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Home My WebLink About0074 BELDAN LANE - Health 74 Beldan Lane ✓ Centerville P A = .189 031010 ,% 4 No. 42101/3 ORA do? E019 U O 3 100 1. `' 0 0 0 0 I .. .. No.. 'U.... .?.? — Fns..... ��.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF__HEALTH L✓✓-------------OF../�s��/?/1/J��I�,/! -.__.... .................... Appliration for 11ispasal Works Tonstrnrtinn tirrmit Application is hereby made for a Permit to Construct 41) or Repair ( ) an Individual Sewage Disposal System at: ---��C_ ........ lQ......: .... .. - ---....--......----............... .............--------------•------------------•-------------------.......-•-------.........------. Locatio Address �(.o (7► Address Installer Address //� �` Type of Building Size LotA _____________Sq. feet V Dwelling—No. of Bedrooms......... ............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a Other—Type g ----------------•----------- P ( )--- Cafeteria ( ) d Other fixtures .----•----------•----------------------•------------......--•------ W Design Flow.......... d.....................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/W..P.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—N9. .................... 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"( ) 41, Percolation Test Results Performed b _..._.._ ---- -- Date. . . _, -� Test Pit No. lk—fr......minutes per inch Depth of Test Pit............. ..... Depth to ground water.. ... f=, Test Pit No. 20Anf_�.minutes per inch Depth of Test Pit..... . ........ Depth to ground water...��G��P/�iF w ..---•-••---------------------- ...............................................--•--•... ---------- •------------------- •----------- O Description of Soil...... -----�d'C�J.. .. 111 moo- -_....... el�-" ri v �r...... '��n�� f�' J -- UW -----_ 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'LI'ILE 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 boar of health. Signed. = f......................................... 'A'`-- D to Application Approved By. • 4 ,� = .0----------- Date Application Disapproved for the following reasons:......................................................................... ............•..... •............. --•---•--•--------------•-•-•-------•---.........--------...----••---•-•----------•-----•-•--------........--•-•-.....--------------------------------------------------••----------------------••---•--- Date Permit NO.......................... Issued. —� -----•..... ...................... Date FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l t, n . ....... Y ! Alipfiraation for Dispati al Works Tonotrur#inn ramit Application is hereby made for a Permit to Construct (, ') or Repair ( ) an Individual Sewage Disposal System at: ocatio Address or I.ot No. �� .................... .........�'�'---5%C�..... fr r cif .............................. Address ........................ ...................................... ••---•...---•----••--•....---•-••-----•....•-•••••-••••......_.......... ..........__........._ Installer Address Type of Building Size LotCJ_. .............Sq. feet �--� Dwelling—No. of Bedrooms........ ........................:........Expansion Attic ( ) Garbage Grinder ( ) 4 Other—T e of Building No. of persons............................ Showers — Cafeteria P-I Other_fixtures .................................. W Design Flow.......... ......................gallons per person per day. Total daily flow..............._......__.__...._............gallons. WSeptic Tank—Liquid'capacity��....gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. �. Seepage Pit No---- --------------- Diameter.................... Depth below inlet.................... Total leaching area.R .......sq. ft. z Other Distribution box ('T ) Dosing tank (,, ) '~ Percolation Test Results Performed by.__.... ....'��.�E.....�� _��L..... ............ Date....- ,/ --_--_-•-----___--- al Test Pit No. -------minutes per inch Depth of Test Pit.................... Depth to ground water..1!:e7 :&...... (i Test Pit No. 2T�-^ x�..minutes per inch Depth of Test Pit----- ..... Depth to ground water___t ------------------- ------------ -"-•-----------------•------....."---------•--•--------- " ..:.."-"-..........."-"•------."...---.... 0 Description of Soil..... -"'. .................................................c"n ; , `?- -" �--� �" _. _4 -1�G-._...... ...................... xW ....---•-•......••.............................. y Y . .. .................... -� 1'...........0 . ------•------------------------------- --•-•••. -•-----• --••---• ......•• •........... _ ... ...�%?... .... -------------------•------------------- 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 TITL2 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. Signed_fft• � ::..." :r l "/ L r -•- �i ----•-•--------------------------•- - --- ate/ Application Approved By -- .. .�1_`..!.!�C�G�e__._ ....................••-.-• -�?..... r-1 ............ Date Application.Disapproved for the following reasons-----------------------------------------------------•---------•-------------•--"-------------•-------.......••-- ..--•-•••-••--•----••-•---....--•••-•----•-•-••----••--•------------•-----•................••-•--------•-••----•--•--•-••-------•--•-•--•--•-----•-----••-••--•----•-•-- -------- ..................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (9rdif iratr of TompliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed. ) or Repaired ( ) bY ---.....•= ----- ---- --------------"-.-------------------..----------- ---------•-•----------------- ..._ Installer at---•••-----•......... .....--1D__.j/'f.."j... /i i . has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.G.Qi-..3_>.2.�............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. /? DATE... .....................�`_.......--�....-----...--"-"-...... Inspector.---"-.............................. ............................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �-; 7` /. — No......................... FEE........................ Disposal ork� nno . inYt rrmit Permission is hereby granted_. _ /` / .`_... ..____.. to Construct (°") or Repair ( ),an Individual/Sewage Disposal System atNo.............................Z?:/C............................................./ � ..................................... Street as shown on the application for Disposal Works Construction No..................... Dated.......................................... .o �„ - --------•----•------------ Board of He DATE '`"'V...ie4d..................................... FORM 1255 HOSES & WARREN. INC., PUBLISHERS ""�'' ti ��•,s �" � t ri ^ a:K � i I t q -It}*y I'`� r -� `$ 1!a �r ..- is ,'t T� � H d� �• tt..,¢ 'S. +•I 7 �,� r } ,` ..�, f. `� �i �' r. ,} '4+ R fLra '* ei y✓ ,L 1. 'Yx 4 pl SG ya i n•W' r 'aL •�L '� 1G Yf h ix .. t fit. I F� � a - , '� i/' y `' 37 NO f 9 . Iq AA 0 F AY ,Z t• - ��o ROBERT, iT Y to o rn BUNIKIS IS a r No.22162�0 SS'ONALEN� t t r y l'EGEND y>EX'ISTttdG SPOT-ELEVATION • 0,0 CERTIF(EO PLpT PL AN EXISTh;�p. .00N TOUR,-. • _ P�_ kiSHfv0 , SPOT ELEVATION . <F1ytSHEOCONTOUR 4 �AFOROVEfli:- BOARD , OF HEALTH �« j IN x a ,� '. 0►ATE - AGENT . � j` ` J49 _ SCAL. 5fO DATE t �64" ENGINEERING CO.-IIVG' 2 E�/D�$ CLIENT �_} , ! CEtiTIfY.` THAT THE PROPOSEpt' r � I fG1STEREI� �R£Gi3tERED +C,IV,IL` :i LAND Jo N0. �9 v d q.: BUILDING .,SHOWN ON'' THI$ ° PL q"(� I;SURV€YORS��' '` 0R. BY -�� ,'f� /L,"'' CONFORMS TO THE ZONING' L,AVM�'=k:':' +rY " C. tMA`N - OF BARNST 8L M y a' „ nC MA'IN' ST' CH 'BY•� 1 >C' tiAalyiOS. tN. M.►5;. HYANNIS MAC SHEET pf�.. 3 i OA E REt3. LAND �_. a SURVRYQI " '0 p", eAr TW =P77C'IrA.V.4c�" OR 07 Z /V 0 R,-- 7-H A.,V 12"SEL 0-FV AR, 7 5, 0E, oA 24"VIA Al E 7',,wR CONCA: r.C— CO$-14roe �-PL-8E-SR0045/477, 7-0 4MA 1>,E.�.,-41V SNA 67,0 FirTRA CO1VCR VC, P/pz V Y CoA 5 7 -IV C OP,-R =r. 1J=/A' A;p R1 VAF WA Y "i srv--_r co �18 Qz- X, A CC3 Poll=- locz RA Z>4- 0 , C L FA,,v .SANG LIQuID LEVEL "LAYER -17 4" CAS7' V18 ",..I IRON A-/P-- 6 0 2 GAL. 0,0 WA 5 HeD 57'0,IV4E' M)/V. P/rew D157.' SEPTIC 7AAolK e-M 'p BOX v 314 Vz WASHED 0 f I A 5 7-S-FAEr-A' 6 E- 4 P17 ,OR EPLIIV. 6 I)VYE,RT AT &Z111-DINCT Fr C SEE 7-,10 Z1J-A-r)oA�) INLETSEPTICTANKFT. olA M OUTLET SEPTIC TANK -5-437F7- GROUNDioVA 7,�--, aox. 5-<;L,5' FT.. SECTION ol=- TABLE 0UrL,-7-D157-,Tl,&&-r1oiv box F7 1,V4Er LEACHING om"'.7- S,4%0 Fr. -rA8ZILATIDIV I-EACH11V6r O/T oijvl-=NSI 0 A/ A ' 3 SCALE �/o 0 IT. DES161V CHI rAFRIA VS/ON Co -lk F 71.,41 IA-1. NUMBER OF BEDROOMS 3' SOIL Z-0 C7 Go4R45A6.C*A00 15,,1705A.4- UN I r SOIL 7LUS7*2 S011- 7-,E57- T07'Al- ESTIMATED —I-ow 3 0 o,44.1AoAy SOIL. TESTOA T-E Or' 50/,L AIUM8-PA" 0,- 4--ACHWa S, I-A--4 rEsr S/L>_=4eA cq 1,vc, PER -/-r I RIC SQ. F7•' Q.- 2- l ' , — . RESULTS AV17-Al&SSED BY ,CPO r-rO^l Lr.A CHIAta PER SQ. Ar 4..0,4-Al -&rvcozA-rlow RATE,*l LDS S M,,Alyl,NCH 7-07AL 4eACH1,,oy& AREA, slo 'Fr S,:6 )=EjeCOLA7-1OlVRA7,EA2 2,0 'Fr gg�,fZ.A C-5 L.- -or 0 I i co A--,?- ..4 06ERTI �A P., Ao.22162 0 � T 712 MAIN 33 NO,14AIIV Si-. 01, HYAIVIV �,&--r,4,4mourw MASS `SSy-ONA 71ZEA�- JrA 75a 6q V- 4, --2-0 7 V- COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS t d DEPARTMENT OF ENVIRONMENTAL PROTECTION a wM 5�0 o� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION Property Address: 74 Beldan Lane Centerville J U N 14 2002 Owner's Name: Chris Gallagher ABLE Owner's Address: Same TOWN OF BAR HEALTH DE TPT.. Date of Inspection:5/16/02 Name of Inspector: Timothy Lovell v 15 Z.�- Company Name:Accurate Inspections �IAP I `9 Mailing Address: 550 Willow Street W. Yarmouth,MA. PARCEL ' ..� Telephone Number: 508-771-3700 LOT . � 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority /Fads Inspector's Signature. ' Date: 5/17/02 The system inspector shall submit a"Opyofs inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 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. N/A 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 infiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: N/A 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: N/A The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): Broken pipe(s)are replaced Obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 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 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _N/A_Cesspool or privy is within 50 feet of surface water _N/A_Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _n/a_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _n/a The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _n/a The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. n/a_ 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _x_Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _x_Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _x Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _x Any portion of the SAS,cesspool or privy is below high ground water elevation. _x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _x_Any portion of a cesspool or privy is within a Zone 1 of a public well. _x_Any portion of a cesspool or privy is within 50 feet of a private water supply well. _x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: 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: (The following criteria apply to large systems in addition to the criteria above) Yes No _The system is within 400 feet of a surface drinking water supply The system is within 200 feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 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 the system components pumped out in the previous two weeks? _x _Has the system received normal flows in the previous two-week period? _x Have large volumes of water been introduced to the system recently or as part of this inspection? _x _Were as built plans of the system obtained and examined?(If they were not available note as N/A) _x _Was the facility or dwelling inspected for signs of sewage back up? _x_ _Was the site inspected for signs of break out? _x _Were all system components,excluding the SAS,located on site? x_ _Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _x _Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _x_ _Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CNM 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_Number of bedrooms(actual):_3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330 Number of current residents:_2 Does residence have a garbage grinder(yes or no):_no_ Is laundry on a separate sewage system(yes or no):_no_ [if yes separate inspection required] Laundry system inspected(yes or no):_n/a_ Seasonal use: (yes or no):_no Water meter readings,if available(last 2 years usage(gpd): (2000)65000 Gallons(2001)61000 Gallons Sump pump(yes or no):_no_ Last date of occupancy:_Current COMMERCIALANDUSTRUL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqk etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Owner last pumped March 2002 Was system pumped as part of the inspection(yes or no):_no If yes,volume pumped:_gallons--How was 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 system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1998 Were sewage odors detected when arriving at the site(yes or no):_no_ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 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:_30' Comments(on condition of joints,venting,evidence of leakage,etc.): Line looks in good condition,no evidence of leakage,Venting is good SEPTIC TANK:_x (locate on site plan) Depth below grade:_1' 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: 1000 Gallon Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_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" How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Pump everyyears,Tee's are fine,no evidence of leakage,liquid levels are at invert out, 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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 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.): Liquid levels are at invert out,Box looks level and in fine shape,no evidence of solid carry over 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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _x_Leaching pits,number:J_ Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Cover 2'deep Liquid level 4'below invert in,No evidence of hydraulic failure,no ponding,vegetation is normal CESSPOOLS:_N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Water Line Back of Home 3 9' 28' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 Beldan Lane Centerville Owner: Chris Gallagher Date of Inspection: 5/17/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_20' feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _X_Accessed USGS database-explain: You must describe how you established the high ground water elevation: Information provided by cave cod commission well information well#SDW252 shows water table with adjustment at elv. 47.3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL A � 9 ' DEPARTMENT OF ENVIRONMENTAL P ` ECTION ONE WINTER STREET, BOSTON, MA 02108 617-29 NO � V00 WILLIAM F.WELD NOV 2 5 1998 r TDY CORE Governor TOWN OFBARNSI Secretary ARGEO PAUL CELLUCCI S' NEWN EPL� Au11)B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION R Commissioner PART A CERTIFICATION 74 Beldan Ln Centerville Patrice Johnson Property Address: y �^ G" Address of Owner: Date of Inspection: G� (if different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Servi _A Mailing Address: PO Box 1 089, Cent-ervi 1 1 Py MA 02632 Telephone Number,, 5 0 8 ? 7 7 5—A 7 7 6 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-ftrnction and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Z L Inspector's Signature: Date: �— The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: 19 I have not found any information which indicates that the system violates any of the failure criteria as defined in 314 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] S STEM 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. Indi to 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 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. ( vised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep e'j Printed on Recycled Paper s �I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM —�- PART A' r CERTIFICATION (continued) Property Address: 74 Beld.an Ln Centerville r} - Patrice Johnson Owner: % )r t}fit~�i. g'—Cf Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) �+ ��,� tSe- age 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). Describe observations: f 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] FU HER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface.water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and 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 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 74 Beld.an Ln Centerville Owner: Patrice Johnson Date of Inspection: 9 o2,gj"C' D] SYSTEM FAILS: - Y u must indicate ei;!,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARG SYSTEM FAILS: You mu indicate either "Yes" or "No" as 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 o ner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program 'requi ements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 74 Beld.an Ln Centerville Owner: Patrice Johnson Date of Inspection: 9.,!Zg'-y7— Check if the following have been done: You must indicate either`'Yes" or "No" as to each of the following: Yes No LI _ Pumping information was provided by the owner, occupant, or Board of Health. 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. S/ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ` The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ 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)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION Property Address: 74 Be ldan Ln C eritervill e Owner: Patrice Johnson Date of Inspection: cj'—;,F—r 9— - FLOW CONDITIONS RESIDENTIAL: Design flow: 33 O p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no):_�o Laundry connected to system (yes or no): 4 Seasonal-use (yes or no): -s zl 1996 20, 000 gals Water meter readings, if available (last two (2)year usage (gpd): Sump Pump (yes or no):/ 1998 4, 000 gals Last date of occupancy: f!J COMMERCIAUI NDUSTRIAL: Type f establishment: Design flow:_gallons/day Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-sa itary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last to of occupancy: OTHE : (Describe) Last d of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: - System ;5umped as part of inspection: (yes or no)./—Z,n If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM 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. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 16 Sewage odors detected when arriving at the site: (yes or no) U (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 74 Beldan Ln Centerville Property Address: Patrice Johnson- .. Owner: Date of Inspection: ''= 11 ING SEWER: (Local on site plan) Depth low grade: Material of construction: _cast iron _40 PVC_other (explain) Distan from private water supply well or suction line Diamet q . . Comme s: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on bite plan) Depth below grade:—L. Material of construction: �foncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: K' '-le Sludge depth: t/" > > Distance from top of sludge to bottom of outlet tee or baffle: 1 ' 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: /p How dimensions were determined: cV �► d- ) Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of li uid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) -� G a . 67 L. 5- der r.-� � GREASE TRAP: (locate on site plan) I Depth below grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dime sions: Scu thickness: Dis nce from top of scum to top of outlet tee or baffle: Dista ce from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Com ents: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural inte ity, evidence of leakage, etc.) 14 (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART"C ' SYSTEM INFORMATION (continued) Property Address: 74 Beld.an Ln Centerville Owner: Patrice Johnson Date of Inspection: X�F— 9 �7 TIG T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (Iota on site plan) Depth low grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensi ns: Capacity: gallons Design fl w: gallons/day Alarm I el: Alarm in working order_Yes; _ No Date of previous pumping: Corn nts: (condi ' n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) -6 Ck-1- PUM CHAMBER:_ (local on site plan) Pum s in working order: (Yes or No) Alar sin working order (Yes or No) Co ents: (not condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 74 Belden-hn Centerville Owner: Patrice J has on Date of Inspection: ?!,2 q--9 V- SOIL ABSORPTION SYSTEM (SAS):z (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: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic f 'lure, level f ponding, condition of vegetation, etc.)r _ IS X 70CdLTU � CESS COOLS: _ (locate on site plan) Numbe and configuration: Depth-t p of liquid to inlet invert: Depth o solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Inclicatiod of groundwater: inflow (cesspool must be pumped as part of inspection) Comm nts: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of'vegetation, etc.) PRI _ (locate on site plan) Materia s of construction: Dimensions: Depth f solids Comm nts (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 74 Beldan Ln --Centerville Owner: Patrice 'Johnson Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I � • ) (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 74 Beldan Ln Centerville Owner: Patrice Johnson Date of Inspection: 2—m IF—9 F- x Depth to Groundwater !tnL-Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) n,�S (revised 04/25/97) Page 10 of 10