HomeMy WebLinkAbout0068 BELDAN LANE - Health 68 Beldan Lane, Centerville
A=189-031.001
Aff
UPC 12534
No.2-153LOR
HASTINGS,MN
� l
Commonwealth Of Massachusetts
Executive Office Of Environmental Affairs
Department Of Environmental Protection
TITLE 5
Official Inspection Form - Not For Voluntary Assessments
Subsurface Sewage Disposal System Form
Part A '
Certification
Property Address: 68 Beldan Ln.Centerville Ma.02632+
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
Name of Inspector(please print)Sean M.Jones#SI4522
Company Name: S.M.Jones Title V Septic Inspection 1 L
Mailing Address: 74 Beldan Ln. '1
Centerville Ma.02632
Telephone Number:508-778-4597
CERTIFICATION STATEMENT,
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system:
X Passes
Conditionally Passes
Needs further evaluation by the Local Approving Authority
Fails
Inspectors Signature Date: 07A u
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: f
****This report only describes conditions at the time of ins tian a d under the conditions of use at that
time.This inspection does not address how the systezui fi O'ns in-the•future-under the same or different
conditions of use.
Page 1
6 � ; d 16 t �
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(cowiNuED)
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B.System Conditionally Passes:N/A
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 the 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 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(coNtNum)
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
C.Further Evaluation is required by the Board of Health:N/A
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 310CAM 15.303(1)(b)that the
System functioning in a manner that protects the public health,safety and the environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
Surface water supplyor tributary.to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
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 '/2 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 cesspool or privy is within Zone 1 of a public well.
X Any portion of cesspool or privy is within 50 feet of a private water supply well.
X Any portion of 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 pp,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
X (Yes/No)The system fails.I have determined that one or more of the above 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:N/A
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:
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 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
CM15.304.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
Check if the following have been done.You must indicate`des"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 system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
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 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 tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
t
_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 Cis at issue approximation of
distance
Is unacceptable)[310 CMR 15.302(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
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 gad
Number of current residents:—I—.
Does residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no): no [if yes separate report required]
Laundry system inspected(yes or no): n/a
Seasonal use:(yes or no) no_
Water meter readings,if available(last 2 years usage(gpd):_2005+2006=204gnd
Sump pump'(yes or no): no
Last date of occupancy/use: current
COMMERCIAL/INDUSTRIAL:N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): bd
Basis of design flow(seats/persons/sgtetc.):
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
Source of information:
Was system pumped as part of the inspection(yes or no): no
If yes,volume pumped: gallons--How was this quantity pumped 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 the 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 informatiomori i ial system 1980+/-
Were sewerage odors detected when arriving at the site(yes or no): No
I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
BUILDING SEWER(locate on site plan)
Depth below grade: 2`
Materials of construction: cast iron_X_40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints were in good condition,no sign of leakage.Vented through roof
SEPTIC TANK: X (locate on site plan)
Depth below grade:_20"
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`6"X5`6"X4`10"= 1000 Gallons
Sludge depth: 10"
Distance from top of sludge to bottom of outlet tee or baffle: 3`
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle:_6"
Distance from bottom of scum to bottom of outlet tee or baffle: 11"
How were dimensions determined:Opened covers and took measurements
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
Septic tank should be cleaned in the near future,and then every 1-2 years to maintain systems useful lifespan. Water
level was at bottom of outlet invert.Tank was not leaking and outlet baffle was intact and in good condition.
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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,.liquid levels
As related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
TIGHT or HOLDING TANK: N/A (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:_X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
Leakage into or out of box,etc.):
Despite its age,the distribution box was in good condition,no rot holes and it was not leaking.There were no solids
carryover and no signs of past hydraulic overloading.Water level was at bottom of outlet.The cover was replaced at
time of inspection.
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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address: 68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X Leaching pits.Number:-
1-Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternitave system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Leach pit was located but not excavated,the stone surrounding the pit was found to be dry at the time of ins ecp tion.
Soil was also dry and the vegetation was normal.No signs of past failure.
CESSPOOLS: NIA (cesspools 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: 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.):
1
i
f
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
SITE EXAM
Slope XX
Surface water XX
Check cellar XX
Shallow wells
Estimated depth to ground water 20+_feet
Please indicate(check)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)
_X_Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
X Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
Groundwater elevation was determined by accessing the Town of Barnstable groundwater contour map.The
Barnstable Topography map has the property at 59.85'and the groundwater map shows water elevation at 20'
leaving a separation of more than 20'.
Also observing body of water located nearby ff uller Mill Pond)Property is situated high compared to edge of
water.
I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Beldan Ln.Centerville Ma.02632
-Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or.
Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building
i A14K
REAR OF HOUSE A-1=111V
8-1=31' it
B A.-2=1
B-2=35V'
D-BOX
" 3=19'Z
deck B-3=3W
L.P.. -
A.-4=32.'
1 B�=3T
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1NE Town of Barnstable
F 1p�
Regulatory Services
BARNSTABLE,
Thomas F. Geiler,Director
�$ 16 9 ��� Public Health Division
prED MA'S p
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 - Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a'particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
t�k ,
b commonwealth of Massachusetts
Exebutive Office of Environmental Affairs NECEO ` D
Department of DEC 7 1995
Environmental Protection HEALTHbEPT-Yi¢ t}
x TM 4FBARNSTABLE >', .
Willlam F.Weld
.'., Governor
Trudy Coxe
c SeertI EOEA is).� �Aa;
David S.Struhs
;? It Commissioner
}
i to ir..., ] , + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION ,
M�+Ov
Property Address: �� 3c,9�o_w �G-� .. Ge�-T. Address of Owner.�w-G G��
Date of Inspection: i -�' (If different) '
Name of Inspector.:2o SY, , S
Company Name, Address and Telephone Number:
� w
CERTIFICATION STATEMENT
`I certi ':that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate `
t t P ) P g P ) P
'� ':and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
a
.te maintenance of on-site/s/swage disposal systems. The system: t q t tt a4
/ r -rvryr , e rx, �xz^
rd��S ri` t Passesi , :itt1 tJ :.f., }+-;+•': : f 1 .:i r +� + is grits a 1Ya tg, r)t i �t
Conditionally Passes
r ^tt st it}rd�iet ?t l:l�s4 T e
y, 1 Needs Further Evaluation By the Local Approving Authority 9 t ° x
r�'�t ^} a"a':i,�'16pi P3 y.��;•'Fatls f ;:3'•i :" ':tt1 ;: r'';JW k';. t - r' , s ; '/:.' t,°J .+ v:"A ,t q.9 ,iv "1J39. -t! e.a' :.i4
'.t..,.`�._A/...� 'I - t• -�#.1i ;t.le5�,7VA i,+4tt z
pector's-signatur Date: e 6
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t�F' ',',The-System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
y� mspectio4.lfithe,system,is a shared system,o►,has a,design flow of.10,000 gpd or greater, the inspector and the syst�eT o vnei shalI submit
` ,at he report to the appropriawregional-officeof the Department of Environmentat,,Prptection. 3 .
The�ongrnaltshould be sent to the system owner and copies sent to the buyer, ii applicable and the approving au:hon,�
A -All
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� INSPECTION SUMMARY:.
140, }'] {{ , ir{s,f t:ifo h' + rkf lUi� : p ��`�,p�t�,�
�1� "r-z },s.r,� �.s:l,tl�f st4ia`'`.!, , ;s .t• ij�st,E s; ee.s t skti.
( Check A .B;C, or D ;v rt rcr�vttk.it, it) ?3�si C rt; r. :`ir s' n ,r a JJssnIT
a ,x
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+A 'SYSTEM.PASSES r�,,:,i1'!t�t vit it:+4!i k�'��c: =R,>l}� +,t;+ } ;. .. .�•'.,:�, . t '• ,
) T c$,7,13E! ,i,:,
s,. ty.:9ajteg
tan ,9�5 V} �# Srt;ist ti i ;u +•, m t r
vfi4 � o, ]s• have not.found any information wNch�indicates that the system violates any of the failure criteria as defined to 310 CMR 15 303 , ,
s hAny failure criteria not evaluated are indicated below.
y TFti "i7i�kti��E $ ,
B) SYSTEM,CONDITIONALLY PASSES
rb�r i, fq P" +. t` � 'y' �f A,`,i"t 9 t �tt 3d ssitiy,2r^ s�• t t v r- si $ d�,-'i, - - ,h Jt�Kr.r ti t# �•..Sit s a, f:d'Fr» , ': t. ,.., - d"AtiS t+f'; rt r tr Atilt
,One or more system components need.to be re laced or,repaired.,The system, upon completion of the replacement or repair, ,
i a• z y ,P P . e s+ rr 7�ta ,attiltts9�+z,�trtt`t � x ,
�ali t E� passes inspection. q , a y a
P� 4 Y }9f19 {PJ,' S a
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r;�Indicate es, no, or not determined (Y,,N,,or,NDM),Describe.basis of determination m all,instances..)If,",,,; ot determined�,ryexp1 16 why not) tl $
sre , Y �f
xThe septic tank is metal, cracked, structurally unsound, shows.substantial infiltrabon.or.exfiltration, ortankfailuremis S � �7
�; st i€i ct� f imminent t;The system=;will,pass,,inspection if the existing septic,tank,is replaced wi ;a.con forming septic tank as; k �` r
approved.by the Board"of Health.
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lrevised 8/35/951" ) � `AAr{
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tit` 'FtsGL+ 'L> a,j + `, • _ r •.' ,', .�!y fl:, ,
One Winter Street •. Boston,Massachusetts 02108 • FAX(617)U6.1049 • Telephone(617)292 SM , ,I {{ ;
Printed on Recycled Psper. , i 2 J r
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) ':
i'O1''h f
{property Address: &1dan� CU i`I W.
3s
wner:
fur
nt ,O f t�lt�S P 'P��
`1! Date of Inspection: 12-lR
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BJ SYSTEM CONDITIONALLY PASSES (continued)
#� y
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
F Board of Health): _*
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced r !f
^ � The system required pumping more than four times a year due to broken or obstructed pipe(s) }The'system will7pass.. t, k
ti inspection if(with approval of the Board of Health): !r )P( '; °>r: rFs �F"
a 5;i a ja= t rii
broken pipe(s) are replaced
� ` * s obstruction is removed K �, ��;
«�R ;1
d i°' G�f�t✓, �3�Eat t���s '..!,i, "t +-17.�. tlt .1 5- , ... . ,. •+ 1f"?( t 5�1 (i {!+�.» `,S'rxR�i 3 i '1��
e 5
��+�`�lt� X�Ed�14C,S�'�t?q ,tr'R t J S't f,'a l.ql;i +` t �' ' "'k%t.� t / '.. . <:t�'. - i' 1„rti, t�. i1t >L; .5 imf�:S.�lkt t.i 4�*'(2#•�-$sr�±S fkt�iii(
�.c����N ;
� itC] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: * + z,i' ''ifa
'Conditions exist which require further evaluation by the Board of Health in order to determine :f the system:is failing to protect the r .
4p public health, safety and the environment. " i',#;:: t`Y(s::xp t M ='
• SYSTEM WILL PASS UNLESS BOARD OF.HEALTH DETERMINES.THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
h WHICH WILL PROTECT T _ 9 i ..'R
HE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT " £+k� ,p �L
�a.rye ��L:::.p "` S-,.., ' .' •. <.., j : � ', .,?..r..?,� 1 •'' �,'`t`yT, `� "'` �.i1Et5S°1�#�'��'`�(t?,��'� +ZB>'�
Cesspool or privy is within 50 feet of a surface water
gmarsh. f ,f .
Cesspool or.privy is within feet of a bordering ve elated wetland or a salt
���}rt a .,t. rtl €:3It,)w'13'IA� s! .S`S4�q ,f�...✓;.� !.. �,, t. - -" t
? r 2)' SYSTEM WILL FAIL UNLESS'THE BOARD OF HEALTH (AND'PUBLIC•WATER1UPPLIER;iIF APPROPRIATE)iDEjERMINES,THAT
t j ,.THE SYSTEM IS FUNCTIONING IN.A MANNER THAT 'PROTECT'THE PUBLIC HEALTH.AND315AFETY AND T:
End IR01A1E1T. �w• ; t ,
2 o- '�t4 � r a f ": q
x ��. i ThP ��'stem nay a septic tanx anu soli absorptiun system and is within i0G (cet to a surface 'rti aker su'pirii or*tribJ�arj IO a ,
4 M£k 7'4
�y �x surface water supply. a Pirsif !
The systeni ha a septic tank and soil absorption system and is within a Zone I of,a public water supplyxwell N
The system has a septic tank and soil absoc tion s•stem and is within 50 feet of a rivate.water su I well:
) P ) P PP Y .
The system has a septic tank and soil absorpt ion:system and is less than 100 feet butF50 feet or more from a pnvate,waterS•
supply well,"unless a well water analysis for coliform bacteria and volatile organic compounds indicates that hebwelljSy
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or.less thaw.5/
i� tl� l l T«tJlliXl? i A'r'33
�yari ,+ ( S. 7�.., ::2•I! �S, a dE11A�E t! �jf%t a
Y . O� SYSTEM FAILS:
Ski
have determined that the system,violates=one or more of the following failure criteria as defined iri'.310 CMR`15 303 ��he�basis�
}d14,n .,fy; .<. ..� 4i1 Y t+' n.. 'f! "t
' for.this determination is identified below. The Board.of Health'should be'contaded to determine what will be necessary=to correct
rtX ^`id " c �te 79 rh e a*r
a NORthe failure fi ; d` �k i' t{t5`�`L.�t#�i?"•.ae- °'C.•,,.y'{te o1nf�t+ S..o ' �....,.s;i1 •. ' ' '-. ;, y �,-
Backup of sewage mto_facility•or system component due'to'an overloaded'orclogged SAS rror cesspool 1is t ;�< .�� of i' _'t•.
PIlk 11} 0 ii4f Otk#!l!,*?(,t i3 td�ifi (SS i :it. -,�1', s �"1?. • i7-•.3i ;t s �e ( t:,11 tyt. �# 4{> k t 6 ?''km � .5.
f
;rztu;.'£e. f >Sfj.S t�rr,S,' ,f1tt ei,5t:,.
x � Discharge or ponding of effluent to the stitiace'of the'ground or'surface waters due+,to an overloaded or clogged SAS ors '
• R r 01
cesspool
x, ynaM�s*� P '.? - r sa t•'U"}'€ n _ t `�••a�•*``S+ Jt :
rff a ' 1
* (revised 6/15/SS! Z k • _ 4 .�aY �
��e
•.y'k�t4;{y'� 4A, BSc P!k L`''? �"fs+a t�3 : fw'... 'w j Y �k' ,y k,rb;y.:t.� r z. n j��.� t,,a 5�#^b " 't'.�+t?+}{{�" •r" '.' ,'."C mF k
f rA tV . C�itx�,irt v '� Tjai #�t ' T�i
2, i
s�x
' ` SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
r4 PART A. ,, .. .
CERTIFICATION (continued)
. t
1 ,
Property Address:
Owner.' tf`'j ?are l�-
' Date of inspection: i "Z.-U
ciao-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 flow. _ rk`
1 , t
Required pumping more than 4 times" in the last year NOT due to clogged or obstructed pipes)
Number of times pumped A� 4
t, Any portion of the,Soil Absorption System, cesspool or privy is below the high groundwater elevation:
ao
'Ariy portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
� ,xyp,�
i
Any portion of a cesspool or privy is within a Zone I of a public wellRm
4�
R
k � a� 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 SO feet from a private water supply well with now
'�, acceptable water quality analysis. 'If the well has been analyzed.to be acceptable, attach copy of well water analys►s for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
RANj+t¢�, ?.
;ATE)LARGE SYSTEM,FAI LS: ; ' `"
• �� rc �
i he`following criteria apply to large systems in addition to the criteria..above;
Ire,
'� 3�Th0 design flo%. of system !s 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety Rs
and€the,environment because one or more of the following conditions exist-
"
� G the system is within 400 feet of a surface drinking water supply
y4 t
the s stem is within 200 feet of a,tributary to a surface drinking water supply
M�-*� r ..-.' -. t yT S �y,, �•+y
,r , the sy stem is located in a nitrogen sensitive area-(Interim Wellhead.Protection Area PWPA) or a mapped Zone II'of a�..,rJ .
� �Ll, publicwater.suppiy well`' x r r i ;fir.,.fa. ��iT'�'�•4' ��t,? ''`S€ .
The owner of operator of any such'sy'stem shall bring the.system and facility into full compliance with the groundwater.,treatment piogram ,_
; requ rements'of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for,further information' rg =fis r
S'r•An } r r - 'y€.. •x s+: •.s.4sa' v�is1 't°r'pry},x.,,SY
y 17
°hr1
�. +�+
�� �6"^t r i!•'r�.-�,.4�2 r 1 '- >' ,r# �'rt ,' '�'�. ` ' �:^ -" '� ;i a��� ?ta E�� ,�F�� e� } 'i° �
� .r ...�� ? � S i , i tJ` kl S,`�",�'`�5`tt��}`Y•'�t i?. '1S S
�✓�� Yt�y�j � !� t• t �y `'' r :4i. Y' r'Yt�'�a v 'i,t`�� #��t��,;�i,���yt�'s-�.Y
ire vised 0/15/95r) 3 r, NliwlTE i s
'`{
-si
'u-,4
iW .:rycF'�:sX'" i�.3? a r { A `'t. - _..����S,hwi�.'"�L'^,i.r. ;.4..x.4 _ :4 t•+:ti.
dt
4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM *
PART B
•; . CHECKLIST
f
C V).
G `a,Property Address: tP3 ,4C�
I LA
O ` . ��Ve-t. �
Date of Inspection: IZ- —�S
� F.
6 .
y"� "Check tf thefollowing have been done:
� r5 a Pumping information was requested of the owner, occupant, and Board of Health. ;
-None of the system components have been pumped for at least two weeks and the system has been,recervingnormalflow ratesw
t; Z i �during that period. Large volumes of water have not been introduced into the system recently or as part of this Inspection
rat3. (�As built plans have been obtained and examined. Note if they are not available with N/A.. •`' " ' '
4�SS " f�The facility or dwelling was inspected for signs of sewage back-up. `
The system does not receive or industrial waste flow ' } *� Y
rt 'r The site was inspected for signs of breakout.
w L14P %All system components, excluding the Soil Absorption System, have been located on the site.
Q"•'�4 1 iFc t y� �' , - .,,. 4. t,, r:Tyr,,, 't }t` Y The septic.tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles orf
r 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 been determined based on existing information§ors x
,t `,approximated by non-Intrusive methods,
• �r��-a!'rJ'. � t _ r r 2 .,. t' y'if f•.
�� �1/;he facility _ c ;end.occupant;, if different from owner, were provided with information on the proper maintenance of Sub-
e'fi� k �7¢s�n Surface.Disposal System.
��$+X 3 Y�Y?�� �ft y - -dtt^".flX •,' �A.3J�i t,^•'3y
titefflA
r
i j ASQ.'�`fff
�� � r'J �� 1r�s_'r Y { y Ev l 'e _ ?�t' ✓�, :-�1df`�i��"" •� i� '4ru
- 1,��i $ !a E �' ,C�u tpa. N.
k.'`-ryt,
r•� I0,
°rr. 4,c 0.z.,�r - ,'�. ,_# „-•� i s ... _ � xt r� ; e ' •-k }� �� _
Xl ;.." °` `*1 ".}!qe1". ss'"�yx.
A .4; yi..eUFcn,.`i''.-ir3
� ,�y. K'S�,� •i �"[ 3 * .te ° r'r^"��#S,K� 4�'�w..�r.-ar{i. ,
t � r r• 1 _ y,�: a;,^.ert.! A, 1' �b ' t 5�,€-a �.•
*^+.s�'r •l d ; � 'a r e{ a:+,.ems ��{'6. �am�• d li'�,w'p Jt����:
l (sevisedY 8/15/95l �`. 4
> s ge��t�k+d�t y: r i �, s5 a_t° ,r��,:-5} ��"+`��#�' �'•
J' ,� J,.' ,� + ..p y.. r t r C .+��CS�r 7-�i k��.r t�* 'ttl•'�;�
� ����+ `�` y r �•jt•d^�r}+„ a ..t;+( �`p. # y'"w; -°,r-+. �t�' ",� �a�"` `�� ,x�F�q r
����.°r� "� r ,"st•t Y' s.'`n• �.,•• Z •. .�`k„ .'�sy c�.a �" af,•i'�; ,?,,°�,s'
,. Y ,. �. } ' •. .. r +kS*y'yh< ti ,«d`+Fy tt Y .
•. .m..�L.�,..,,ar,x... f '�- �. - r M' c.4..ia,'�. S."�" :, �ap�r
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C k°
�t> h • ` :;SYSTEM INFORMATION
. .. pertT Adldrless:
�"Owner r rs
� IfDate of Inspection: }
FLOW CONDITIONS
RESIDENTIAL: `
Design, low: d lions >
V11 mber.of bedrooms: 3 ✓ ��_' +)
Number of current residents:Q
arbage grinder(yes or no): H
,^ La#ry`connected to syste (yes or no): • Ey '��€+t� s, 3
Y v-Seasonal use(yes or no): ter,+ ' , . ♦1 +rs ,i' JtJ1� t}F�t# 1y1 alm
4 'aie meter readings; if availablei'
r. .
•i
,' 0r �GSrw'C�
411,k <Last date of occupancy:_
`i`rlil$"` ' j K7X,ya313,$'A -
} j 4'COMMERCIAUINDUSTRIAL.
Type of establishment
', &Design Oow
`Gyre aser:!trapi t allo'ns/day
�
ornc t $ `c� z3�s(71!rYs piesent: lyes a
.10dustnalb
l QWaste Holding Tank'present (yes or no)_ -' "' t?wa �
,Non-sanitary ste discharged.to the Title 5 system '(yes or.no)_
hJ ''� _ y'.NJ,.#`"3+'R+Mf•^' +3•h�+"'CFM,�°fe1P'�gYFMF. hn `
Water mete
it available:'
kLas�date of occupancy
��{,OTHER• Awwo
(Describe) a )Y0:
W-Vdate of occupancy: c} a{� }`y�
+�f ZJ' , � j96d•SY Y (J I�.t�AAV s
a�
GENERAL INFORMATION
-4 ,}S'�' Y• M +w.,F.�y. #M.•eppya9Y' � ,p��t F
�., '�+":' �" -�+.G:"�j'pY.>c .,'� ... � j ... +rN. m--•ram"<w -M,.w'H.,ww>r F s� i',��;.
PUMPING'RECORDS and source of information:,. n ( sr ..�tFr� t'rgi+ F
{vr.'''.',:+: O1`+�-:, :. •.
uSystem pumped as part of inspection: (yes or no)_ f t
�� f �>"-If yes, volume.pornpPd:.; Qallons
� ` ' rReason,for pumping `. .
�q + s a
;iq -Of4 a t r't j !,.°•:/ ti } ° '.:i'V .: !�tl:r�.•.: i I,t7 1't tl ti4tf"11J,? ,f�.„f"�4t�fia.9' (H�c, f.
c RZi !'.�F({fi�y i
TY�E OF YSTEM �
tit':tank/distribution bo�soil b orption system
ol
m-e Single cesspo
£ V ,
4OVerfloW cesspool M1�y i�,ra
..r.�..�'p W 7 "y;�e ,j„t r�r� t �F t. - e � ,: .�"�y(�.�^ln' .. f i��u�� �
.,..r...-.*— r `{'r-•� t`r"�'�. x,'{„� .:n�'. -ry=; ! �' ., s'`••' 1� s'r'x�?.:.ha.4 ,' ` �s -x
,Shared system;'(yes oryno)t(if yes;attach previous inspection records, if any)
'€
Other(explain)
�. {�f'r
',�f {� 3s�
i"�1•Yb? ..3 f:' `.� JW"1yA�;,Y V,.: fit *.! • IN 1 AA fYw ik.# ' + �'w r
? APPROXIMATE'AGE of all;components;rdate installed (if known)and.source of information-
age odors detected'when arriv}ng.at'the site (yes or,no F {
4
.fir '"` Y 2� ♦ x T R'by;.x, • },,�'F
vjgav `"rt`'. + ;iu +' - 4i.'�f{ A ° 5 ,�. t + .y +/ rec n i �'`' " .fi*".;�+'S- ..
fr;spvlsea'0/35/951 �rY+t fey f
f !' _ 3 '''' k'�•yn �j ' ���i' s#1.
r®' g �'[-t 4✓ v,u ,'s•"#S��rc i3 �$
� '{ 4�?Fiu,.f i,� : I.' �. •� �'�i'^4t�1� � � �5..j�"`cfr-�' '.�. 3b'x �.
w ray c rr#p w oval �t
�� �'��asr� _. `• 5 �}.I s t`k'`- s.i k S� �>-i'y 'A�'.
*+HY'>d d„�N... +«n .s>+ry, '� .1.,•?'�ps,M:. +1 de. � .n,�,�.Nt. �, x AF.fu N s'�., a, �
v
i F•
+�s�M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMky,
PART C .
4 SYSTEM INFORMATION (continued)
a+ Property Address: $I�Q IGt-C{n C'vI I .
A ta3i , G
a Owner• !, i`.t r. q
Jr ,wDate of Inspection: .
41
, SEP,TICi
v (locate on site plan)
M
Depth below grade:
:i � r' �� {t,r,k~i''tFt y,.�w>3f t T,•���CtS1�_.
d Material of construction: concrete._metal _FRP_other(explain)
V� Dimenstons:
r� Distance,from top f sludge to bottom of outlet tee or baffle:
Scum thickness: ) - 2
i � - I/ •� 1 �upy>,y � �y;��+FM"N')StJ`' �f2 +�6�
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: �
f w 1' ^•t a r c ' t t;T'ya?," ER 1
IV!, Comments ,
TAM
S 9F A '�
�. (recommendation for pumping, condition of inlet and outlet tees ol bafflgs;'depth of liquid level m relation to out�et inyeft�', structural
�s 'integrity;evidence of leakage; etc.) /Na `-d� 5 SW
��4�1
j�'"`n'rs
d GREASE TRAP:�`I � ', � ¢ t
X(locatemop site plan)
epth'below grade: Y
l;,Matenal,of construction: concrete metal FRP_other(explain) `
, wn ,�
Dimensions V+(} r
Sc6rn th lCkness:. +
r k.. J# !-Ilritt1 dCt
' pistance from top of scum to.topYof�outlet tee or baffle:
Di lance frombottom n i hnnorr, o o.),a tee o battle �"" " ft�
ovv
'�tUilt
treco mendetiori for pumping, condition,of inlet and outlet tees°or baffles;'depth"of liquid(level in relation to outlet�in CiLj, structural �
inte rry, evtdence of leakage, etc►
el " ��,
.�
gm
e'� � �,�: � + r f` m t' �# P ;,,Fk i , + �.t �C-r.'>rr •.�, Mgt;h}t �i
�"f+
� x;,4 t�,% iT�7rMJ'y" 'V ..1t _ y R ,*.twV++nt' ^N+ .:1.�^7y...s »„ a�.y'M Cr vaV +r w+w."„W'kMN)MXY�w•1ttg'+T�i f����^ 1/S��"�'4�.3�1, .
1 r , �s-�,*=yMro � Mr"� z'a ✓.�✓n.7��eYs,>u, b +1 Y.�: c sir Jx S p k��p� ':i `��:R.+�wlgyar�ryn.t,n.+sri +ui•+..+r.r.mr✓.,rt,p.4t' '�k�r i i-aaw . .._....--» � v.+..:- s �++ .�c«a„w.F- .,,,rty,�.°-.yr+p„�,y �� ,�'1.'4 t+3 _4k��.V�,;x `�'r�
y 31 ?C�>< y� 1 '+i.� �hrn x e. _ 3 �" •"wfr,.i,} 4+' � i 3f ,pr.
u;�
.tC�' J' +",r.,# t1t.?d rt�t �xgy�v :'a>,�y y.: ,meµ}�y a7N' �'fl t"1'f' rs.vy+.yry.^p5.,v�M r"y�'^5�,Y 4h' ,f iMA fM'Fn r. 1 iM k 11� }F,0;Q� O Wii'.'� ofv " 6Tt'D 311,
¢ .1
''(, ry i4,y s.,, :it q. 1+• ohs e ,h�yr, s IL''rho4s[ �, +-
a�i}�1. 5KIWI .'K Y
50
��2 t a r
��. �+ ,y?fps ,�h.•�f,, .t Y
*- (11 revised 6/15/95)' -z �t
{
� Yt '#+ : "'%. 'y, ! �r'Jr• #+'.Md Y a. ft y,, tt~ ,+ �'#-j a. a`r
�- �b d r ,`f'• r. i . ....•_y S dL'�i...9�,�,mr i i
,Fd� ,� C1✓` ��' t �, . . . ky,dy. t"Yt 1, tys,�i�.r �v
'tk
k
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
av t PART C
{ SYSTEM INFORMATION (continued)
1 Me
;'Owner . I r 5. ^±'
A't{Date of Inspection:
TI PR HOLDING TANK: Jrr:},t.-ei rrc.:.t, t : - . . > i';{; r." i) ,nG��# �ari� rs w o)
(locate on site plan)
}Oepth below.grade:
s Material of construction: _Concrete_metal _FRP. other(explain)
,�l t��"rr'� tir w 3s _ � _ _ ». ._..._. .,,,,. •M,.,,.ea t:+.ae r+••,n.+r,•..Reae`.
Y x
1 v ?,,I q,
, 3
1Dimensions
` Capacrgr. gallons
erllir r,7aa:k n ^l�rl7sd� e ��
4- 1Design floe► gallons/day
r�a rq r-r e41
� sAlarm level
Comments:
(condition,of inlet tee,,condition of alarm and float switches;etc.)
"'' A""s�dtC kl •: ' a -. ,n. a w �«,.�. +*-trW+•ei+«�+wrv.».,tz•.•� r
'i'ttn�xl%yet ° i.. ++ins<<. .€. . . .d s My• x 3f,3 ��4 ,,w }'"sxap
SS
DI TRIBUTION BOX:
ot`io R `
f to on site plan)-',
zzlan), _ anti t�tr ti, to dk fisd-441. 04,iiclivl
Depth of 01
liquid level above outlet iinvert: ��t 5 � k f �
ar^,t^^ Wx F .+ b
cart.. 3•-s"1rr{} 5 yaps, r,
j , r }.Ar
ram-
�:�.�,;,"oy�
� p,.s fait• y.i• ,• - + tit s„y
E :g1 ote t! lever andrdrstributwt, t:ry�4,, e%*nce of soa�d., catr over, evidence of leakage i/n�to or�out of box, etc)
' ''k` 'W iz •,9 �.'Cc S bv' t�VG-G K.�P ,.,.,.. ,.,�„..a* w•h+� -y ,. t f+rii= �,' -.
AM
•�•' 1 tb}yy'4ta .:}': .. + , *•. .. ykw'•'r"T1°"""'d'aoy„^ty,��4 ,�,.
M
w P
M w--.!•F• N ^' 'W `4FnR+'if MM' .f+•ex4µah�'F'•
�•t��`,s '4;s, '.. v!•r� , '•� - s z r h h, r.y V4
?�'� '•~ rT !�Y: , }� } ir�tdXCrA�awcgi�F ls,,l ta• a a-!..;'art .1/''"'R` a )yc�f ikt ' ,''� } �f s° Pd 3 a r7 .i ^#
+� V
r PUMP CHAMBER: "
x.•>%' w' „i.M hs +w�r,H'}r�rmm�...u-�..,r• .T. '., r as. �' .s...•., ... "T"�' .. t -•mpa`F+u,-3!�r 4»,R+..,++. -. ��� '���
r �(1 cafe€ n','sit11e plan).�
Pu ps to Worklng order(yes or no) b' � {� �'•, ".1
c� ; .
y� .r
,.f� st
11
�note ctind:bon of pump chamber,'condition of pumps and appurtenances, etc.) "� '� 'E ��`
..,k�ap *i-} r`'� +r°,;..r:r ..' Pi't+�:',-H+s+£�r�r""�,, - ..- �t 1 •a3. :� :t<ifij,�y,+�yT,r�,r�°}�r,."�}{{�.�;���'
�y :.Yi�+�.A .1 ' .' .. - � .. w..-!t».y.. .n i^!`7 .}.'kr eFSr N*:iT��Y•FrK'+4}��6+f- F
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' " s PART C I
M' SYSTEM INFORMATION (continued)
se a
i >* Property Address: U7,
h t #Owner.
{ Y Date of Inspection: f; *
Js
�'L-le—°i Sa cr '
` F
�, c V
..
�i t w5 SOIL ABSORPTION SYSTEM(SAS):_-
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If no determined to be present, explain:
� r r +.«• ar �a
leaching pits, number:
leaching chambers, number•.
.... ._.- . . ...._,. ',.j.,a.., ,' .i.•. �...M ,u�'-,.a-<t5.k''4.�i.a>:±t6�.A' �j�4".3
_
leaching galleries, number: 'r'`}{�` "' im e
`leaching trenches, number,length:
leaching.fields, number;dimensions:
°overflow cesspool, number:
_ .. *�' .f 5`63s§•y4_ 'r1°✓. �5
,Com�'ents mote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) 5
���it t .vH�Bs rF.-,a..,.�. ., ..~+ .p.. „ ,. ,... ..• ,. .• - ... . ':` � .. r 4.v5. y. .� �xa«e.�'`t,.iw v+.�w,+..,.
C SSPOOLS:
(locate on site plan) r ,� , Y
� 'M1l /j
M.�t7yNumber,and configuration: asr
r
Depth-topyof liquid to inlet invert:
Detiof�solids layer. t,
� Depth';of scum layer. >. a {�7 ���) wla�P)
imen" ns'of cesspool
rv :fNatenal%of construction
1?M
lndieationrof groundwate
`'rmfiow(cesspool must:be pumped as part of inspection)
01
a <
'� . ��� ?� �,.�` to .•n .�i? Ie..t t} .. - - .+ .' •. � r�l a4 of x '�`�'7.4h�+•
Comments (note condition of soil, signs of hydraulic failure, level of ponding,"condition of vegetation, etc
,may h. ; -... �•, z ..:
wV ,�y�p
,PRIVY f h
(locateion site plan) 'R <�
ns{��y{'}
�latgnals of construction
Dimeons
vE '1N.rs'� : +zr+s.Mew•w.ap.nM({y, +a�ros�'r?S�i„aak� »,„h•,:ta. .-a..:,.,.,
� Depth:of solids �,�
> Commenu r(note condition of soil, signs of hydraulic.failure;leveF of ponding,"";condition of y etationS etc) , ram
je Y 'tt`>C ,q•' r}y. .s' c_�.' M•' i A
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441
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i"` �^ �.yb+-ter" a` f.' �,a,+s Yr'�°•:rrF .�. a"�a h �'�F�-g�a '�';'`.�.
IreYiaed B/35/951
F" p ayt.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM }
i k
PART C
SYSTEM INFORMATION (continued) .
0 I( -6k—r\ Lam. 1 5.h
Property Address: l( k3 C {� 0--\V. 3 I
Owner
t ,Date of Inspection: '
12
{ i 'y •
,.�, SKETCH OF SEWAGE DISPOSAL SYSTEM: . .
'013;5 .:include ties to at least two permanent references landmarks or.benchmarks
locate'all wells within 100`
R &
. 3
�,x �
r •'w�,. as i' �9r� �, .. t Yi ;� •, (l�;t'�i<. �a;:
s 'sR y •e K� �'v � .t s-*.,•�a"z>i�.s,,ti .��,if
��AIr :utRd &y'ia i H""",;d'lit °vf�'.�t};r, K'•v;'i `; i��"° tr' �i is'. tr,•
i>
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y��.a
r �r t
e L•{ t v :Y i •C 'INf yriM r r.+'� �^z *n 1'4` .
�• "'to✓ �
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`DEPTH TOGROUNDWATER3 ;u j
t as�J,S,rLz 'a' � tr t .- c' / i a{,�i✓.Ft ta',r k, (Ny��rFt ` i ♦� � ✓�`O. r�r�v ` �°4
i 1 I., CG G
pepth tP groundwater ; 0, P&V
od.of determination.or approximation:
. axt6t g br "'' z wrr 44,
.,Xk
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+� 3'Y•�J�.: 'i`i a'F' fix' .5. .. ... t 3 .>rs�� 4��„ ",��r�. �;.
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rQ iaed�":B%15/95),��'�r n++•e s af�"' v s:'.{i.. K;LL2t 9 k�'i _ 9'p"' +`z.x2�` '�dl ..,.pp,,`{ti.�aeds,Ep»ar.,~t¢" yi"�"D�ti{r 'y�r.�• .
gai
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I
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s tti "v t � t �'-Y}h'�'��.'l t�- �'dz N,� �}�,� '3��'y��-gi9le •.
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Beldan Ln.Centerville Ma.02632
Owners Name:Carol Constatine
Owners Address:68 Beldan Ln.Centerville Ma.02632
Date of Inspection: 12/1/2007
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or
Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building
TANK
REAR OF HOUSE A-1=11'10"
B-1=31'
V B A-2=1 51
B-2=35'8"
DI-BOX
A-`.=197'
deck B-3=39'8"
L.P.
A-4=22'
1 B-4=37'
A
O 2
❑ 3
J
4
1
LOCATION SEWAGE PERMIT NO.
�-rti /-c/i' C" U --2 73
VILLAGE
INSTA LLER'S NAME i ADDRESS
3 U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
I
�"
a:
,��T /�
�j ,.
- :
.�
.,,K�,
4
.........
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD- F• HEA TH
Jul
........ lo✓ ............OF,...... .....�` ../,...../d....... .
Appliration for Disposal Workii Tnnstru.rtiun 11amit
Application is hereby° made fora Permit to Construct M or Repair ( ) an Individual Sewage Disposal
System
�a �l � •- ��LC ..._
� 1, Location- ddress or Lo o.
5..1. �'G�ry 111.G`?.U... ....r,.,�. _42;.lam li ...... . ..........
.... - � =
Owner �� ..--•.--.••----------•----•-Address
------..
a .C, �rY.....L........ :.n �, ----------------------------•--• ----- --------------------
Installer Address //
Type of Building Size Lot../4,/,.4L-_l7_.._..Sq. feet
Dwelling—No. of Bedrooms........... ..........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................. Showers — Cafeteria
W Other fixtures ----------•.... ............••• •
W Design Flow.........�.-3.4 ....................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity/..gallons Length................ Width................ Diameter________-___---- Depth................
x . Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area............ .....sq. ft.
Seepage Pit No..................... Diameter............:....... Depth below inlet.................... Total leaching area� _....sq. ft.
Z Other Distribution box K) Dosing tank )
aPercolation Test Results Performed by....... ..._.. ....•.. Date.......... ....... ...................
a Test Pit No. lAfl._7ylPAinutes per inch Depth of Test Pit...Z?........... Depth to ground water.Ao,,.,&..........
Test Pit No. 2.... ...._._minutes per inch Depth of Test Pit.................... Depth to ground water...
---------••• --- ------.-----•----------------•.
O - _.. ... . ---•---- i j. .
Description of Soil....__0..._._ _. cQ�!?.._J
---------------------------------------------------------------------------------•---------------------------------------------------------------------------- ......................................
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ssued by the b rd of health.
771
` p�)
S' ed
••._..... -----•-•..................... ! ..`.
D to
Application Approved By................. �`='���= � � ------- ----•- /���1�
Date
Application Disapproved for the following reasons:................................................................................................................
-----------•---•-•••.....;.---•-•-------•--•-••••.........................•-------•----------•••••...•-------•-•----••-------•--------••------•--••----.........•--•-•---•------•-•••-•-•---------------
.•Date
PermitNo.................................................=....... Issued...... --- ......... = -------•----
Date
ti
3> _ F�$.3...D. '._...._
THE COMMONWEALTH OF MASSACHUSETTS z
BOARD OF HEALTH
Appliration for Uigpooal Workii Tomitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System
s;// at: . . ` . ...................................... - --- ---- ----• -
... !!�`c/: r .. . ................. •••••--•-•-•-•--•-......•...............
Ir
I '
Location.Address or Lot No. j
....---cJ......_.._r _:�.....n:_....----•---�^-----------------------a----•---•-------•-- .....
_..----•..................._. ....._........................
fh wnerr1 t Address
ir
...................... ..._....._. F__....f......pi _.. ............................................. ...................................................................................
ai Installer Address `� �L f
d Type of Building Size Lot-_/_____ ____________._....Sq. feet
aDwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------- ------------------•--- -
W Design Flow......... - '...................gallons per person per day. Total daily flow.............-..............................gallons.
WSeptic Tank—Liquid capacity fG!..gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area............_,.......sq. ft.
Seepage Pit No..................... Diameter........,----------- Depth below inlet.................... Total leaching area��?a.__....sq. ft.
Z Other Distribution box Dosing tank ,/
'-' Percolation Test Results _ Performed b ......�_ !'�....?'(._ ^�✓, � "`' _. '>_______ Date-__.__6./ .......__J.____....
Test Pit No. 1--'° ,1 . .e---minutes per inch Depth of Test Pit___ ____________ Depth to ground water,*._-.
GL, Test Pit No. 2.... .....minutes per inch Depth of Test Pit-------------------- Depth to ground water---4� cw:u"�/Lf �
O Description of Soil 1 :` ' 1�r 4 Jc ,�T-----°j-•---•--•-�-�-- --- f�—--����-'"�`�-----•......-----•-•-••-•-------------
(� ......•-•----------• --•••--•••-•••••.................. r---------------- ................ -----------•------.....--------
W •--••----------------------•------------...................................---------------•-•-------•-•--•-•----------------------------------------•---------._._..__......_........-_._._._......._.
VNature 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 TIT112 5 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.
*� D to
Application Approved By-••-------- : Phe!�'"'�__.__�� �✓..............•••-. __.;+' ?r'' '
Date
Application Disapproved for the following reasons---------------------------------•-----------------------------...-----------•--•------------••-••-----------•---
•.................•-••-•-----•--••-•--•-•--••••-•---•-•---•....---.............................................. -•-•-••--•-•--•-•---------------•-•-•------•---•-------•------•------•------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.'.� �✓
(9rdifiratr of Tantliliaanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by........:. ..:... ......................................----...................................................................................................
_1
Installer--
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
b application for Disposal Works Construction Permit NoaO-_��.7..................... 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
..�� ^J j r �,
"'............................OF. .. 1:- ,-/.C�:-� .............................................. r�
No. ................... FEE._. d. ' ....
�io�os��al orko/ �on�#rnrtion rrmi�
Permission is hereby granted_.___4?� ! -f'/ - r
to Construct or Repair_( ),,an Individual Sewerage D_isposal System
atNo......................................................................................
Street
as shown on the application for Disposal Works Construction Permit No____________________
•��� d Dated
_--_ __-----_.
----__-_-_--_.....
DATE.............. =--------
........._._........._._____._....
oar
`t
FORM 1255 HOBBS & WARREN, INC.. PUBLISHER
�# � � �,' �� ,. -:mow' ._.__ -_.,s -_,=' �� �_� � "�_._'.� , ..� �? � ��;;� ,•
Sn "et 43
" In.53
Al
r �-t. -
ROSERT `h✓
BLINIKIS
No 22162�0
t LEGEND
EXISTING .SPOT. ELEVATION Ox0 CERTIFIED PLOT Gi AN r;
EX15TING CONTOUR - 0
� FINI SHED SPOT ELEVATION 0. 0; -�- >>
r.FIN! SHED.. CONTOUR . O �" /!;
k IK APPROVED ; BOARD OF HEALTH i N
DA,rE AGENT Al E "- ' DA 'f
Fl D RE DMG,� ENGINEERING CO MCICLICT
ENT
1} / I CERTIFY THAT rHE PROPOStD
�tEGISTERE�, ,' REG;STERED ; JOB NO.�cIG' 69 BUILDING SHOWN ON THIS PLAN
1 CiVIL. LAND _ � , CONFORMS TO THE ZONING LAWS
ENGINEERS, c SURVEYORS,I DR. BY t . fi •� J _. OF' BARNT4 LE MAS . .
t x - 9
CH BY :
i. : y y _h ',E�,,i �I M•rS J. f�rai l`��1 �'' � A C. _ JE `r
SHEET._ OF 2-. /DA T REG : LAND SURVEYOR
F
20 Cr M//V. G.EACAI//vG P/T ARE MORE THA:•V11z"sE4OJ
�e---•---..._ .. GR.4 DES f� c�4"O/AM ET.ER CO/1/G'.+FF_ T.E CO!/ER
' /a FT. M/N• SNALL BE ,9i?OUGH7- TO 6/gAOE°C.�iN EXTRA
Q"PVC P/PE HEAVY C^ST /?O/Y, GO�/ZR S11AL L Cie USEdO
CONCRG•TE M/N. PITCH
-�-; L%G ,• D; IB PL
COVERS • �,Q FT
o-- CD/V CRE TE
4RAOE CLEAN SANG
CO ✓ER
_r F DQUDL
= _ 2 LAYER
�.. i o r'Tr�'r'•'7T'-s-rrr-rrrr+rr��7,. R�'r'o
4" CA57-
i IRON P/PE I. /D O U o. o
GAL. 0 1 • • • • 1 r a WA 5 HFD 57?�NE
f a M/N. P/TCN b
U/ST•Ai r • e • • • • e l l �°
_ u q
T/ TANK ° ® s • • • • I A ° °
is ;•, BdX c • � v
i
a.:...i � o v v � � i 1 •EFFECTIVE 'A• � ` 3/4•'- f ��2•
�'I b WASHED STaiYE
•., p r° o � r • • DEPTJa • • Ile o
..-:a L IZ''i Y.• -it 1: , P.._.�. r . -. ...j 7 c, 1 r •: • • ! • • 1 1 �, o p C p
a 4 / • •i • • • • • 01411
PRECAST SEEPAGE
a am ° < re • • o • • er / D P/7DR EQU/V
. 0 ` n rr •i • ` e • • e1 /� CAD
NVeKT EL E VAT/ON S
INVERT AT BU/LD/IVG FT.' �w FT. D/.�11+1 C SEE TULATION
1
INLET SEPT/C 7-AHK
OUTLET SEPT/C TANK 56 9 FT GROUND WATER TABLE
INLET UI5TR/49U7'/ON BOX YC, � FT SECT/O/V OF"
OUTLETD/STR/BUT/UN BOX S s FT SEy�A6 O/S'POSA L S3�.STEM
INLET LEACH/NG �/T FT TABULATtDN
sfr
r, LEACHING PIT, U/MEIVS/ON A 3 FT.
SCALE %4 p/MRp;5loN $—�— FT.
DES/GN CR/TER/A
O/HENS/ON C—�FT.�/'✓
NUMBER OF BELROOMS _
OG
G,4R6A6EVISPOSAL (/N/T'_ SOIL L sp/�, TEST
TOTAL EST/MATED F1.ow 3 3 v_GAL./DAy' SOIL TEST Al SOIL TESTgdt2
/YUMBER OF ��4cNlNG: w/rs_ E�EY. ELE•1!- ,DATE OF SOIL TEST D /
f r �13v�iice.�-s
S/DE LEACH/NG PEIK P/T _Lr�_ SQ, FT. µ RESULTS /�//TNESSED 8Y 2 —_
PERCOLA7-/D/V RATE */ LASS /y//V�/NCH
6�TTOM L ggCH/NG PER P/T 7 - SO. FT L o.�}-ter �.!> r✓
-� s�,3 cpiL AERCOLf1T/ON RATE/k2
TOTAL LEACH//VG AREA, .- SQ. FT.
Rt�sERVELEi4CHINGARE/+_a'� b SQ. FT. 1 L, Ali � /�• y%/1 2
C/?A
(U suNix!s. L�LOfiEDGEENGINE�RING C0,1/VC.
\c�p' o " c: :, 7f 2 MA/N ST- = 33 NO. MA//V ST.
� .
"•. HYANN/S MASS. SO. YARMOUTN�MASS'
ENCOVIV7' EO*
TER AT ELE.I/ JOB
N0 SH
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