HomeMy WebLinkAbout0078 BELDAN LANE - Health 78 BELDAN ROAD, CENTERVH LE
A= 189 031
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UPC 12534
No.2-153LOR
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HASTINGS,MN
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
< ONE WINTER STREET. BOSTON, MA 02108 617-292-5300
WILLIAM F.WELD 3I TRUDY CO)M
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION a
field n Rd. Cent�ew( Ii>Q
Property Address:-7g Address of Owner: qVIA-, �� RECEIVEO
Date of Inspection:�f pZ$Iq (If different) <
Name of Inspector: S EP 4 1998 o
am a DEP approv d system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: TOgHE HADEPLA
E k�
Mailing Address: \�aq
Telephone Number:
CERTIFICATION STATEMENTrv ) 1,
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
/Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
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] SYS M PASSES:
I have not found any information which indicates that the system violates any of the failure criteria a5 defined in 31a CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date.of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or 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.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:Uwww.magnet.state.ma.usrdep
�e'j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
S
Date of Ins ection:Iv►a-
bI9O
Bj SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION 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: -72 d 0Y1 ROOLd
Owner: S� I vt A
Date of Ins lion:
8fAM
D] SYSTEM FAILS:
You ust indicate eit!,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/
_ o� 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.
EJ LARGE SYSTEM FAILS:
You must 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 owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: T? 6e chn
Owner: SiA,Via—
Date of Ins ctio 8'��8 t�
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yet, No
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.
V 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) ?age 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
o .®�
SYSTEM INFORMATION
Property Address: 1 0 ee'Idon q
Owner: $ lvt&
Date of Ins ection:
81412tq9
FLOW CONDITIONS
RESIDENTIAL-
Design flow:- e.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):�
Laundry connected to system (yes or no):
Seasonal use (yes or no): Al
Water meter readings, if available (last two (2) year usage (gpd): 1\(
Sump Pump (yes or no):
Last date of occupancy: i;
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: I
Hb�rav CaY���
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: eallons
Reason for pumping:
TYPEYSTEM
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:
Sewage odors detected when arriving at the site: (yes or no)
revised 04( /25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: S IvtA,
Date of Insoction:n�
BUILDING SEWER: oC0
(Locate on site plan)
Depth below grade:
Material of construction: K;st iron —40 PVC V"other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
0��
.Depth below grader
Material of construction: oncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age — Is age confirmed by Certificate of Compliance —(Yes/No)
Dimensions:
Sludge depth: 3c�
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_ rr
Distance from top of scum to top of outlet tee or baffle: /0' c
Distance from bottom of scum to bottom of outlet tee or baffle: L3
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffJP,s, depth of liquid level in relation'to outlet invert, structural
integrity, evidence of leakage, etc.) Q00/) Coo.d/f)-I vim
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
p nn,�� SYSTEM INFORMATION (continued)
Property Address: -iO BeActOrl Od .
Owner. 5LJ I VI GL...
Date of Inspection:10 019
TIGHT OR HOLDING TANK:d(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:I�d 2 `
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:(
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10i'doh R"A-
Owner:SLi 10 Gl_
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
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 failure, level of ponding, condition of vegetation etc)
'0 T
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: _
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: [,[
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �$ 96ldon Q/
Owner: Jq0\A 0,
Date of Inspection: r��,'��
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)
�eC✓
27
a7�
d
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�Q SYSTEM INFORMATION (continued)
Property Address
Owner: SLJ j VjeA -
Date of Inspection: O Q)AIRMF
Of
Depth to Groundwater 31 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
—zUse USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
(revised 04/25/97) Page 10 of 10
ni
•:'' �. Commonwealth of.Massachusetts rlavi_oie�
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Executive Office of Environmental Affairs�f,,., 40
Department. .f
Environmental Protection
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.WBIIaun FF.�W_eld
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st: I{Yt�u��
to NV611n, ,;,:. ",f SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM} ;
A PART A
k4 Yi n ev
„gam �z CERTIFICATION
Property Address: 78 3� �u L w4-e—60,- ' ; - Addressiof Owner: rate.�i t✓r n D
Date of Inspection: � (If different) J
Pam. 1 3 .t Y:�1 x� r 1 i � ! ,•F � {4 �� t � '
3 ,Company Name, Address and Telephone Number:
1✓�:L'r�l'i.i �,�L, t��. 3,�• q tr' r '�,s',a' w ' 4� CERTIFICATION STATEMENT
�I tertfi) that I have personally inspected the sewage disposal system at this address and that the information reported below is true;accurate; ;
�and•complete,asof the time of inspection. The inspection was performed based on my training and experience to the proper functton�and, �'�
maintenance of on-site sewage disposal systems. The system: t,„# ;$ ;r.; _;7,3Ra;r'i ; �; :' �3r itl
mYe e'1 fi `EI�aSses!: Frlar 9�k tiff
kzi r .�"1 f3td { rd� .rtaMS+# .r
Conditionally Passes
Needs Further Evaluation B the local Approving Authority;
' y+ `# a C )7 i '4 I;u{k "Y fn• P; - s r� sir. i - li," v r:_e -- `�F" -'�
,� h4s�Y-'e�iyats. e '{� e� k t I +'.a !(.�..i,+ 1 r •n.i t r q, - _ t) S Y R ..� Il ;r. j•N,�7 .`rsf .»LSS
K il d{a .{ H {,
rury Date. ,
� tinspector s Sigel re t ,I tiff a �,
04.
" y'ilr 4 eCr S idf ors za, � " '
ti � t,,,�'Ef +((y� tr .y r,�,
ty`y' ,r ri'�ln .k.°'..t Y�+ ..,{., 4'If1i�,1�srk�.
x r-'1'4�. i
�r, The.System Inspecto�shall submit:a copy,of this inspection report to the Approving Authority within thirty(30)days.of completing-thiOY Y F1
r kmspectton .If thea��sem��s�a'shared system.7br.has,a,des.ign flow;of,10,000,gpd:or,greater,the inspector and.th system owner zhal csubm►ts t
th4 ri'to the°appropnate�.regional,office.of.the.Department of.Environmental Protection „ ,. �, I w,�;,it tt tat`� L�s t ' t r�r
J he.ortgrnal,should tie sent:.w. the system owner and copies sent to the buyer, if applicable and the appro{•ing au;hon,�F
7a. f.
v1t'�.4'' S•.• +dt
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'�,. tiktffy"+2Jam,ruv,p:%aa J��� �;I7{ tf , fi„ •. r �,a�, 'k t v+ ni7Yafa <xa6 !cam17
t11
INSPECTION SUMMARY
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��, rysa e r •¢ ,: .. _ h, I�y""�. fr''I t'.+§,;�1 s. •�.'�
ACheek4A;6.yy���:OrdQ.ti�bi��4i� LfifdhrlK' a�y" !sp't'st
d7t'�}oTl 5tf��i'{(:� 10).:Fg 11tS� h;7 b r-'''iFYa •.ii `1 .iii. k k.',^. P ?, rr� 1IS U a st s ,ad tdT � a�sx wt' +.
�- `•" C, ' 1iQlj.:;�rt1.t"yi,fi�F, .11n {)�fa'+33f.f,�l,r1.'! ,�M,;y,s�xttf ?n#?.s45 rYryC£,�4 ' ,5e,..<._!+.$ 'qrf; } `," f. •'.s - ^^'ta} i1x,11>U�rl�P, n'4x",�t as �1i x w '`.' ^�=tft,x�v
ve,not found any,information.which indicates that the system violates any of the failure criteria as defined m;310 CMR 15 303 '�;
Any failure criteria not evaluated are indicated below. yf ,
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'BJ SYSTEM CONDITIONALLY PASSES „' fA
i x ,
-fie •iit ��x �:*.J� -.
. One or more system components to`be replaced or repaired.•I The system;upon4completiontof the�replaf3emeMo�repai�r T
� :y � ,�,i'� ,"`'•
>�,'� ��,kyr T,.. {, t�'y s '�` t, K�"t�.#1"wa�*S `a�,'S�T°�, v}�,x�ns� 0. i��,��,.
:� 't xr Pig' � � � 'f' t.�r �s���.. .�
f Desaibe basis of determination,in all instances. t "
,NG) "not Bete med ezplatn'�h
dedicate y��. o,ot,not determined�(Y,�Ntror, . :` ,f. ,t�.rs, : wn"!, by'�'�}'"�
ry The septic tank �s metal,';cracked structurally unsound,'shows substantial tnftltration or exfiltration, or tank,fallure>i�
r { t 'imminent,'t=The system,t%pill,pass,inspection if the.existing septtc.tank is replaced with.a conforming�septic tank`as M r `;
s.- - + r a,aw s,.t,i e") ,'Jd a rN•r Rti rr;
,approved by the.Board of Health, h, t � � rs�r w
j, .4"1 t +.✓ .i s •.Via, c 'e 2..° A.` .,3 #, d -,�xr>5 $ "i..
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" On�e'vAnter Street e, r Boston,Massachusetts 02108 •>.• FAX(611)556-1049 . e.91
Telephone(61>�292.5500
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T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � �d} z f ,
i xt h' PART A t
CERTIFICATION (continued) ;
yr4
V�V;Property Address:
ffflOwner; [
[ I Date of Inspection: I-&-,%�=
kYY Sy
J y
4u:+ t f4
v r D]SYSTEM FAILS(continued): , r
qY$ 'z id level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool}W/ r
' Static liquid Y:,
�, r ,' 3aad7 s
Li quid depth.in cesspool is less than 6" below invert or available volume is less than 1/2 day flow
V q .
'Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipes) � M �
Number of times pumped__ q..r , , z h /
U r 7 +fir '- r°: i * 'n
k1
�r 6
� cesspool or privy is below the high groundwater elevation , , ��
Any portion of the Soil Absorption System,
ing
n of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply CCC
r rs P ter:
Any portio „g. ,. ., ; '` a S � rt
" Any portion of a cesspool or privy is within a Zone I of a public well K �f
well {
' Any portion-of a cesspool or privy is within..50 feet of a private water supplyr � �+3ak .. �h
°� r ly well with no
f
of well water,analysia for
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supp �;
Y, acceptable water quali� analysis. If the..well has been,analyzed to.be acceptable,*, copy
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
X ��� .
111-��yr��W'Tt �F,' . .. { fi�i����s1. "".` 4•a' ��y���.=f��9�,;sE]LARGE SYSTEM FAILS
r
�#��. +L'•fct' ',' it j•,5.. dr. �f
following criteria apply,to.large. in addition to the criteria above:
e= 9= ' ,.., de5i n flow of system is.10,000.gpd or greater (large System) and the system is a significant threat to3publcheah an40
d sa ety� .
.: y Thf g ^nli� rti Y �r1*i4Tf ° *,•
the environment because one or more of the following conditions exist:
a•. ,rr "rr -' ' .
the system is within 400 feet of'a surface drinking water supply vV
i r r
-`the system is Within 200 feet of a tributary to a surface drinking water supplykT , +c �r
i, r
, "'lipped Zone II of a s
the system is located ►n aFnitrogen sensitive area(Interim Wellhead Protection Area IIWPA) or a mappe x+T
F ` well(, 1 y ,L..'ts,• ''�`*rr54g ..g. r r{ �';�- R , r3y�c . ..,._
public water supp Y � {
p i?e'YF1x w•n _ r7:.
y
k
spy y, rtment.for furtheriinfg tionn,
' The.tiwner.oroperator,of any such: ystem shall bring
the localnreg ovald f4 ,office of the Detpa Ce with the groundvtfeatmen pr
;,Please co 3. �,. . ; .-.
3} tregtitrements of 314 CMR 5,:00 and 6 00 a, ,z
''x
yu+�f4.}.}j F k '[�," •ri•V p `y9'.f'P
'S os` fi sp 7,y'4 { Y-S ,y{, 1 '1k #6b 6 k m' 7, ,:Y.* 4 innF 't4 x�A�,°' .' µ"` _ `
7)'"=t- r^` � i 4f ay ��� F +tt ; A .
3 Q• t 0 y n"v
.�� �}+41:'E •T-p yasK :t� t : A �'x'n'i 'sK�t r �..� �:}.�.
�;� � ,yv�`���x+ y f c r ��� >a€ 3` x� � �,r A, = ""irh,q'+^s't(�"�`�pi;' �, *��'�t•
r �(.�k *y�r t f t r s'A _2p�'� ' ? k x.:�.. y,.. g a 'i .4��a�3F,#�,y�•��f„�. � f
# ^'" •xg? v p d t ,6;..' c� '( k'p"a: r. § " 'tu` 's i
} rxt "y 'y'''"[ 3y.,
_'�{. '4� �a t F?�� � '" ,t "a �``y` wtl�a,L: "*�s;:[ ,« �`y,+4 at+i �,s, 5
'�'"�fi�#r i• •� A �i¢'t n,s ,x .reF , f ,1T Fs
;poised .5/15/8 ► rs4r�,• t t
K"IL
L
AaAiZ
1J
$ t r k s E s,. 'X:7 aF' �` 1 tom^ "§•_
L}
4
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47
SUBSURFACE SEWAGE DISPOSALy SYSTEMi'INSPECTION FORM a # urf , �
PART A • ,
CERTIFICATION (continued).
k 3r
ro
` , Pro°'e Address: 7 Ce�-t. �ti
.i rr4bwner•
s 5wt-';'Date of Inspection: lay k j,y {
BJ SYSTEM CONDITIONALLY PASSES.(continued) �� a , - ,
Sewage backup or breakout or high static water level observed in the distribution box is d stru
ue to broken or ooval of hey
k � pipe(s)or due to a broken,`settled or uneven distribution box. The system ass inspection if(with app
will p a F
f ° Board of Health):
max' broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
,The system;, i pass4 ri
h� k The system required pumping more than four times a year due to broken or obstructed pipe()
{ �x� a 3t
4 ,, ,,� inspection if with approval of the Board of Health):
2-�{,_< A broken pipe(s) are replaced „
,,c A d a^k
obstruction is removed w }, 4 ifi�5)
y���� �,a• .v a, a k4 {� r a,i' S k v ,;:7 /Y ';.2 }; �,.:� �. 1)i�� j�^i.�.�t� yr�'.,�G��� *��,��3���"���
� �L7;'�� iR�`y�e p.7yF .,K()i{ al.'r�:,`$!°rr.� S��"�1s,��i�l.-{.q.�7'f'i� it1iY}."r 7 . yv( '• dt'f'-�.5( j r .. x: .r p.r(�i t k C '*Y'i s.�% ��v ei33�a�
� ' o x it+�tR� {lstl ilbjGi 9 il.;ii tlJf tl `:* S1 i, lj "'N
?` ( ATION IS REQUIRED.BY THE BOARD OF HEALTH: �� ;��
CJ HER EVALU :
n b the Board of Health in order to determine if the system is aahng t p ted" e
' t'�' Conditions exist which require further evaluation y , � a
public health;safety and the environment. ik , ,, Fts_;,� r.t# `t +i F ,k # "�' ' *
r t.,( ., ' ' t(��, i.J.� r k +7. 'F � 2
t
tI1) VSYSTEM.WILL:PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONINGrIN AsMA
*t HICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT
2i t•y 1f f ' '
f. } t r `' ty,�M1 ., L
T •. ,. s(f„ / •. 'b t t;'rdfA"°�v��'k+'�,y�.�s�„t??_
Cesspool or privy is within SO feet of a surface water .. drk ,
Y'R Y'f R y` tY+ E X +s
� � ���. '• C
{; esspool or privy.is withinr50 feet of a bordering vegetated wetland or a salt marsh
'd,� e; n .$ :..t.'t;i_i �Cj»w'ic IYii? tr,} °. kr1�rt:x''�k i$tt.t•','e.k�t`a{! °I'P11,i",' j'Sf 11. i .,.f.�5.P,-, tzrl ,,:>7'�•.`1� 3it44 Xl, (CjC1� s:$1$tlsd§.r, E+,,s_r'•. h� -' es�`' k�Y` ,.
( fi,:: OF'HEALTH (AND PUBLIC WATER SUPPLIER IF,APPROPRIATE) DETERMINESTHAT
Ks �ur Z)�'�dSYSTEM'WILL FAIL`111VLE5S 7HE BOARD.
49
V'ls'S'fjry+f+Tky`rf�`.' 4
i.. THE SYSTEM IS FUNCTIONINtGj INiA1MANNERjTHAT PROTECT=THE PUBLIC H}EALTHdANDtSAFd)ETY AND7�Ha s
} Xt `E(��'IRONMENT'P" l
cyctem nas,a septic tank anti soai auyorptiun system anti is withiat i00 (ck i lv a Suda.c 1M1oc! 5frbuta 1
surface water supply.
,. The'system hay a septic.tank and soil absorption system and as within a Zone I of.a public water supply well r �x s
The system has'a septic tank and soil absorption system andris_within 50 feet of a private-water suppiWelt
ly
el
� . ..=1 �>
K1.
` The,system, as:a'septic.tank'and'soli absorption system and is less than 100 feet but 50 feet or more from a p e well',i
supply'well,'unless';a well wrater analysis for,coliform bacteria aonia nitro ennd volatile rand nuratePn t ogen lsj�is oUPCda equal totortlesselhan 5
t xT
� r , E� ,_ free.from,pollution'from'that facility and the pre ammonia,'r+nitrogen,
� i�� m�tt�a�, ro
�� • Fts m � y jFY3ka3 =atNk
,t i
oi p ., pP df." ` ly:.�i e�i�,'7 F f �k.1�
r+:hj..
a£ DI f#STEM FAILS:
d
=ya w', e f he following failure criteria as defined in 310 CMR 15 303 7h' bevs-
have determined that the ystem violates one or more o t peoessarya.to Correa
,# k Y + ' f' -termination below''The Board of Health,should be contacted'to determine�11 what wll,be f �
„ for this de ,, r� f�
the failure
,!`7 yY 1 r .. . P,af" `"spo }- .
' *R '+ .r ' 4 ' i"'oris 4stem component due to an overloaded or clogged SAS or cesspool nry�s {
t Backup of sewage into faulty. Y .; � f'
a, "'; {{ sy` +, Sttyy ftas �34}i s�3�r�x o;J4i3litia l&4t ttbcf;)2 �r;it 4 tk� s3. , i::krtsrfil ,t* hf e.;
zv 'r.... f,�...Y�ri ,m�firit in,d✓,'r',L taz_.,'�m, 1
•wia % f r+'N7^:.. v} x!1 � '�`
K
Discharge or pondmg of effluent to the surface of the ground or surface{{wateirs`duehtao�aner�lded or.clogg � or
5. 'Y h P e ,✓.yyr' e "` �` _ i d `t 3 b'a.� ` t,, �.,c a3,
s �cf` ry d iY "n q;5 # a c �7'd M {� � _ f as r
�5 r 'ter
,* 13
,z' a. 'sy a. }{'M ry §' (s Y ja M• a k 3? 3 f dr ��h22sssvvv ia"'
'�1>�t"s1. '�'r.• ;� "dye,'
•lie;q�r� M�/�'S i3 c ^.b''�q' [},p��'.Cyyy�M„)N 'i�i'��' .i�_4 F tk'�,#"673',�,Ir^,n..'�} t,i R' Ft�''i: ,7• $./'�.'�'r�L�+'$r3�v�i:4ii�'',&.P$�"t! 'sii',r''k'�.dr'��`�.*'� ��`r jl,.q]q]y y. ,r,,t �::
�'/MR ,i T R•X Xi ,. wr. i!' k �.Yf. T[+ 1�6'4€
'`"� l3�� ,�Tc� � i., r r `: r:'.,. � c ��� ���<'A c�'` �4•�s k •
a r »-t ' vv�
,. o e d t y
s$ry. r '��_k�,3-.$ 'a`�q' t��,rk•s..a�„�� � �`�,�"�
y+ a ar�t'3+.5 t {.. i �e6. • 1 ', E'-r'•y Y"''
''07k' -ik. ._ Fa. D,l°w;:�✓r.,.;,Ra.Ya,+t;c.;?;f,.r �. .
,
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r1:�. Ax
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B y
3 t CHECKLISTGRN
dress: 77 �
Property Ad
3���v� �4.v� �sc-t' r k
IF_T,,
Ownerr,;Gv'gce_ G,j ic,O
Date of Inspection: x ,
S -
M1
Check if the.following have been done:43
t,
t
�tf
,'hl `y Pumping information was requested of the owner, occupant, and Board of Health.
2+ 4.;
� 04 None of the system components have.been pumped for at least two weeks.and the system has been receiving normal,flow rates �t
during that period -Large volumes of water-have not been introduced into the system.recently or as part of this Lnspection
� ,�t��[3�f�}"`�t� ,`;. •+ - ..:. .,. .. ;.. :1,,
RAI
x •- As built plans have been obtained and examined. Note if they are not available with N/A. tY" x
rra •`�} �"_� .x 'The facility or n was inspected for signs of sewage back-up.dwell _
the system does not receive non sanitary or industrial waste flow x` „ �� ♦
r,sqpS ✓The site was.inspected for signs of breakout..
3 �``b 4a 'Y: .• - t f"t 3s'ui4 f k3k- ;,4
� qa All system components, excluding the Soil Absorption System, have been located on the srte;' 't � ,
�Ht �c�y
s �`�; The septic tank'manholes were uncovered, opened, and the interior of the septic tank was inspected fog condttion of baffles orr
{ ,'tees, ,material of construction, dimensions,depth of Liquid, depth of sludge,f depth of scum Y v
sty y�yY{
A �ic=s� 75fi;r�r 3�'� _t3 ,' � .` ,xy��'.- ��. `. .- _ .- :: �. .• '� �...5'y �F`k�{ �4�S.
at,k.q•
The size and location of the Soil Absorption System.on the site has.been determined based on�existing information orz,��� ���.
roximated b) non-intrusive methods. x r "
TheS�sY y
faC.iii,� �., c.',a:,.� o.c p� were provided ts, if dirferen! from owner? with information onYthe proper,maintenance of Sub-��•���f
Surface Disposal System
�� � �(p�kf £ } -' �a: gyp, € '�r 4 �� • ��u F3.tFt (
t .. -.,r' r+.�-♦'- +*VI-a �F,
s��i� F r.., t ("" 1 i•.. - 1 '. .F a ��' y�"� ;fe a1P,n3i:»� ys
i»�'�✓y�-4 �'ddr �`
,-.� J,�t�
r�d a
;f *' `F.## t - ?. r {,F t s}l♦,u r,} ,5 / t
� %'r. 7 .., r r#a 1��'
fda .. .'.`4� `'+ t ,- �+1 ' �
3 .
-�t" i'�'�•�+s a - t { �i f - _ .�'�,l��` � s d(�4ip
c
agr N.T .
i E { tr - vI``.�*,a � L � 1.•s'�.�&4';�..sn�j � .( "A,
-w+4-..,..� �•>a.^f".•St ��.+�f' k
" Fm`:ke "i.y T.:'$ify
�`
4{j "✓`' d
�Y�.Ti�Yt��V C:-�!" 'qu�1Y ',1 9 Y�y, .h,&"� � �.,, '� .e'.' A ,�� � �,�e*ryrh 1' y$•� 5 S'
rG �� e` '�%3 r,r�'�,♦�,,,�� �� r �{ �� F % v.tq#r d w ,� `, ,° x r �k=.'t'7,"`-'�';''`�°..f�`"7F"��' t +�
i , +'� ¢ f ,.Y v .R�3 u�R�:��•'-zFr"a � f��i„ �,�.`�y�', ..
Y .'-' <"yy� ���ri�A to � .; y f ax ; �� � � �'' f ����� `•^:;`r -� �z
yyi # ry.,, {'#a ,• .' jt�' x �." "sfit r ht'r t;.��$,}F+r �4 -•�t �I�b p-T y�' I�_ r. {�. 1f 1 ,R . '3 x"i FV R .k" 114 S '�'�
(Feed61i5/k85! {5 L 4 b y r 3 fly
at*r
LX
x�S" .s r s^ .+-- x.,. ,e' '3.2 „ak,a:a'• 1 y,��..,� �lr� �
.� -:,' qq. 72'�1 '€,,, �s r x r �,.,.• - € > -`fit`' T:fk
x�'*v'
";. ?ky,'±,a;s.-.cr, ':end. •.F"'<•',,e:..e h-;%. .. t.rs ,, _ z:�'3v 'RA�td .M r."i:
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: &-:« G :c.j
Date of Inspection: _
FLOW CONDITIONS
RESIDENTIAL:
Design flow: * V allons
Number of bedrooms:
Number of current residents: O
Garbage grinder (yes or no):_
Laundry connected to system (yes or no):"/
Seasonal use (yes or no): 114
Water meter readings, if available: rV(dt-
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title S system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
yr ,aoL-f
System pumped as pan of inspection: (yes or no)_
If yes, volume pomnrd gallons
Reason for pumping:
TYPE OFfYSTEM
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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: .yr�
Sewage odors detected when arriving at the site: (yes or no)L/
(revised 8/15/95) 5
fir' a�
ji
G
e p
rt
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SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
r1 PART C
SYSTEM.INFORMATION (continued) ; 7. , r
Property Address: ol+t• 4. GC w1
- t + eta{s 3tt She
Owner. 6LT:r �
Date of Inspection:
#Vpc�h//� 7 xr3? _ �t.7�• •��. .a ,t: ..? . k } 7i*?0,;�{{ ,7ry{:;
.rd3 S f x;y�+t x
e `�SEPTIC TANK:
� (locate'on site plan)
�iwr�:sra >. t 7� 1 tic i$ t ttxrt1'j+x4 t�7�`,fa3' -
x 1
' Depth belovr'grade: ; +, 1� '? t '�
Material of construe�ion: concr a_metal _F'RP_other(explain).
{ ,
,.+ a v,,rJx>`k -.,b• `i tart } waif
' N? �, y.:t! yl' - ; 3'• J y'YE' +�I7 jtaf'�°. P_i 5.F ap'�P
�Drensions
13t�aiSludgedepth. _`
SDistance-from top of sludge to bottom of outlet tee or bafflerM.
SCUM thickness:__ s �
1 Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle: `�
✓ rra a,?'S'-;-,i ' p. :, .:. , .... •r r, ,a.,<,...;«, m9s �.'` `•j Fi° t,.#s;.'� "�J''s}7' !,
i t:omments `
( �o emendation for.pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation �o outlet'tnvert, structural t is i
itriegnty,evidence of leakage; etc.) A t es.T c, n.,e z r e S ^ " ¢� { �
c t `f{tC{ N; a?'"tr['llf7 '2 A;nt>�!'.✓* tKi4 't£ -
a•�} .� .T s jc zj;.;, xa ^S f`{ r,43C t,!�'r $'�!'xff'S.i1 fit•?sr•:l '?/"1 FrvaV'1£�� �f Y,
�eb�,s++a+ts�^r, .«,...y. »«... .} -a.•z-t'..<.s,•,+P.«i-n.,l+-. iw,>n;,
,� ,�. ?!s +n:� r�inrh�'ie K+@TFLF7i•t��"i'
V!. '� + anS`n ''w- w,+.,;..i ^:+e•,t.w ,,x .v�>.. r _ ,. ,«.. Mx „. r N!,'$a`S S a� < •£, �,y#-,"-�'.-� t
GREASE,TRAP. ' � f �. "
f ''3r we€ti<K,. V w k t,`� �t En y ,
r, a M gat
x (locate]on site plan} ( (A �
µ }'�-�•1'�i�'� M iru't^^� �.4.e}.g..;;.,ra,v (',.. a.W-•,eyp• ... ..� .w . .. ..,:..
s hrr:` +'t :° . ...• .. -n.s w+a.}' Qs� tr s:
Qepth below grade
x`atenal of construction: _concrete _metal _FRP_other(explatn) - rY*
sgfvy;° - t 2:#-,...3 S >F.:1;'t:gi'r e•'. '''d ''a
pimenstons A
rfS�um thickness:
1,: 1 tiY p y"5 Jitip?'7.�`t�m,Lryy(
r� Distance from top,of scum to top.of outlet tee or baffler .t } { ;
"�ISta'lCP from bottom ni Fnm•tn'hnnnrr et tee.o battle' tr - ++� w•v� wrx N« =r,r ,�
��t'� - yr` �f',; � :'-$ �, t f r '✓!T;ttl !f2 f�5q
� ' � � +" § �,. ; <,,..+ tri•}.ir;�:��+4�r'+,d:�ax � Ti�f�g��tif3Zy��r ��b«" iy`�'�'ats�''t:�
�, omments
4'Arecommendation for pumping'condition of inlet and outlet tees or baffles, depth of liquid level,in.relation to outlet invert, structural
integrity'evidence of leakage, etc► ya
a 7v,445. ixF„ � - . :.+1,� 7 ,. "+�a t. {ts:3 �.Fr1tryE� ttd'Sti'�ai�°ct,�`4!"9v'9F?t'Ea's"fs�«..•'1����
Ti+f'
S1p ,lr::atPt Z hY �=i) ( Tir`'*:a +'1 •"t+�t7ry v {r'�•fi %' d'
r e ;Yx +{ .E AAA
" •w R'Vf�' NN{<.+�Ga'P^'',''x"'Yt'd4'Yr+tYr'*�+ kt, r`4`s"Y'�'M'�-r�aFni .M.wn �rwF>�.«�?+' rw-r ..; + M,«r ri �*•rnn 4•wNg�e� F� a�i
Zk
T.
i p�?�, rFt �+a�.. --'s"C"*T'a*+k.+.."*.'».+.'44a ,+k-e +++ero•m..+49nr,rt :_r .,...w � ,;. t r.s.;. f' M<rya!w. ,w.aegs k"'�v{w�r>««*Yw rh.,4,.�'rl�R ���^�Y��S
y,s� may,,
's.Rk 4 Tyr a7 `� '" n tCf' x, a ,:'i yj�tx'�� ,i4 "4$fl 't?z kn�, yC ,R i+•
'''- '. T .: ;... t.' .3 4 t tt,yr�Yr ,}tr '+'.a`'weg, ,,. i*i.,y;s i;t:• a�fi
� �ag�e+?'+i..�r�n,r��.+�r.:'t'..,..•d-elr.+irw �r..r.a.
F,'f+„;t t� w'L •i,7,,/P" ,� i .v`�, a S i
3' k`
iQgI ,.:� t,�t) �'ri, i§71:}7r}is+iial 2# °t``1`�i Y$ M"" ?raj 5"'•-M' },7�
Yk t 14:r �"' a�"€
,1 l�,r *"�
+: is 6� - �+,�c � ,�.�'�' �x 1� 'PF
sevised a/15/95> q {
?a" i. r "� s ;'3x�]`a t''
� 1. `i.'��) ;may, • k >. I. .� rt � f- r" .� 'S .T 6' "Yy' �u3
jC
SY
�..x ,�«�^SPr�S�-_L,S�- ��" ._�.. t a� .t: .F..:.: a �..•'... �aria` wt �,�:�'a°'�"S^:,,' � ��.a .
}
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A
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t
•"�' SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
4fx� '3. PART C x
r ti SYSTEM INFORMATION (continued)
Property:Adddress:
Date of Inspection:
iz
NIGHT OR HOLDING TANK:�� are x ' f {t tray $rlf. £
,(locate.on site plan)
3T,
.; f ,a. :. .1.. ,. §,., ,�4 !' :f? ti;Y°.z .ifi5f9r${b"• E�Sp S ". i,7sd
'Depth below,grade.
Matenal o(constiuctjon _concrete_metal ' FRP=other(explain)
REDimensions
I,"
iz01 aciq eallons s
fry,
t, Design flow: ¢allons/day
lam level
A.
�� :
31 �t , irJ vaft� 3 a , 1
Comments
� Acondrtion of inlet tee, condition of alarm and,float switches, etc) te a "
,,�3'yHQ�.S,J_` g, Y ' y. :.S,E•w aa,�v,'�yt ��
.A r I wJf {�7 4��f fayt��• .
DISTRIBUTION
e r
(locate on site plan, . ;� F
Depth of liquid level above outlet.invert;�OrZ044
'4tx 3ta a �'•e i k r - ,�r ; fi E ,r•+c.s d.3€^`�
Coments .�,, E,;zY ,, -,«h�..�_«.. ..�,..W,,..., ,..,•k. 1
' j ' rotxrt�a ; i�orb
} lnotef�ii"rle�el and distnbutw!, , rtjua e%!aence of solid,, coir�otier, evidence of le(akage into or out of box,etc)
a I4V IV$
p
r 3
�, r�aRR�-r''+..`;st4i ,N•et s,X .,..,.:.�.-.»., �,;. a , j�. t M4;1.lKeaah+a.4'.:ioV fA}i7 t€.j5 '�i.a�•. t
'� .�k m � ,ry :M 3 •ram :..a. w...... _ � �...,,!>b .a'wa+w.-' � ,� r•1���C
yC�'T G
PUMP CHAMBER: r -t>t �rf57"�rA to ro1<a � y j 4 � �
�,. ¢t �!3t ,j ,f } i stti t'31 fR G! ry�'£f'�IF1e`i,{'r6'i�533491f� i�rr �
''y" x7«u+n r : vwe•�-v 0,
locate on site plan)S!s y r t r 4 } it ewr1 C t $a
.,fps?a ,rnA i✓•rwt+myw^ce�•r+++wPx+A ,w r n+.'.• ro•.r�•aeapwr-- u .,. \uf. A , ,.:tv'nir.t jos .r. 9f i'c'{•*. rr i ,Sr w e k"jw s�a¢
yy�M '�ECf ",t ,., a,jc6, >r.s•a.i...wmw+t.1.�.,.r^t`?I.''^.« .*nx?hw.t,a.Sw �4s»w*F+-:�Y
s
PumQs m workmg order(yes or no)
,Comments3 � +?� �F
r"x. ✓ 4 e « .
e On it of pump chamber, condition of pumps and appurtenances;'etc)
x .4 9'7 4a F
'F 15�c•w.k;-g,. .,y.K ; .. y -{w.. ) .�..}f y w ttv..i r110i�a¢y1JNd,.e1.k"Ail,,t`f,ip2j�31{,If
�d° !,sN+� �; N "„y5 �` _ -.. y � f- �'i 4 � '"i:i'�' �_'�, •r• d+cyr��iy�}yryr�,•} �mk -n.� ., ar x'ew_ax+aen of+�.m1�' bFw
ls+e �r`N3ftry-•a^Nr- ,.w•.ar..-rn„yt»wv i.r�dA•ae:ew .,.,.a _,..v«. �• z •,^ am ,N, `R'�`' f''fi" aa!,> �r rx7T.77
' w+, r.+'�w W y7! >! i "'� �_` r*- y. ,-„� ,.,.- r+W aq, m!!t 3 •smrma#wa .,,!.x+' �3� ..
gg
we ".,
�,ft
1 .:; eta• s r!{- ! - '', a v ,y v,t'�, rs, n s'�,n .,a.� '
y �
� 1 ����1•f�trt� y'. t a'4s+ a X,g .,r !� 5.' r�+4T 4 k�P� 'y
8/15/9$)
fC:..
�"y', � � 't `.�o�s*a �•r: s ,5�`a.r , ,a + iu {i�� cs ¢ s,z.. '
I 421xy 1iw ac a 1 J x-. •1 _ _ } 7.F N }K�� Fa' "T"}ry� .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,` '
: � PART C
r SYSTEM INFORMATION (continued)
4. Property-Address; 77
w# 14 Date of Inspecti 1
`SOLI ABSORPTION SYSTEM (SAS): ' �t
�''n
" rWr �,,,(locate,on,site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain: "
�!'OI(J�t� per` .. �'�A;t��t.� ~�`��"t'
3
`t leaching pits, number:
y �.. „ sou,. ,
0"� `leaching chambers, number:_
leaching galleries, number:
.leaching trenches, number,length:__.
' leaching.fields
number, dimensions:ON
ryti s overflow cesspool, number: y
fit- t
a7. i y
Comments note condition.of sod, signs of hydraulic failure, level of ponding,'condition of vegetat{on,etc.)a
gi
., 3i8+ �e,2'�'a gar�+f u3 -i
�. CESSPOOLS � '�z
4locae on site plan) ��
J y, IV , x t#R
� Numberr,and configuration: +*
Depth-top of liquid to inlet invert:
` ` Depth of solids,;fayer. #` :4
n. L mDeptk.U'scuT layer: !.
s ' , �Rimensions'of cesspool t Y
aterials of.construction:
:}
" {ndicat'ion of"ground+ate ~~ s , max
ri 4, inflow(cessp4.
ool must be pumped as part of inspection)
ty`+.} xyi °3`e'n4'hueks+4'�mm+✓,y+r•..fr Mae:•+-a..�.M�v+'+�.me .., +r rr .� kAf'n'a^�.:.a 's
:
Comments wlnote cond�t�on?of soil, hydraulic fa
signs of ilure,'level of ponding\'condition of vegetation,
r
i 4xi f�t�. �
, (locate on srte plan)�. _� r, � i°
"<`I R's g 'l�sia
}� y"�;' �5��� j-f,:+..,,� i �>u.�. t/..,,�J F'_ _` _ r..; .. �' z:_•t. V*� '4 t ,� -'S'Ar,'� ti,. .�.�.... rL:�: Sty„�'t'`�xy�' t°ih��� b'' 5 `* ��r�X��.
..Ma ,� �» a , - N DlfnenSlOflS GN
�terlalsiof'construction
- '+k�R?�a+".°5.+++r-s+Vjvf'7q��`�` *'•�.nw.siYV�': n .r,:r,;.,.. a r_. _. s �. w..n,..� :�;.w. .-..tir;g.w-a...w.�-.r.»SM,Twa'"�+-✓5�-+�k.7 '�at�
Depth�of toUda ... .
Comments (note condttron of sod,signs of hydrauUc failure, level of p,onding, condition'of.vegetation,:etc)
-
Tel
~ r3
'�+�vn,..es,:asr..,;iFr�.�,�a".�:.+p�+sm11'w..wti;�w•,.np+,wv'. wkacs, , .A �xc��r� wFl;<;l`e ':. �Shs.#,rrl�k,+sq+ `u�T"tr'^�`
yM ;4Yr.`i r.. 4.:.,3. .. .� �.k I✓f.. .�YYlM' ..•..�Y� .-prrr. NO17
f a�t'A ,q'�tOr 4
i
ee^ „tz¢viaedtB/15/85) ; ,
'{ "�L,.u�F��a���.
,€. x�. "'r�x}k i r; � S•- z i"5w.b����k3f�d�s. � .. Y r i�.' M„ ��
tic a+°' ..•- , w x �. s, �;.�,.,.. .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E
x� I PART C
{, a SYSTEM INFORMATION (continued)
d�P operty ddress: `/ '
h�
Owner:..GYace• 13
' Date of Inspection:
;SKETCH OF SEWAGE DISPOSAL SYSTEM:
� � `mclude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
h�
a
z,,,
X Bait} N' • �. J ��r +�' � t '�;�
617
.{'ran
i i s
o
4,
v }�� }} � � I..i�'` `; are• ,y i�d',i„g� ,�'a �`�kLa,?,
sy'_,
•G f! .e' 'i Y ���.
S15
'"
a.
5,�f3sE!;i.
y a„¢.��..��lks ��x is ;t ",'�•'cf+' "�r,#� Y��git�,y.�� �' :.
AN
.v� S1 t
'�'+ �'' `iazt i.1fc _+ �,r' -,yS"' j�:• .,ia tTmr r' 5•piaf�lcra' 3 :rn W i'+§�,�.s,�
-
- •. i r? 3 �� µ
DEPTH TO.Glt DWATER F is a r, ?°
.�q�ry�'�x"�..�•r�„�,c tZ•��,k ''�. ��. /(.4�1R'/4'T�!r �;, ,�.r ;` `'�£ I �` "`r �����ta,.� r r_
weptri tQ groundwater 1`/ .,..Meet�" a•�,;+ Sv �Yt 9 Y5?'�. ;a s /4 60✓�/�-Y$'." �F lLGt rCr. + y€f
od of determmab mat on or approxiion:
e i
l +r
a"`"2r � "sd4' 'It'�a �.`><�v Lr c...- N, 7 r .1±. . �.�.iA �S 2 fi riy `�«•"`i'x`. ya
9xF x e - r �yyf
A � a �.
iA
�• � } 4 �! +ar•7„e[,_ 7 3:. c. E xt Z'I "_° � �'r+ 4S
v- l.rcr+y`a`# 2 i # .I
vyvla 34i t . �:*I C;
5 , �zi� {
'1> "i yE � s Afix �,y,.a./ _ e ,,,... ,`"K"+.`tip t Y.° "k'• 7�` "' Yr s +rtairt r)
No.--•-••-•.......-:�2. Fizs.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F H EA I—t
e. l -..---- --OF.... .. .......�-� � .............................
, ppliration for Disposal Works Tonstrnrtinn 1hrmit
Application is hereby made for a Permit to Construct) or Repair ( ) an Individual Sewage Disposal
System at:
.... -- .....-__..__....... •- -------------------�--. _..... ........fir_.....----•--...----- -•--------- ----......--••-.....--
o � `.
........._ �r P - � ..., ......,fl----- --- �r �r� • Cr-Tr
.�is l�f l.. ......----•---
L Owner Address
a (�d ...... 1 /�'✓�� ........................ .....................
Installer Address
d Type of Building Size Lot �1ii 0,___.Sq. feet
Dwelling—No. of Bedrooms.... ......................---------------Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
dOther fixtures .-•------•---------••---•............••-•••-•-••••••••----------------------------------------------------- -------------------------------------
w Design Flow............ .. �..........._.._gallons per person per day. Total daily flow..........................................._gallons.
WSeptic Tank—Liquid capacity/6A 52gallons Length................ Width................ Diameter................ Depth..............
Disposal Trench—No.-------•-•----_-_- Width.................... Total Length.................... Total leaching area•-___.°-�•-�-••..__._.sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..ctxs_�__.sq. ft.
Z Other Distribution box ( ) Dosing tank �•
'-' Percolation Test Results Performed by......�` V4� _. ^ / °c"�l __. Date._.(t_ i �
a ---_....
Test Pit No. 1—le�f_f......minutes per inch Depth of Test Pit . ......_ Depth to ground water
___________ ._..__..
(s, Test Pit No. 2 _____minutes per inch Depth of Test Pit._.�..__...____ Depth to ground water
/ ...
O Description of Soil......0=ems ..........�A.0........
...
`
x
- - --------------- - -- - - -----------------
UNature 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 TL 1 5 of the State Sanitary Code—The undersig ed fur`tlier agrees not to place the'system in
operation until a Certificate of Compliance has bee, issued by t boa of health.
. o
Signed --- --_- ................•• ••-• •••••-
.. :
at.e
ApplicationApproved By---••---•---• ................................................. -•---_Q. ..........................
Date
Application Disapproved for the following reasons:................................................................................................................
•.--•-•--•-•---•-•••-••••-----•-••----•••---••••-•-••••-•--•--•-•--••--•-••••._........--•--•--•--••-•-•••--••••--------------------•••-•••••-•-••---•-•-•-----•--•-•-------•-•------•----------------
Date
Permit No..:.-4 ------------------------- Issued
Date
No.............. ...... Fu$..............................
THE COMMONWEALTH OF MASSACHUSETTS
� ._J BOARD OF HEALTH
t / � ,. Ju AL
�'z .�' . ................OF.... ..........� ---------•--------..........................
Appliration for Uhip opal Works Tonotrurtion Prrutit
Application is hereby made for a Permit to Constructj(t ) or Repair ( ) an Individual Sewage Disposal
System at: - AV
..... - -................ -----------------------• =• • _... .......----.._..__.....---•••-----......---•------._...._.....-•---•-•._........................--
Location-Address or Lo—No.
vv/
.._.. ._.. ................: : `.._.... --------------- ..................--.....
1_71 Owner Address
a C_) 11C l/ / �4-'"'✓f/I/2� ' ..................... ........................................................
Installer Address 7
Q Type of Building Size Lot!2;. !` .(.._..Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------- -----------------------------
W Design Flow............ ..' r~�._.____.__...._gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity,-P!.U.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..c2r .....sq. ft.
Other Distribution box ( ) Dosing tank,(/
Percolation Test Results Performed by.....:................. •-��.;✓!/L >� __ Date._. ,,.._.:._ ._...._._._ ........
aTest Pit No. ......minutes per inch Depth of Test Pit........... ..•.. Depth to ground water,/�!�!--: .........
Test Pit No. 2 . ^_'?'minutes per inch Depth of Test Pit_ !pp.......___. Depth to ground water ,rrtCf��"
R+' •r ....... ----------------------- ---- -
O Description of Soil ------- .......................................... 0/ . �-�-�---.rA........�._.....�'O�)t 'ss :+.!1G!
W ------------- ---- ... --•---.�.-�-•--•--�i� . ` ' ,- .:_..------...._......._.
--------------------- -- -------- --
UNature 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 IT LE 5 of the State Sanitary Code— The undersi ed furtt:er agrees not to place the system in
operation until a Certificate of Compliance has been,issued by the boar(of health.`/
Signed,.- (�.....
{ Date
ApplicationApproved By...... .+1 ........................................................... ------- .' r _ .....
Date
Application Disapproved for the following reasons:..............................................................................................................
-•-------•-----------------•------------•-----------------------------------------------------------------••-•----•--•-••••-•------•-----•--•--••--•-••--•-•---•-••••--•----•-••----------•-••-••--..••.
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARDi OF HEALTH
........!. ...(i`f `J..........OF...�.✓.. /l� .. �L../... .r ........................................
Trrtifirtt#j� of ToutpliFatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed_(—) or Repaired ( )
by ... :.. % _L .1�?-E'1l_► ? '"--------------------------------------------•---•---•---•----........-•------.........-----...........-----
+ / _ j`
has been installed in accordance with the provisions of T :_Lw9 j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..__.._J._. ,,? -- ............. dated_.... ........__...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... 11_._......... -.!lam---------------------- Inspector......... ....---� ..._.......-------------------•-••-•--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
LT .. ; -.-.Pt'/..........OF.... / 1�:. t� - ............................... �
No... ....... FEE---.....................
Diopoo.Al Works Tonotrnrtion an it
Permission is hereby granted__} tf..�`.... .t.�.......C-------------------------------------------•-•..............-•••••............_._..
to Construct ( ') or Repair ( ) an Indi idual Sewage Disposal System
at No �' � '/rJ, it✓ �^/. .� ��;�tisrr/ �
Street
as shown on the application for Disposal Works Construction Permit N ______________ '�
. •• Dated-•-••-•-•• �....
.....---•-------- . �l. e..f- ---------------------------------_
Board of Healp�ti/
---------------------------------
DATE................................................................................ �
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS =
LOCATION SEWAGE PERMIT NO.
{ Cr .._..., _
VILLAGE (j0�
--l
I N S T A LLER'S NAME i ADDRESS
BUILDER OR OWNER ,A
DATE PERMITIS-SUED
DAT E COMPLIANCE ISSUED,
c:a-ate �o
I
��
;d
4 `
•
r
��
• ;ti
fv
ks,
(.� .yam
Zl
may//[•
Z _�
L
l t{
�y fi
02 vi
ROBER7
}. LEGEND T P.
EXISTING ;SPOT. ELEVATION`, Oar✓` �- BU"IKIS y CERTIFIED '.PLQT 'l i £PLAN '::
EXISTIMG CONTOUR ; -'° p - — �A pNo.221s2�0��
FINISHED SPOT ;ELEVA7_I.O,N 0..01.. f�i�`G�6TEP \`` for u9 13(fz- } �-� w
`m
FINISHED,,- CONTOUR p NA�� �L-y1/j ;:%
FSSIp V
APPROVED =: BOARD OF. HEALTH
Y Ys DATE - . AGENT SCALE /d— 40. DATE 6
8v
1!L.DREDGE ENGINEERING CO. INd) a,
r. CLIENT .. I CERTIFY THAT THE"PROP03.E0 f , .
`7�7 *
EGISTERE� ( REGISTERED'] JOB NO.�. 6 r,� BUILDING SHOWN ON THIS `�PL 'A-w x
s CIVIL ! LAND CONFORMS TO THE ZONING LAW$
.c ENGINEERS,i i.SURVEYORS� OR. BY 0`1 OF BARNS. BLE , M S
rk. d _ s
3'. ..^iC MAIN ;�� 72 MAIN ST CH. BY . �
;�:;, �ARM �.,o 'li, Maims. HYANMS, Ma._ , SHEET_-�- OF ._ w °rDA E EG , LAND SURVEYOR:
20 FT, M/IV. ' /Y07"E /F. E/TNER 7'N,E SEPTIC 'TANS DR
GEffCNinrG PIT ARE ./YORE TNA,iy /2"BELON/
/D F7: M/N. rR 4"D
AOE, /q..2 /AM ET.ER CONG'it' T.E COYER
g"PVC P/PF SJ,rALL ®.E /9RDUCsHT TO 61�i4 0.� .(AN
�L`� 5-S-O M N. P/TC NE'4VY CAST /RO/N Co//ER SHALL SE USEL7
o _ _ COVERS .. IF/N ,DR/VEIVA
2� M/N. C4/VCRFTE"A! °:� it GRAOE CC.) VER CLEAN SAND
DgUID LEVEL
:) 4" CAST 1 .. R•2:r,. 2'LAYER
"• 'i IRON P/PE / O
MIN, P/TC/I GAL a I • • e • • • • r ► e o '
WA5HFD S A/ST. 4 7tINE
Rem �T SEPTIC TANK . . . . • • n
BOX o ti - f.• •
Ir I d d f f •EFFECT/VE • • , v 34
a:� �. : ;: -. :mow p::a.•:... o • ° i f • DEPTH • • f • m o WA5HED STONE
n 1 f • • • • • • f • o 0
e�� a t • • • • • • • • • • o o a iPREC.ASTSEEPAGE 'a
!NI�eRT ELEVAT/DNS o o • ■ o • • • • • • e ° o P/7 OR EQL/IV
EL 4 3 P o ;
INYERT AT BUILDING �Z�O JC _6_ . D/.4M.
IW L E T SEPTIC TANK S 1, S FT• / FT, o/A M E(SEE rgBatCA-�'row�
OUTLET SEPTIC TANK Sj 3 FT.
INLET D/STR/BUT/ON BOX S-/••a FT. SECT/O/V OF GROUND w,4TER TABLE
OUTLETD/STR/BUT/ON BOX S-a. 10
INLET LEACH/Na ,—YT F SEN/AGE O/SPOSAL SK57-,E/w
LEACH//VG 10/7' 7A464/1—ATl0/V
DES/G/V CR/TER/A SCALE %4 = /,- o" DIMEN,S/ON A 3 FT.
D/M.ENS/oN $ 6 FT•
NUMBER OF BEDROOMS 3 D/HENS/ON C FT. /
G,4RQAGED/5POSAL UNIT SO/L LOG
TO TA ES L T/MATED FLOw 330 G,4G.1,9Ay SO/L TEST ,#/ SOIL TEST*2 SOIL'TEST
NUMBER OF -.eACHINI.: PITS r !^ELEK SO•flG BO
S/OELeACHING PER AP/7OFr� SQ FT. Ir , , I� ,DATE QF SOIL TEST �2— AO 2 RESULTS h/ITNESSEO BY � ��i!<! S
BOTTOM LEr4CN/NG PER FT 4-a 4=,dFRC0AAT/0N RATE#/ Le5'S !y//V /NCH
TOTAL LEACHING AREA , Z& b SQ• FT. — <�✓�StJ/L P1E/tCOLAT/ON RATE I+7IN.1INCH
RESERVE GEACN//VG AREA SQ. FT
e>. CDR-'I2 5 C
UY
ROBERT;
p «
I� P.r• t'roAID
�p *gyp, " x
•r ,..a I
BUNIK.IS' to y - ,tx. "'•c .. `*k "TR t.�.`. i. • - x
N�.zzasZ oELDREDGE:ENG/N.EER/NG CO /NG.
r 712 MAIN
��; �_...� � ,(•\ Ca\i '•�-'t.. �s'•'" r„F,. � .•��"r'A a 7yy. �. bya3. 1.,
'€ � r `a < f . .�.�S,+ONA�- .R NG G,IeO,[JNL� yV.4TER.ENCOUN. TEJZEo HY.sNa�� " M,�ss - :So: ri'R'MGurtr,.dr ass•
� � F' C�KDUN�' Y✓A'T'E.Q'A7` ELFI/. � � •..,� 'Q ps . .� ,,• ..Cc �-' .w
e^rt, �X. 5y e'd'V. .,, s „4; • a ..: _ .. x_; r. •p F. M t a -,�p;� VOG/ No.
iy .. t... a .'i F. S y n, - ww , j.3'f v, .4•• pe k h