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information:Early 1980's 18 to 20 Years-per Owner&BOH Records Sewage odors detected when arriving at the site:(yes or no) No revised 9/2/98 page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC SYSTEM INFORMATION (continued) Property Address: 10 Beldan Lane,Centerville, MA Owner: Mr.Richard Pearson Date of Inspection: 7/14/00 BUILDING SEWER: (Locate on site plan) Depth below grade: 18 inches Material of construction XX cast iron 40 PVC other(explain) Distance from private water supply well or suction line 26' Diameter 4" Comments:(condition of joints,venting,evidence of leakage,etc.) Building sewer line appeared to be in good condition with no obvious signs of cracks or other problems. SEPTIC TANK: X (locate on site plan) Depth below grade: 18 inches 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/No) Dimensions: 5'wide by 8 feet long and 5 feet deep (1,000 gallon) Sludge depth: 4.5' Distance from top of sludge to bottom of outlet tee or baffle: 2.5' Scum thickness: 1/2" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 16.5" How dimensions were determined: Measured 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.) Structural integrity of tank is good with no notable cracks or leaks(Used mirror and Light) No evidence of water infiltrati exfiltration. Inlet&Outlet Tees in good condition Liquid level equal to outlet invert GREASE TRAP: N/A (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: (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.) revised 9/2/98 page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC SYSTEM INFORMATION (continued) Property Address: 10 Beldan Lane,Centerville, MA Owner: Mr.Richard Pearson Date of Inspection: 7/14100 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or 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 Alarm level: Alarm in working order:Yes_No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: No D-Box Found Comments: (note-if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.). PUMP CHAMBER: N/A (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.) revised 9/2/98 page 8 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION S ECTION FORM PART C SYSTEM INFORMATION (continued) perty Address: 10 Beldan Lane,Centerville, MA ner: Mr.Richard Pearson to of Inspection: 7/14/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: leaching pits,number: 1 leaching chambers,number:_ leaching galleries,number:_ leaching trenches, number,length: leaching fields,number,dimensions: Comprised of stone and plastic flow diffusers. overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) No sign of hydraulic failure Ponding or stressed vegetation Top of Pit is 3.0 feet below grade Pit is 6'diam x 6'deep. Pit is constructed of ore-caste cement. Recommend Riser for Pit Probed Stone for evidence of hydraulic failure. No evidence noted CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of-vegetation,etc.) PRIVY: N/A (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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC SYSTEM INFORMATION (continued) Property Address:10 Beldan Lane,Centerville, MA Owner: Mr.Richard Pearson Swing Ties: Date of Inspection: 7/14/00 g SKETCH OF SEWAGE DISPOSAL SYSTEM: A- Tank In-32' include ties to at least two permanent reference landmarks or benchmarks B- Tank In-20' locate all wells within 100'(Locate where public water supply comes into house) A- Tank Out-25' B- Tank Out -248' A- Leaching Pit-44.5' B-Leaching Pit-62' Leaching Pit Septic Tank Deck A B Exist. 3 Bedroom House Driveway BELDAN LANE revised 9/2/98 page 10 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORI PARTC SYSTEM INFORMATION (continued) Property Address: 10 Beldan Lane,Centerville, MA Owner: Mr.Richard Pearson Date of Inspection: 7114/00 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth:Shallow___Moderate Deep SITE EXAM Slope Surface water X Check Cellar X Shallow wells Estimated Depth to Groundwater 20'+ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) X Determined from local conditions _Checked with local Board of health Checked FEMA Maps Checked pumping records X Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) Bottom of SAS was determined to be approximately 9 feet below grade. Based on the USGS Quadrangle the depth to groundwater is approximately 20 feet. revised 9/2/98 page 11 of 11 p �1� r LOCATION SEWAGE PERMIT NO. 40?- VILLAGE -m C3 C 6V 7--i-Ai-11, /, INSTALLER'S NAME R ADDRESS d U I L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED S� s-4-41 Raw 5� THE COMMONWEALTH OF-MASSACHUSETTS BOARD OF HEALTH 0 F....-�*XWXZJ7 ....................................... Appliration for 11hiptial Marks Tomitrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .................... 4...... .... .e- .................................................................... Location-Address i7 6 or Lot No,::;g 6 ----- ------- ...... ............. ...................... ......................... caner Address ........................... 7 .......... . �•--- . ............................................................................... Installer Address Type of Building Size Lot.. ...Sq. feet Dwelling—No. of Bedrooms-.......3...............................Expansion Attic Garbage Grinder (No) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 04 Other fixtures ........................................................................................ ............................................................. Design Flow.........//.&.......................gallons per person per day. Total 6ily flow____ .4?_..........................gallons. 9 Septic Tank—Liquid'capacity-/jOGD.gallons Length________________ Width_____..__.____._ Diameter________-______- Depth____.___.___._-. Disposal Trench—No..................... Width__._ __._.._._._.. Total Length..___.__ ... Total leaching area sq ft. Seepage Pit No-----------/---------- Diameter..../®----- Depth below inlet..... .... Total leaching area............ ....sq. f t. Other Distribution box Dosing tank 0.............. Percolation Test Results Performed by......2�/ /,'C k.........4... ........ Date...M-;-`/"Y­­ Test Pit No. I.....4-7-------minutes per inch Depth of Test Pit...../_3....... Depth to ground water____0............... Test Pit No. 2................minutes per inch Depth of Test Pit.____._..______.____ Depth to ground water.___._.____.___.__.___.- ............../ ......Z-----------------------------------------------7 ---------- ......... .. ......0 i� V" ,0 Description of Soil.......0....../....................c4nl....tl e��(.zz_ 11.......................... .. ... .............fm........ pL ;r'4_1. .................................................................................................... ------------- ................ ------------------------- --------............................... ............................:...................................................................................... 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 TLME 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the boa3A of health. . / f�,�` Signed. ............................... 7/ ate Application Approved By..., .................................. .............. Date Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... C) Date PermitNo......................................................... Issued-------3..............P............................. Date THE COMMONWE•ACTH OF—MASSACHUSETTS BOARD OF HEALTH .................oF... �.�! 4%.-....................................... , Appliration for Uigpaaal Works Tomitrur#ion jhrwit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. l �-/�' i-/�✓ !�! -` =.r^-t �_.0 :t !c.f - � '.._.. !/ ...f.:�.! e"'.' Ir!.v1,e........................... - 4 pwner Address ....................... Installer Address ,s d Type of Building Size Lot.e!_. c.•�_----0....Sq. feet U Dwelling—No. of Bedrooms.......: ...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ........................... No. of persons............................ Showers (/ ) — Cafeteria ( ) dOther fixtures . ---------------------------------------------------------------------------------- W Design Flow......... .......................gallons per person per day. Total daily flow....51.0 ...............gallons. WSeptic Tank—Liquid capacity/t).O.O.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ................... Width.................... Total Length......_...._... Total leaching area...... _._ .. ._Sq. ft. Seepage Pit No........... Diameter....��_.._...... Depth below inlet....l ............ Total leaching area.. _..sq. ft. Z Other Distribution box ( ) Dosing tank ) '-' Percolation Test Results Performed b ..... AP Date._ Ao. � ' A, a_ ••°•----------- ------------ Test Pit No. 1....�.......minutes per inch Depth of Test Pit.... �7.....__.. Depth to ground water....Q............... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.........:.......... Depth to ground water........................ a O Description of Soil .... .. ...`...... � t?A°►... ' 5✓ ........... ................ .f 4 It•Ir9�4- ... �- V ........................... ••...�...lr� t .... s,a�,: ;'"'-�c��........ 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 T*I p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the boar of health. Signed ._� •- `�.e:*�._.., . �°� ,�-�� Application Approved ate ---------•--!y -•------ ----------------------- Date Application Disapproved for the.following reasons-----------------------------------------------------------------------------•-------- ......................... ..------•-•----------•-----------------------------------------------•----------------._.....••••--••••-- Date PermitNo......................................................... Issued------------------------•-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ti OF........... . (Intifirab laf Tautpliattrr THIS IS TO—CERTIFY, That he Individual Sewage Disposal System constructed (1'1) or Repaired ( ) by....._... ....:.!::...... - - '.9 '!`':. -•-•------•------------•----.._.. --------------------------------------------- --------- / Installer ...r-^"' l / �A f •....... has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._ ".J , 6.............. dated_......................._..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 13hip sat �r Cn�rtt # ttr uoltt �ernti# Permission is hereby granted-... - .? r!!1?C " ---------------------•.- to Construct ( or Repair ( ) an Individual Seisposal System- wag at No................. - ......-d ,Z�-, r!' ---1--...... = Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... . ......:_................................................................................................. Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS E �r it ,�sin ,r._a — _. t,•. Ay . r !f «r �r�,�Y r r.�r t�s4 •�. _ 9 a [• �_� ��i•Sf+ q fCoyp//O�% ^ s'41 ,v ,tt"c..slak¢� �^)? ® }_•��l - V Y�1._'. C./���I/V..�/iI'/9 'a-'T II N� Iti p to P " / 1 ! J e�t� . t �"Aaw, /�s.•t _ �g v F'y=i a Y A 1 '1.�� C, •, r' _ SL'PTi C... ,�rl! (.4 / s, r �l'S� i2. "�' r. 4`3(a^t r«� r�' _ „�• � +r t.at 'yt. IN 0 ji1 + Y �..Al' 1. Y t3?x a! `•ri t� .v E £tom �.�*����«��+"�> t �rJ• a` t , s'' �J c 7 + yT,eN7 ft'+i �} �� r �i, f / /� /�/}—//�]� �.Gp� ., .. - (\/��� •j i '. •A •l�'G7`s 4• f9f 4� t fFprizr' k �...s.F O P. ' Pn—,S' Y• . �( t� \\ No.2216 �6 ,rr IST ,i 1F t YaaM s rvrf`;'Ltx S+ Fos A jONAvv ` "LEGEND� — CERTIFIED PLAT : ., PL �' � � INELEVATIONS�®� ELEVATION ®no t�36'M CONTOUR = - ® - — - 2-0 T i 7 _UAre$ pq SPOT ELEVATION t;3M1;6`-60POT0�1R IJ t,4 j ter"�, IN ���,09YED - BOARD OF HEALTH _ AGENT SCAL E — 4O DATE :.3�' !/ �i'®`' _ _ _ s J 'RE®6;E. ENGINEERIN CO. lAlG' __ .. - CLIENT ._. I CERTIFY THAT THE PROPOSED h r` E,GIS�'ERE[� REGISTERED j J0B NO. 7-90 6,9 BUILDING SHORN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LADS S, D R. B Y !} .f} 'n 1.PN®INEER [ SURVEYORS) OF BARNSTABLE , MASS. .NC` fVlAlt� ST 712 MAIN ^>T CH. BY 'R. - _ .__ / rt' ,4AR.M.OUTH MASS. HYANN•15 .MASS Z �I /���� � � — '� ,y. ., , • TI- OF _- DdTE REG. LAND URVEYOR ' • �- _,. .. .,..:-,. -' .:,..-.Ka.... .:«.s•acv.-h;-z. g. ..i'=ems._-..•w ;'--,;'"a,+s�•*:p,> .:_ :::•�s:.>}ry -S`e4-""*+.,..'..,�rf^,.-•.•:� ��•x•ti *'„K..."✓:?t..-:=;� q. .y�.: vb,ay - .:,Ry" -''6,_. -r k'.K'. :`i4. .. -.+r'" _.�:tkl - -^.�.-t. .+sr.. .:'. a>,.- ...•y.,:..�':E�.�'•....t'-.... .. .."�.•?i->�"' ....�.,. _ .t". ..^,..ta c.a.K : s•.: @•.M ".�s.- '�',. §.•W..x,:x. .�'�''�a, -._.',xi1�'*tt•. _gym, .k..^. .sue :.� "� �. 'rs'L. �'° .w+-..�•"L s ••-«R h c- ..{•;. 1's• .,. .. „+,�. _^t�, Y si .� -..<� d. •' -, i, ,.may,r.ry' ,r.^cam =..,�,""... .:.`r :.'r*-+:r*... -. .,.-�+.-sr.. ...�E1- ,.- -,'�?x-•..�,ti, :.a •`�2' i:-• .. ....r. - .... -w...,:. ._.__. •�,rx5., �.+R,.. _.., .� ;.r-..a •.,. ,.,. ri.".., � raASw .a+r. �:r may'. 7; .F �.i r� s tk. ,:. r:-.-pk.. .-,,. a r""ki: ...:i ..�-s�,.: .,- .a, �. .. ..._ 'e$i$. �.' '�..>a fir *k�_.a.. a,.r... .,., a`:. .. i�-:,. -i4.,, e,�T Stc '�`.a-.:,+� I� ,tea try�-e)�•+ ./'�T p-.�•,TN.sy,`� .�F ''.. ..:. ... >, r 2 r 'r,>: -.. K..F'a`S ... .y. .�y-.�.. _'rl ......_ _ ._ i-,..°,.. i`E r ,_R'. �`!n 3�,.:1.. -r�.a<G.�.��!'� �� ,p `"`}G_ e�6 � �,y,,•«.r.s. %'H z�,�-•�'',..,F. ,. f ._:; a dt...,.:w ,:e.... � r .-.a;.., ._ .., ..a, ,- -...�: .n?. 'r,,.-a ,:6 K' � _ ...v'�.`�•. _,.,„t�,'�S r-., >.� _ :ti. -,� u �� .�.,:z y��4,'� -^`r'Kf'r 1 g Yt X• :ar.- . E'a'F .L' .c.•...�{r•I'r� (_.oT•'/9/ ' SJy. 4I1.. .'' ��X�, �''�,:'Y _3'; ...,. .F.,m ��"4. .. .- �.� .. .. "^� �_.+'?'- ri. .T7..._" `r� "Y:�YT�� �p.y-.V-u'•p�f= /�T�9.�:� ,G9�i�,t �/'9�,� /�'''�.Os'°a.L:Ci�•V� �;.�: ,y �+ x 'z.- } s _ -'.-"--F"*t-r5�,.•, .-�....:....,. :� __.�• st..>a--n�'� ;,'^�+-,.w '�+,-+^. i�P.;`.F ,f"'.. �f <� - .,3- = S •�> ti.r.�`, v. •rr"'2__ .,... ',. ,:>..'.--.;.t, ;� .n.y+-+l-•ra>. ,`r• �'. .�.s _ - ,:.' - t...' :� �.fir_•ti.. „._ �t.�ja:'->a c'�Fk..sQ„ . .`�« ^..x _�>* _.., ,.. C ^R.t�-��a� ��� .:��A�L��' >6- C A--, i`.'W -Yy�.:1,.::w _�: .. .lata4�] '�•,S.e �'r,"."�SAr t..°.'1k.:Y... .fW��. .'FF.,a.4 M1•.yA�s-�. � .� s`3 «.."i Y...fa_'i •� R: �{J - 4.:. �..,�e .� ..,.u.. .�- ,-r '. .°#..... .'. +s3. _fy, i} Cr._d� a,.. � .., el•...p+.., .� ...::.�•'. ,�.- ' 1 t.- s ,_ _., , �qq„= ar..;:� { �:�,"'tx '• -, t. 5,,�,r< �-*'.` .,,ar. `>� .`' "i�'EAl�y> �A.�?'/Y?�,%1/�G'0'l� �-� YA"L �E :s' • .. " �P Cam.� r...�r _ .�+ ,�=,�`S®TiG� ���1� a ... °•a .f�F1D sNi� .. i..A^.,f�per.,,�..c f r�pr� _ ®: �,_ ��_ �.•x .r r j 'fir '� _ �" �.�� � % ����� 4 ,. •� , .. .. _ _ • L k. ,� ,. r _ ®� CU 6lER CLEAN SAIV O ° 77 r, I RO la/ API PE o e, OF 0 a o o o. N7/iV.l�/TGi/ - CA4 ' 0 0 0 0�0 0 0 0 o o o I� n a4, WASHED 5701YE T'�� D/ST, ® n 0 0 0l o o c o 0 0 0 o n u q ®O �} k 0 0 _I a o 0 0 0 • i 4-;I L _ ss�� . . � e p 2� a a oEFFECT7 6�� o� ° o�— 3 v 0 o DEPT!•/ 0 0 0 o e o 0 WASHED STONE I o 0 o o o o 0 o a p 0 4 9 v 0 0 0 0 0 0 o m�; PREC45 7 —PAGE v P o c 0 0 of o o' a o 0 o a ® fl P17 OR EQU/V IAlVCT7' ELEVAT/ON5 /MV,EIRT AT ffU/LD/A/G FT. �C---G 1 INLET SEPTIC TAINK ��0 �FT L� FT. L�/Ally'/. C(SEE Tf1dULAT)OW� OL/7.2ZT SEPT/C 7AIVX �°5- FY. /INLET V157R145/3'/ON BOX PT. SHCTIO/V aF GROuNU WATER TA®.LE 0u7L97-o/57-R1®9T14)/v BOX FT FT t+�l�I�E ®®c�'d�®c�A d. l�T�/�1 'TA���.d�T�®iN LL EACHII V �0/7' PT. SCALE %4 " _ !°_ ® DIMENSION A-- D,E5/GIN CR I TER IA ®/M--IV 51 O Al 0— F•T. MUM&ER OF 46EDROOMS _ DhVIENS/;ON C T. GAR®AGED/SPO.SALuN/T__-- 50✓L_ L®C7 - TOTAL SOIL TEST Atl SOIL 7EST#2 NumaER OF a::E4GHlM6: !�/rs_ / �^F'El/� �-EL�a! /.SATE OF- S0/L. TEST I S,DE L�AcH/NG PEK P/T-�� . —SQ FT. I�ESU�.T S fss//T/VESSED �Y ®wTTU/w L—=ACH/NC� PAR P/T sQ• T. S��$ Pdt`NC0,LA7-/0" RA-ro ,'/ 0©-�_� M/N.1/ldCH TQTAL LEACH//YCr Al/�EA SQ• FT / =�CBA� /CN /SATE �4` `' MI�v.j/NCH RESER!/E LEACH/NG AREA FT. LT �OU/VT��'cO riYANN/5 /'SAS:: �.'�. �'ARA✓ls/7 0dI /e� y,yr3?EFL:- Ia/ fs,�+�rss rs A• ,f, C� GI?®u/ylS��tid�7" R A. �L Wit/ JOB /vc. -SHEET o`