Loading...
HomeMy WebLinkAbout0076 BRALEY JENKINS ROAD - Health 76 Brailey Jenkins Road,Centerville A= 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 Lu VILLAGE y 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 I V a ({9�_if W d� pe,L\ s SOI L. L.,O G 1p I ' BY: ham' 47 ' w " w _ Suc-scsr,� : r At , k .. , R-x - X N 0 14) pr000 0 I f N 4 v�144 TlF ter ovve�L:�, v,c, c.) c J ! AAA NHOLE � AND COVER TO BE 13UILT WtTH1N`ELE V. TO O F FOUNDATION -;. 12 OF FINISHED GRADE . Q / _ .• kA1N• 2/"' SLOPE FIN - o ► tSHE:D 6RA aE ` , .. a� a- CAST`r RO :... , PVC sCis 1 D ►yi PVC-E: S d H. 4 t) ITCH FT. , . .•r .. �r4 2 �.E Y E L �/ Ad t.N. 2 LAYER s' „. ♦,. .� wit' I r e 3T" Z3tts� k' { a I t3 t 2 P : -- ,> T. EASTON E Pr + .::.. .-.. , - , r. ® : ,��F � T atST. �•� ems.: ! N`V R T ..•: ._. ��. � t V R T ._ I: GALLON _tN Ia a, { i/ // s ? t� tv T BOx. ! t a ! A ♦ _ a 1 4 TAN t.� . �, SEP7tC T - , aC a 'INVERT � � ._ SHED STONE .. , 8 ni £7r .. ALL AROUND . . r s �.3 GARBAGE .• .. GA, t3 A 2 , •� ti. I�.. , . ,r _ ELEY. 'BOTTdM A 0 tut!N., , V. s.., G� E L E 2,.gC3 . r F W 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 . �. 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 r r , s AT LOCAfitO N .,' TEST NOLE MIN. REAR SETBACK . AV 7483 .N C . � fn/R . �► � � � .� STE ION EN PROFESSIONAL LAND SURVEYORS S ENGINEERS AL tSSG MAIN STREET RTE, 6A EAST OENNIS MASS. 02641 ) - J1 N.