HomeMy WebLinkAbout0076 BRALEY JENKINS ROAD - Health 76 Brailey Jenkins Road,Centerville
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UPC 12534
No.2-153LOR '
HASTINGS,MN
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM 4
Address of property &,4Z1e y_ ��y�/ter/-S �q� ao
Owner's name 19
Date of Inspection J v / l 7 c� S5rpr ��
PART A �v
CHECKLIST
S �
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been 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.
C-As built plans have been obtained and examined. Note if they are not
available with N/A.
C___The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding the SAS, 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 SAS on the site has been determined base
on
existing information or approximated by non-intrusive methods.
C--The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance -of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
Jr
FLOW CONDITIONS
If residential
�.��number of bedrooms
—,7,— number of current residents
garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
CUs1lPr��7L Last date of occupancy
GENERAL INFORMATION
Pumping rec
q_or ds and source of informatio
� 4 System pumped as part of inspection, yes or no
if yes, volume pumped
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) '
Other ex lain
( P )
Approximate age of all components. Date installed, if known. Source of
information:
"Sewage odors detected when arriving at the site, yes or no
f
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
/ SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade:
material of construction: / concrete metal FRP other(explain)
dimensions: O 2'
�l �l
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
iql ' scum thickness
distance from top of scum to top of outlet tee or baffle
! distance from bottom of scum to bottom of outleL tee or baffle
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, re ommendat4ons for epairs, etc. )
deg
L '
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 0 out of boy,, recommendation for repairs, etc. )
0/1
PUMP CHAMBER:
(locate on site plan) J
pumps in working order, es or no
l
Comments:
(note condition of pump chamb conditio of pumps and appurtenances, j
recommendations for main nce or repairs,e . )
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATIONcontinued
SOIL ABSORPTION SYSTEM (SAS) :
V
(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 and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of_, vegetat ' on, recommendations fo intenance or rep rs,etc. )
CESSPOOLS (locate on site plan) :
number and configure n
depth-top of liquid to i t invert - -
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of constructi
indication of grou ater
inflow (cess must be pumped as M�`
part of ection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of of
Comments:
(note co ion of soil, signs of hydraulic failure, lev of ponding,
condition of ve etation recommendations for maintenance0�re airs etc.
9 P � )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE -=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 00 '
l
c,
13
- = 37
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximat' n:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
Backup of sewage into facility? ����.,
ADischarge or ponding of effluent to the surface. of the ground or
surface waters?
AStatic liquid level in the distribution box above outlet invert?
,Liquid depth in cesspool <6" below invert- or available volume< 1/2 da
flow?
� Y Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial ,�
infiltration? substantial exfiltration? -ta failure imminent?
® Is any portion of the SAS, cesspool or privy:
/v below the high groundwater elevation?
within 50 feet of a surface water? 1 ��
within 100 feet of a surface water supply or tributary to a surface
water supply? -L?-- -
within a Zone I of a public well? _
Ot/ within 50 feet of a bordering vegetated wetland or- salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of
a private Ovate supply well.
P r PP Y
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 ana -
. for coliform bacteria, volatile organic compounds, ammonia nitrog
and nitrate nitrogen.
TOWN OF BOARD OF HEALTH
• p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
4ZA i)
STREET ADDRESS 5
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Ek-a ,d AQ_ :Z.2-
PART D CERTIFICATION
NAME OF INSPECTOR
COMPANY NAME
COMPANY ADDRESS __7 57 9A
Street Town or City State ZIP
COMPANY TELEPHONE ( 5-4 �) FAX
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposil system at
this address and that the information reported is true , accurate, and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check . ne:
Check .
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED
The inspection which I have conducted has found that the system falls to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this i ection form.
Inspector Signature Date 0,�67Zy*,F�-
17 7
One copy of this certification must be provided to the OWNER, the BUYER
(where applicable) and the BOARD OF HEALTH.
If the inspection FAILED, thre owner or'f'�I6`pe*rator shall upgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 ..
partd.doc
J
No. ..._ .
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
L ................OF........�. e...c-;...............................
Appliration for Disposal Works Cnonstru.rtwit thrmit
Application is hereby made for a Permit to Construct ( i.,j or Repair ( ) an Individual Sewage Disposal
System at:
0 ,ea9c�Y el rcaa�� C T
Location.-Addr or Lot N
..... __. �- a ...._` T" s..x- ..i 3> ��.v �P o.
�:c ---- Z �4+ f. ....
a — g z� 1'`�ess
1 .. �^{4' �4�� L� 7 zJX
Installer Address
d Type of Building Size Lot... _�' �' ®---Sq. feet
Dwelling—No. of Bedrooms.•..�..................................Expansion Attic Garbage Grinder H
4 Other—Type T e of Building ��� 1 pa yp g _ _________________________ No. of persons........ ................ Showers Cafeteria (�'
p`' Other fixtures ................................ ........................................
Design Flow............................�. ...gallons per person �r day. Total daily flow............... Z!p..............gallons.
WSeptic Tank—Liquid'capacity/OOQ.gallons Length._�___�!_._. Width. ... ®... Diameter...:............ Depth_v�_!`..61.
x Disposal Trench—No..................... Width.................... Total Length............._..___..Total leaching area....................sq. ft.
Seepage Pit No............I...r. Diameter...... Depth below inlet... ... Total leaching area._Z'4 4 .sq. ft.
Z Other Distribution box ( I;,- Dosing tank_(}--
'-' Percolation Test Results Performed by.... A_x.T�� -._� � ............ Date_...L:_ ��® ..".
Test Pit No. L._'<.2._minutes per inch Depth of Test Pit..... ..2..t... Depth to ground water....J 2_c___"�"
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -------------------------------------------------------•---•------------............. -------•-•---•--....---•-•----••--------• •--•-•......--••--•.-----
O Description of Soil............ - ' `ram...... r�------. ....... G-
x
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
---------------------•-------------------------------------------------------........-•-------------------------------------.....--------------------------=-•----------------.......---•--.-----
Agreement:
The undersigned agrees install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Cer Compliance has been issued bathe oard of health.
tSi ned..- 1'� ! ... _.. at.._...
_.
Application A r� d B .._��___.__...�-�_ __ "-" f
Date
Application Disapproved for the following reasons:................................................................................................................
--••••••••--.....-•--•---•........---•.............................••••-•--------._..........•------•-•---------------------------------•----•----------•--------•-••---------•-----••----••--------•---
//- Date
PermitNo...... ............. .W4•.............. Issued.......................................................
Date
i
No. ._. Fizz. 1.`...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............J.U...CJJ 1j.........OF..........
�� 1/ TG _ �%..................
Appliration for Disposal Works Tontrurtion Vrrmit
Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal
System at:
.. 1. ............................... �?� �. .... � � ✓r c--c......'.--------------------------------
Location-Address or Lot No.
.......... .�-:_...... .ems..------- s1.�--------------- f J G� ...roc" .. ---.1 ._... g Nl...3
W r � Address �(�av(�
a -------------------------------------------- -------�---�-----• G�- l-:_!G.......----.........F 47_........_^__......------
Installer Address
UType of Building Size Lot... 6_0Q_0....Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic 4--) Garbage Grinder ( '
04 Other—Type of Building No. of persons........�---------------- Showers Cafeteria (--�
a' Other fixtures .._.._.�________________ _
W
Design Flow............................1:5- per person per day. Total daily flow__.__._..____.___ _Q._.__.._____._gallons.
WSeptic Tank—Liquid'capacity�_�a_gallons Length._p`3___�_6.�_ Width_: ��.." Diameter________________ Depth t__:_8-�
x Disposal Trench—No_____________________ Width______.____.__._.___ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------------- ------- Diameter..... Depth below inlet___ 3-a ___ Total leaching area__'�-.__sq. ft.
Z Other Distribution box ( k'r Dosing tank.( }^
Percolation Test Results Performed by !3 ?_x-%- Z �........................ / G /o £
Date H
Test Pit No. 1._. ._2-__minutes per inch Depth of Test Pitj___�__2__�___ Depth to ground water____.. ..__._�':_-.
LZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ----------------••---•------•---•-••-•••-- -------------...-•-------...-••---------•---•-...._..-----------•-•-•--••......--••-----•----......--•-----_••••-
D xDescription of Soil............ ......... ✓---r----------vv;� G' " � ------'--
-- --
V -------------------•...-----•---------.....•-•------•-•-------------------•---------------•--•----------•---•-•-----------------•-•-•---------.........................................................
W
x -•---•-----•---------•--•--------•---------•---•-•-------••--•---•••--•--•----------•--------------•------••----------------•----•-•-------------•-•--------•-•-•...._---••----
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
----------------------------------------------------------------------------------------------------•---------••-•••---•-------------•••---•-••-•---------------•-•---------------------•-------------•-
Agreement:
The undersigned a o install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT : of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certifica f Compliance has been issued by the board of health.
Signed........ _ �.........................................................
- ✓1 ..,�'C
+Application APP?oved BY �__Z ��..__..__=--- � t �-------------•------_:_--------........._..-- ------ DJ Date
Application Disapproved for the following reasons:------- '.=----•-•--------------------------------------------------------------------------------------------
...............................•------•-•••-------------•-----------_.._..----•---------------------....--•---•--•-•••--•--•--••------------------------•••-------------•-•-_••-----••--•--•------•-----
��,, Date
Permit No......G-� 411.
-------•_... .. Issued to
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
...........o�.v ...........OF...... �AasT"�9!g._4. ...............................
Cwrrtifiratr of TontpliFanrr
--°_' hat the Ind '-idual by Seiwage_Pisposal System constructed (✓) or Repaired ( )
'l f�j --y�..jam �`�- --------------------------------------------------•-•-----••---------------
at....... 0 ---'�S.l----h' L;rY..._ _!"'S./- jIns ^-------_--_____CC5- L..>:e.................................
has been installed in accordance with the provisions of T=r ` f The State Sanitary Code as des ribed in the
application for Disposal Works Construction Permit No-__ 49 ' 40-------•--•• dated---------- _/__1 _(..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU CT ON SATISFACTORY.
DATE.............. .C�..( ......................................... Inspector.........f- .....................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........../C��./� OF.....� '�
._...._..-_•.......................
No....:.............•--� FEE.... .........
Disposal Works TyAlnstrtulion frrutit , '/
Permission i hereby granted........ := %`J___ '�1.1'�______� ��c K-L
...............................
to Construct ) or Repair ( ) an Indivijd_u.�Ll Sewage Disposal System
at No 5.�---- 2,0 ;, ----- G7V K!N..-s...........-L?-------- � C 3
Street
as shown on the application for Disposal Works Construction Permit Nos "____jl_�_C_ Dat .......�//c, ...........
......
...................�''---�-'--......................................................
�, Board of Health
DATE................ !----•-•••--------_•-•_..
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
ASSESSOR'S P NO. - S 3 Q PARCEL \Z
LOCATION �y SEWAGE PERMIT N
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VILLAGE
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INSTALLER'S NAME i ADDRESS
VL N\` .
e U I L D E R OR OWNER
lco%ad
DATE PERMIT ISSUED tC—
DATE COMPLIANCE ISSUED �—zo
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FOUNDATION -;. 12 OF FINISHED GRADE .
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PROFILE O GROUND WATER TABLE z3.�'4nw
S 1 ID S A L. SYSTEM
DESIGN T
_. NOT TO SCALE � G N DATA
A
BEDR00MS
CONSTRUCTION OF SANITARY D`IS-POSAL
DEStG N FLOW .230
G AL./DAY
SYSTEM , S HAIL.. CONFORM TO MASS.
ENV IR NMEN �' AL CODE TITLE V__ (REVISED7- 1- 77�
LEACH RATE . ', MIN. INCH '
AND THE �i`" t:2 ��1 OF
PROPOSED LEACH CAPACITY :
HEALTH REC ULA"I' t ON S.
. 5�3.S' r�' r2,�
SEPTIC �"`ANK DIS`t"RIBUTION BOX AND LEACHING
PITTO B O REfl,-4FO,RCED CONCRETE : 4 -3
GAL/DAY
MIN. CONCRETE STRENGTH 3000 PSI
MIN. STEE 't- �•`t" RENGTH 2O,0 OOP SC
H 1`0 - DESIGN
® DRIVEWA�'S ,NO�" 't"` O BE LOCATEO .OVER SYSTEM
UNLESS H - 20 DES`tGN LOADING t'S , USED,
® ALL PIPES AN D F!TT 1 NGS To BE WATERTIGHT AN D
TO BE OF CAST" t R ON . `OR SCH E D 40 P.V. C.
, � SH. 1 OF SHs
- S (-€ OWING Pi� OF�,OE D . C +� NSTRUCTirJN
. GE ND
FOR .
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OAR O �` HE A L.TH
,�0v'
e' . . ., Ci
R`E F E R E N C. E13
SETBACK REGULATIONS PER EX CONTOUR 16
: BUILDING S _
t R L hNG
;BUILDING INSPECTOR O BU D
A
O 1 STONER ,
PROPOSED CONTOUR . t6 _ D TE AGENT
.. - C MM S
ELEVATION
MIN. FRONT SE
Ex1sTtNG-s POT, ELEVA 17:+� _
rTBACK
OF
R ICE
s
PROPOSED WATER SE V W , `'
-, / tom . �
tvtlN. .SIDE SETBACK , : , CRAaG
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r ,
s AT
LOCAfitO N
.,' TEST NOLE
MIN. REAR SETBACK .
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PROFESSIONAL LAND SURVEYORS S ENGINEERS
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tSSG MAIN STREET RTE, 6A EAST OENNIS MASS. 02641
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