HomeMy WebLinkAbout0144 CAP'N LIJAH'S ROAD - Health 144 CAP'N LIJAH'S RD., CENTERVILLE
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t�k �ECYCtfp
UPC 12543No.53LOO
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ttASMOS,MN
TOWN OF BARNSTABLE
1-1 1014,JS SEWAGE#
VP,LAG ASSESSOR'S MAP &LOTL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY _(UU 0 g'f
LEACHING FACMITY: (type) DITS (size)
NO.OF BEDROOMS
BUILDER OR OWNER
4'ERMff DATE: ( COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) I Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 fe t of leaching facility) Feet
Furnished by ���-�
Al a el
fL-;51 wow
13-,33 63 - Ill A O 's
�Y aq oq, �j
�S-k� as-At
LOCQ,TION ' 5EWiS,4::StE PERMIT UO.
WSTAL ER 1JWE ADDRESS
BUILDER5 QDMF— ADDRESS
DLaTE PERMIT ISSUED '- -6 �� 6 —
DATE COMPLI &MICE ISSUED : 'r?
X7 '
�`. ASSESSORS MAP N(kIV
I
PARCELNO-'� '�_'% unumnLOTTI CONSTRUCTuJ ;: 'td .
MCEIVED
Li7"lA!-f5 APR 2 5995
HEALTH DEPT.
SCJBSURFACE SEWAGE DISPOSAL SYSTEM INSPD�1 1 M""'?� PI!STABLE �
Address
/ 4— 1
Date Of Inspection
PART A
IST
Chet{: .i:f the.: following ha �•e �1.�wn done:
Ptuming information''was. requested'ot the --xv e..-, occupant, and Board of Health.
None-0 f the syst_em..canponerts'.11A.ve n pumped for at least two weeks and the
system has been receiving rornal-flow .rates during that period. Large columes
of water have. not been introduced into the system recently or as part of this
inspection.
As Built plaris. have beeh. obtained and examined. Note if they are not avail-
::able
The facil ;ty'oi 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 . aas inspected` for. condition of: baffles or tees, material of construction,
dimensions, depth of:liquid, depth of .sludge, depth of scum.
�f. 'The size and location of the SAS on the site has been determined based on exist-
ing information or approximated. by non-intrusive methods.
The facilityowner (and occu
pLnts, if different from owner) were provided with
information on .the proper maintenance of SSDS.
•
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INKFMATION
FILW CONDITIONS
If residential
number. of bedrooms
number of current residents
garbage grinder, yes or no
yam_ laundry connected to system, yes or no
_ALU seasonal .use, yes or no If nonresidential, calculated flow:
Water meter readings, if available:
C u1,ren r Last date of occupancy
GENERAL INFORMATION
Pumping::records :and source of information:
010 lezorj /�IC .D
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
Sharedtisystem (yes or no) (if yes, attach previous inspection records,
if any)
Other (explain)
Appro?amate age of all components. Date installed, if known. Source of
information
/f)U Sewage odors detected when arriving at the site, yes or no
,
�R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM DW RMATICIN CONTIIVUEp
SEPTIC TA
(locate.`onsite ;Plan)
depth below;grade: �� e
material.. of construction: ]"'Concrete. metal
FRP other(explain
dimensions:: k l k bf}
g sludge. depth
tance from top of "sludge to bottom of outlet tee or baffle
s�;:thickness
!a: Rt;7' fr' tOP Of .scum to top of outlet tee or baffle ~
61� distance from bottcan of scum .to bottom. of outlet tee or baffle
Comments i
(recatmeidation for pumping, condition of inlet and outlet tees or baffles,
depth of licNid level in relation
1 to outlet invert, structural integrity,
evdence'of ge, ` lotions -for
r re airs, etc.)
O
DISTRIBUTION BOX: _
(locate on si;te; Plan)
depth:-'of liquid.. level above outlet invert
�rziients ,
(note if ievel and..distribution is equal
t , evidence of solids carryover, evidence
o leakage into 0 ou of bo r
oX` ShOU tion fro repairs, etc. )
ec mmen
PUMP aiArBER
(locate.on site plan)
pumps in..working order, yes or no
Comments:
(note condition of. pump ,chamber, condition of
reip ndations for maintenance or re pimps and appurtenances,
pairs, etc. )
i
S[TB JRFACE`.SEFTAIM.DISPERSAL:SYSTEM INSPECTION FORM
PART
SYSTEM'INFCIRMATICN OaCINUED
SOIL ABSORPTION SYSTEM:' ('SAS).:
(locate o : site plan,. if .possible; excavation not required, but may be
appro�x mated,by:non-intrusive methods)
If not'detennined -to be present, explain:
Lype
leaching. pits and.'number
leactung chambers and number
�e8 . gall.er1W r and �- - -
leachjng trenches,` number,- length -- ---
leachirig: fields, number, dimensions
overflow cesspool, number _
Cammentss ,
(note oondition.of soil, .signs of hydraulic failure, level of ponding,
ooixiition of vegetation, recorrgnendations for maintenance ance or repairs, etc. )
CSS (Locate; on site plan) :/�O
number aril configuration
depth top of ' squid to inlet invert
depth of' solids 'layer
depth of scum,'layer.
dimensions of cesspool
materials of construction
indication of,:9roiindwater
: inflow (oesspool`,;mustbe. pumped as
Part bf inspection)' '
CXxinents
;*rote eardition of soil, signs ,of ,hydraulic failure, level of edition of vegetation, reco�m�endations for maintenance or rending,
pairs, etc. )
---
(l.ocate:on site .plan)
materials` of construction
`:dimensons
aePth of-solids- .
Ctcnments
(note dltion of soil, signs mof hydraulic failure, level of ndin
ition` of vegetation.., recamiendations for maintenance or repairsg�
, etc. )
SUBSURFACE SEWAGE .DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION awri VUF.D
SKETCH OF SEWAGE DISPOSAL SYSTEM;
include.,ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
i
i
DEP.M.TO'.GROUNDWATER.
L 7 depth to
groundwater
method of determination or approximation:
rUX/r�lcyj -�� w
V .
r . 77
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?
Discharge or ponding of effluent to the surface of the ground or
surface waters? 4
Static liquid level in the districution box above outlet invert?
>/ Uiquid depth it. cesspocl, 6" below invert or availabl.^ von-ume, 1 /2) day---
flow?
AL 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? tank failure imminent?
Is any portion of the SAS, cesspool or privy,
below the high groundwater elevation?
Within 50 feet of a surface water?
Within 100 feet of a surface water supply or tributary to a surface
water supply?`
Within a Zone I of a public well?
Within 50 feet of a private water supply well?
-4 Within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, net the SAS)?
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, amonia nitrogen
and nitrate nitrogen.
x
s.
SUBSURFA DISPO$AI, SYSTEMIN$PECIZON FORM
PART.. D
�'ICATI�V
Name .of,.'Inspector•: / �C
Ccffq:hany' NameOK7
Company Address P'6 06
Certification, Statement
I certify that :I :have personally inspected the sewage disposal system at
'his ddress and t.hk t the infol=ation reportre? is true; accurate avid
"complete as. of :the time: of inspection The inspection was performed and
any reoamiendations'regarding upgrade, maintenance and repair are
consistent faith`my training and'experience' in the proper -function and
maintenance of on-site;:sewage .disposal'.systems.
.
C1f►eck 'One:.
;:I have not found any information which indicates that the system fails
ao adequately�;protect public .health: or the environment as defined in
=310 CMII2 .15`.303 Any.bfailure criteria, not evaluated are as stated in
ahe FAIIJRE.Q2ITII27A section of this form.
<I have .detertruned that the system fails to protect public health and
`the„environment'as' defined in"310 Q t' 15.303. The basis for this
;deterininimation is provided in the. FAILURE CRITERIA section of this
`;form:
Inspector s' Si Vo
gnature
Date y/c�
Qriginal .to System Owner .
Go*pies;to;
Buyer;. (If'applicable)
Approving'authority
P"
No...C�J
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di!iVn,!3ia1 Work.6 Towitrnrtion Plemmit
Application is hereby made for a Permit to Construct ( ) or Repair (>4 an Individual Sewage Disposal
System at:
........... -......_.. ' L rJ" s C �1 lt_�
---------------------------------------------------------------------- ------•. ------....-,----..........................................
L lion-Address or No.
Eg
Ow er Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms-------------- ----------------.-----Expansion Attic ( ) Garbage Grinder &fU
914 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow.................. .......................gallons per person per day. Total daily flow........................®......__.__._._..gallons.
WSeptic Tank—Liquid capacity_/B49_-gallons Length---------------- Width---------------- Diameter----- .......... Depth----------------
x Disposal Trench—No. -------f........ Width-__-_-�...._...... Total Length.._.:, Total leaching area....................sq. ft.
Seepage Pit No.---.-.- .---_-.-.- Diameter-_---._---_-.-.--- Depth below inlet...l�_ .. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by................ ......................................................... Date.....--------------------------------...
,.� Test Pit No. I----------------minutes per inch Depth of Test Pit._.-___---_-----_- Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit--._----_...___----- Depth to ground water........................
9 •-••-------•-•-•--------•....................................................................................................................................
0 Description of Soil.......................................................................................................................................................................
x
U --------------------------------------------------------------------------------------------------------------------------------------------------.....................................................
1T, 4
........................................................................................................................................................... .........................................
tr:
U Natt�e of Repairs or Alterations—Answer wh ap licable._.1 5��' ____-.�......-/--6� _6- _-.... �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complianc as een i ued by the board of health.
Signed ....... ................... .. -- -- --------...... ---------........ -----...�1�19
Dace
Application.Approved By ------------- ...- 3�.Q:..`.��.
te
Application Disapproved for the following reasons- -----------------------------------------------------------------------------------------------------------------------------------
--------------------------------- ----- ------------------------------.........._--------- ------...._-------------------------------------------------------------------------------- ----------------------------------------
DatePermit No. _------------9� :7. .....�f// Issued �.��_'1�
.-_......—.......- �---------- - ----- '--.... ....
Dare
-7
Fxs............�.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirtt#iott for Di-tipwial lVar1w Tomitrur#'tun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (>< an Individual Sewage Disposal
System at:
Location-Address or Lot No. _
_1!y � n�.1.r ? l y`�-•-------= -•----- 1-1 rk.�...... •.... �cl
Owner Address
ac ...........�-�..�s , .� t ___
Installer
� / � Address
Type of Building t - Size Lot............................Sq. feet
Dwelling—No. of Bedrooms__--_-___.-_- -:?................. ..__
. Expansion-Attic ( ) e Garbage Grinder () &JU
Other—QI Type of Building ---------------------------- No�-of persons_______________________.__ -Showers- Cafeteria ( )
0.1 Other fixtures ---------------------------------- -- --------------- ------
Q
W Design Flow................... .............gallons per person per day. Total daily flow---------------------.......................gallons.
WSeptic Tank—Liquid capacity_14llv_.galIons Length________________ Width---------------- Diameter----- .......... Depth................
x Disposal Trench—No. _......./........ Width........ Total Length.___?S'�,ali�_Total leaching area....................sq. ft.
Seepage Pit No--------_-_------ Diameter..................... Depth below inlet-_-:�.�--- Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by----------------------------------------------------.---------------:.... Date........................................
Test Pit No. I................minutes per inch ,Depth ofI Test Pit-------------------- Depth to ground water-.--_____.______--___.-.
fX Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.^---------.............
P --------•---------------_---------------------------------------------------------..............--•------------•••-•.._....---•-..•...........••---•------
10 Description of Soil........................................................................................................................................................................
x
U -------•---•---------------------------•-••---------------------------------------••--•••-•-•--------------------------------------•---------------•-------------•--•---•----•------•-•---•----------•..
w
U Nature of Repairs or Alterations—Answer whe applicable- �'U.=...._. -------f/LJ_a/.. I...._..1-<4-v
Agreement: _5_-y-(.S>>+'�� �Zjo,,� � —__1
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance/'has Peen i/s�_ued by the board of health.
Signed -1~... f_.� z.,
Dace
Application.Approved By .............. J '�.i-, r. ......--...- - - - ................
Application Disapproved for the f 91 owing reasons- ------------------ ------------------------ -------------------- - ..... . .......... -- ............ -------
.... ............................... ...--...--.._..._.......--...- __............. ............................... ..._ . - ...... -- ------------------------------------
Dace
Permit No. .... J.._�..... t(.._. .......- Issued ,
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gertif rate of Q-1-omplinure
THIS IS TO CERTIFY, That-the Individual Sewage Disposal System constructed ( ) or Repaired ( )
--- 772—
at ................. � y -----� " -- _ -r,�--, s-------�, - 1
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ------��t- --:-------r ..l_------- dated .--_ �.-.•..-��_e.��l '-..--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF Q CTORY.
.�
DATE-...... l .......-_. -.-..-.-L Inspects �' � - .._..-.. ""...-.-..
THE COMMONWEALTH OF MASSACHUSETTS / 7c� — / 7 3 r
BOARD OF HEALTH
TOWN OF BARNSTABLE
�t��uottl urk� Juno#r�r#iun �rrnti#
Permission is hereby granted--------------- C�.�....-�.t-G7 /_____..... TntIC�``lcUti]---------------••--...........---
to Construct ( ) or Repair (,>/_) an Individual Sewage Disposal System �,,
at No. L� �� 1 ' -1,5 �: ---a. I at.._........--•--
Street
as shown on the application for Disposal Works Construction Permit No2r_. _ Dated------
..__.. ~S_:, ...4............
�, �...
-�
.............................................
... Board of Health
DATE _ Ci?- ----------------------•-_..
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
r -
�'. TOWN OF BARNSTABLE
LrJCATION 19Y C0T &AIA SEWAGE # Fi
VILLAGE G��` o�1 `i ASSESSOR'S MAP & LOT/g-)-/73
INSTALLER'S NAME & PHONE NO. ,�Ciy(�►�/W G6"-J$' _"I)k
SEPTIC TANK CAPACITY IGLaD 71-,4,4ke-
LEACHING FACILITY:(type) /9(7' 2 ti&J.) (size) (v
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER
BUILDER
DATE PERMIT ISSUED: 17/--���
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
Nat,
1
COMMONWEALTH OF jVWSACHUSETTS
ExECL'TIVE OFFICE OF EN�r'IRON\IE�TAL AFFAIRS
DEPARTMENT OF ENNIRON;IE\TAL PROTECTION
ONE WINTER STREET. BOSTOS. NIA 02106 61"•:S:•!: '(1.
0.
a11-LIAM F.WELD
_ �qy .l9 D.4Ki B ST-KL
ARGcO PALL CLLLI:CCI
Lt.Govcrnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F 'A °��� 9� Comrrissic^
PART A .: : . • ;.
CERTIFICATION
! 4 V�w 1 fR1V j�Cl a� v,IA'�i'[ress of Owne
Property Add Lt YID► r:
ress; l � �+1w 1
Date of tnspec:ion: Il19c_ C�,'�to3•Z,- (1f different)
Name of Inspector. ►1 E�t.C��
I am a DEP ap roved system inspector pursuant to Section 13.340 of Title 3 (310 CMR 15.000)
Company Name:�17o r r��' �► a' r'�Q., ec•c �"-->t"�-�
Mailing Address: 'Pe-) /;oA P 3;P C.c H f}SNOP_Q. H /7- C7 e E-!-`7 .
Telephone Number: SSG
CERTIFICATION STATEMENT
I cer:;� that I have pe•scnall\ mspeeed the seNa¢e d s;osa! s\•stern a: this address and tha: the information re=crr_' be oN is true. :cc:r::e
and cor-ole,.e as o:the time of inspec.0-. The inspec.on vas pe'crmed based on my training and exile-fence in the proper iu-c;c- and
ma,nienance o'on•s to sev _e d;sposa• systems. The system:
Passes
•_ Conc�nonaii� Fosses
_ ♦eec: Furthe• E%-a!uat-a- ry the cal Approving Au:neon
_ Fa.-
Inspector's Signatur Date:
;;;2 SvS:e^ Ir.S::?^,C' Shai' s::bm;: a co;,,. cr'this ir.spec.an re--cr. to the Approving Author;, within th;r,: (:01 CatS CftCr..piel;n( this
inscec;cr.. It the system is a share= system o• ha. a ce:.gn flee. of 10.000 g:d or, greater, the inst:ecer and the sys:e'r cwne• s b`i sutr";t
the re^.oi tc the a_crocriate ree-onat o^:;ce of the Dep:-ment of Erivirenment:' Frotec;or. The erig-na! s iculd t-- se•:t tc the srs;ern ewr(�'
and copies i-n. to the buve', ii applicable. and the aparoving authorir\
INSPECION SUMMARY. Check A, E, C, or D
Al SYSTEM PASSES:
1 have not found any information which indicates that the system vioiates any of the failure criteria as de%ire: in 310 Cott 13.3C"
Any failure c-iteria not evaluated are indicate✓ below.
C0M.MENT5:
El SYSTEM CONDITIONALLY PASSES: -
One or more system components as described in the 'Canditional-hLis' section need to-be replace'or ne¢aired. .The Uste-T_U!V
completion of the replacernent or repair, as approved by the Board of Health, will pass. -
Indicate yes. nc• or not determined (Y. N. or NDi. Describe basis of determination in all instances. If'net determine,', explain w+vy net.
_ . The septic tank is metal, unless the owner or operator has provided the system insrecer with a copy of a Ce.^,ific;'te of
Compliance lanachedi indicating that the tank was installed within twenty (201 years prior to the Fate of the inspection; '
the septic tank, whether or not metal, is cracked. structurally unsound, shows substantial infiltration or exfAration, or tar-
failure is imminent. The system will pass inspe^.ion if the existing septic tank is replaced with a conforming septic Wk
as approved by the Board of Health.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.�t
PART A '
CERTIFICATION (continued)
Property Addiass:
Owner:
Date of Inspection:
BJ SYSTE.M CONDITIONALLY PASSES tconunu
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
_ pi,pe:si or due to a broken, settled or uneven distribution box. The system will pass inspection if(wt,.h approval of the
Board of Health). Describe observations:
broken pipets) 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 pipets). The system will pats
inspection if twith approval of the Board of Health):
broken pipe!si are replace:
obstruction is removed
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which reouire furthe• evaluation by the Board of Health in order to determine if the i}stem is failing to protect the
public health. safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE;LMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFE rY AND THE ENVIRONMENT:
Cess000l or pri%1 is within 50 fee, of a surface water
Cesspool or pri%, is within 50 ieet o:a bordering veget2tea wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETER.,•tl\E5 TH,A-
THE SYSTEM IS FUNCTIONItiG IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFC;Y AND THE
ENVIRONMENT:
_ The sysem has a septic tank and soil absorption system (SAS) and the Sti is within 100 felt to a surface water supply 0
tributary to a surface water sdpoly.
_ The system has a septic tan}:and soil absorption systern and the SAS is within a Zone I of a public water supaiy we!1.
The syste•n has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply wet).
The syste-n has a septic tank and soil absorption systern and the 5A5 is less thar. 100 fee! but 50 fee! or more from a
Private water supply {I, uniess a we!I water analysis for coliform ba&eria and volatile organic compounds indic3tes th_
. weYs
the well is free from pollution.from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to c
less than 5 ppm. Me od used to determine dismnce (approximation not valid).
3) _ OTHER
---------------
(revised 04.135,3") Page 2 of 10
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
Propert% Address:
Owner: T� 1
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes !vo
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 pan of this inspection
As built plans have been oorained and examined. Note if they are not available with N,A.
The farli-� or d%%elling %%as inspected for signs o`sewage back-up.
_ The sv stem does not receive non-sanitary or industrial waste flow.
_ The site %%as inspected for signs of breakout.
_ All syste'r co-wonents. excluding the Soil Aosorpuon System, have been located on the site. r
The septic tank manhoies were uncovered, opened. and the interior of the septic tank was inspected io! condition of
baffies or tees. materta: o• construction. dimensions, depth of liquid, depth of sludge. depth of scum.
The size and location of the Soil Absorption Svstem on the site has been determined based on
_ The iac.lit\ o%%ne• ,ano occupants. if dtneren: from ow•nert were provided with information on the proper maintenance of
Sub-Suriace Disposal Svstem.
Existing information. Ex Plan at 8.0 H.
_ De;ermined in the field !tf am of the failure criteria related to Part C is at issue, approximation of distance is
unaccexabie (15.302.3):b1t
SL_'BSURFACE SEWAGE DISPOSAL SISTEM INSPECTION FOR.m
PART A
CERTIFICATION (continued)
Propert, Add►Pss:
Owner:
Date of Inspection:
DI SYSTEM FAILS:
You must indicate either "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 cleYied to 310 CMR 15.303 The oasts
for this determination is identified below. The Board of Health should be contacted to deter the what will be necessary to correct
the failure.
`
Yes No
Backup of sewage into facility or system component due to an overloaded or clof
gged SAS or cesspool.
Discharge or pondtng 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 distribition box above outlet invert due to an overloaded or clogged SAS or cesspoo!
h cesspool is less than 6" below invert or available volume is less than 1/2 dad• ilov.
Liquid crept. to
Required pumping more char. 4 times in the last year NOT due to.clogged or obstruaea pipe s .
Number o'times pumped _.
An%- portion of the Soil Absorption System, cesspool or prty),is below the high groundwate• eievattor.
Am por;on o'a cesspool or privy is wtthtr. 100 feet of a surface water supply or tributan to a surface water supply
Any porton of a cesspoo' or priv-y is within a Zone I of a public well.
J
An,6 pe-to-• o:a cesspool or privy is w•tthtn 50 feet If a private water supple well
Am• por.or. o:a cesspool or pri.-,• is less than IIQ6 feet but greater than 50 iee: from a private water suppiv well with no
acceptable water qualm anal%-sis. It the well hjA been analyzed to be acceptable. attach cope of well water analysts for
cohiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] URGE SYSTEM FAILS:
tou must indicate ether 'Yes' or "No" as to each of the foll ing.
The iollow;ng criteria app;. to I.arge systems in adq lion to the criteria above:
i -
The system serves a iacilm with a design flow o 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and saier� and the environment cause one or more of the following conditions exist.
Yes No
the system is within 400 feet of surface drinking water supply
_ the system is within 200 feet f a tributary to a surface drinking water supply
the system is located in a ttrogen sensitive area (Interim Wellhead Protection Area _ IWPA) or a mapped Zone 11 of a
public water supply well
The owner or operator of any such syste,I shall bring the system and facility into full compliance with the greunclwater.treatment program
requirements of 314 CmR 5.00 and 6.W. Please consult the local regional office of the Department for further..information.-.. -
I
,(revised 04/25/91) page 3 of 10
SUBSURFACE SE�%AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTE.41 INFORMATION (continued)
Property Address-
Owner:
Date of Inspection:-I`vl1ct
BUILDING SEWER. � p`
(Locate on site plan) W"
Depth below grade.
Material of construction. _cast iron _40 PVC _other texplainl
Distance from private water supply well or suctton I;-t
Diameter
Comments: Icondition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site pl n
Depth below grade
�Q �'�-
material,of construct;o I oncre:e _me;a _f;oe•glass _Polyethylene _othertexplam
li tank is metal• l;s: age _ Is age confirmec o% Cen.iica:e of Compiiance _(Yes.•%ci
Dimensions 1800 !JVVi
Sludge depth- I"I _
D;siance from top o: swoIee to bono-n of ou:;e: tee o• ba,";e
Scum thickness-
_
Distance from top o; scum to top of outle: iee or bake
Distance irom bosom of scu-n to bo-. om o outie; to v bake .
How dimensions were determined
Comments
trecommendation for pumping. [ondrtion o� iniet and outlet tees or baffles, depth of Itq�id level in relation to outlet invert, stru ural
integrity vidence of leaks e;c ;
IF
GREASE TRAP: LO
(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 islet and outlet tees or baffles, depth of liquid level in rela6o"o-outlet-invert, structural
;ntegrity, evidence of leafage. etc.;
(ra—@ad 04/2s:97) Dag• 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-M
PART C
SYSTEM INFORMATION
Propem Address: {4� v-\� ��A o
Owner: CH INi
Date of Ihs coon: S NC ` oy
b FLOW CONDITIONS
RESIDENTIAL:
Design flov. b R p.d..rbedroom for S.q.S
Number of bedrooms 5>3
Number o'current residents O,
Garbage g`. der (yes or no,:
Laundry cor•^ected to syste (yes or no!
Seasonal use Ives or no!.
Water meter readings. if av Table (last two i2 year usage tgpd):
Sump Pump Ives or note
La-: da:e o`occupancv "W- 1
COMMERC;4L'INDL.'STRIAL:
Type of establishment
Design fro%% ta!ionvda\
Grease trap present Ives or no_
Induvrna! %%aste Holding Tani: oresen; sve5 or no_
':on-sancta,\ Haste d,scnargec to the T,:ie 3 sys;em ;yes or no_
\later meter readings if availabie
Las:jda;e os o ,6;2nc.
OTHER: .De:cribe
Last date of occuoa-ic.
GENERAL INFORMATION
PUMPING RECORDS and source of ,niormatior.
N�
System pumped as par, of inspection: tees or no. N
If yes, volume pumped tallons
Reason for pumping
TYKE OF SYSTEM
Septic tank/distribution box/soil absorption system
Srngte cesspool
Overflow cesspool
Pm)-
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, ryes or no)
.. .-
Irbviud 04/25/91) page 5 of 20
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.m
PART C
SYSTEM INFORMATION (continued)
(r�� t
Propert, Address,:�pl��L `"'4T N L►rtj ,S
ON ner: L P41Nt
Date of Insp ction:3((7(1�
TIGHT OR HOLDING TANK: F-A, ank must be pumped prior to, or at time, of inspection)
Ilocate on site plan,
Depth below grade
Material of construction _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions.
Capacrt\•- gallons
Design flo% galtons-da.
Alarm level A:arm in .%orking orde• _ Yes. _ No
Date of previous pumping
Comments
(condition of inlet tee. condition o• a'a•rr. and float switches. etc.)
DISTRIBUTION BOX:
tloca:e on site p;a-
De,-?`' o' liauid Ie�el a00%e oune: )rne^ Aoj W t
Comane-ts
mote c level and d stt but-or is eciva' evidence of s ds car ver, evidence of I ka e t o r out of bon,, etc.r
PUMP CHAMBER: V"V
(locate on site plan
Pumps in working order: (Yes or No,
Alarms in working order (tes or No-
—
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(r.vi..d 04/25197) Pago 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORk1
PART C
�(( SYSTEM INFORMATION (continued)
Property Addr-ss: �'S� `� L%5J9 1)
Owner: toA
Date of Inspection:2 \9 1 )b
SOIL ABSORPTION SYSTEM (SAS):��
(locate on site,plan, if possible, exca%ation not required, but may be approximated by non-intrusive methodso
If not determined to be present, explain.
Type:
leaching pus. number
leaching chambers. number:_
leaching galleries, number.
leaching trenches, number,tength:
leaching fields, number, d.^nensio^s
overflow cesspool, number
Alternative system
Name of Techno)og\
Comments
inote condition of soil'. s+gr s of hydraulic failure, level of ponding, condo n qi veg tion, c.t
n
N
CESSPOOLS:
(locate on site plar.
Number and configurx,on
Depth-top of liquid to inlet inver,
Depth of solids lave,
Depth of scum layer
Dimensions of cesspool
Materials of constructior
Indication of ground"ate-
inflow icesspool must oe pumpec as par, of tnspectiont
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: IkN
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids.
Comments
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
1 -
04;25/9'•) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued
Propem Address: \p„(��
Owner: ' `��
Date of Ins ct�on: g r1g`
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reverences landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
te
Z
OS
- 33' � b3 - aa'
lrev%ved 04'25!5') Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propem% Address• Ktk cs) uN `(
Owner: W -
Date of Inspeciion: �1c�
Depth to Ground ate•A20Feet
Please indicate all.the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
s
Observation o� Site lAbuning property. observation hole• basement sump etc.)
Determine it from local conditions
Cnec� %%ah local B:,ard o- iea::-
Chec. FEMA macs
C'nect. p'*'nping record
Chect. local eica,-xo-s ins:alle-s
t_se Da�i
r
Des cnhe 11 %:x 0 - ;.P'cs ro••• %o_ es:ac'!shec the 6t,& Ground%ate' Elevation (Must be cornpieted'
Y.q• 10 of 10
` r
44 All
t � .
Y
8
l 1
D 24 q c)
24
' 28, A a'
40
1..cT a
141, 00
PLOT- PLA "
! r 1
S/LL E,LE✓.. _Ff�T 4f30✓E PD.�tD
L O CA T/O/\/ c.G-!'
SCA1.E _ ! =4OL IDATE:
PLAN 86/>-Vc- !o r
I AIL-R65Y CEQT/FY 7;L1A T TyE EXiST-
\y /N6 FOUNDAT/ON GOCAT/ON /SCbeQ.E
G �
��<a S U � �45 SNO�'VN gN17 _CONFOQ�y Wlrq
J.
1 THE &U/L.D/NG SETQ.4C�Z�f�JUiQ6M�t/T
�U N OF 7, -- OWN OF
z8J vvl/9TG
LG'd,?�� LUG✓ J1�. _ _
i C:a G,C.�C",..:�A�./�✓ ��/�l�Q�� C�D tvEG 4 ; T.a YGo2 CO.L'P. �I
9 W 14 40Gt/:a VAIZ"O U 7717:bQ7,A44.
No. a" _J Flea... ...!........'....
THE COMMONWEALTH OF MASSACHUSETTS
�._ . BOARD OF HEALTH
.. .........................
Appliration -for BWVoiial Workii Tnnitrnrtion VPrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
Syst at:
Locate ns or Lot No.
Owner Address
Installer Address r� -�
-�_
U Type of Building Size Lot -S. � .....Sq. feet
Dwelling—No. of Bedrooms---------------------_------------------:---Expansion A tic ( ) Garbage Grinder (NO
aOther—Type
of Buildin '�"�® _ No. of persons.___._.... ___.__._._. Showers ( ) — Cafeteria ( )
Otherfixtures - ------••---------------------------------- -----------------------------------------------mom-------------------------------------
W Design Flow........ .........................gallons per person per day. Total daily flow.......... _ .....................gallons.
WSeptic Tank—Liquid capacityl gallons Length---------------- Width................ Diameter................ Depth....-----.-.----
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area.............-------sq. ft.
Seepage Pit No......../.. p g : 1._..._. Diameter Depth below ink"let______ ___________ Total leachin trea.._._.._..__.____sc tt.
Z Other Distribution box (C� • Dosing tank ( ) eh— C� ,,� / ;L -74
aPercolation Test Results Performed bY.......................................................................... Date---------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water...--__--.__.__---.-___-
fz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--..-.---_--_--.----- .
. _ A n ---
x Description of Soil_ z � - ---- ,=� �' ——
V ... st.......
r r .,c
W - --------------------------7..... /`------- - P,- ` s" __--A -- - - -------------------------- -
U Nature of Repairs or Alterations—Answer when applicable.._.___._... ` " ..___ .._... .....___.. --
f-----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further of to place the system in
operation until a Certificate of Compliance has been iss he board he th.
Sigi4ed --------------•- ---------- ---- ------ ...-.. -
, - _...
ate
Application Approved By__ ----�l" __ �/�.l l t,�i- ----------------
�� r' Date
Application Disapproved for the following reasons-------------•-••--•---•-•------••------------•-•------------•-•-•--•------....................---.......-•------
-••-----•---------•------•----------------------------------••----•-------------•-------------------•••---------------•--------------•-------------------------•--------•-•--•---•-•-----•--------------
Date
PermitNo.......................................................... Issued........................................................
Date
,- w�0No..- ................ Fsg...a.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
®c .�.
Appliratiuu -fur 11-4pniittl Works Tuuitrurtinu Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
-... f -- ---•-----••----•-•---•--•-------•--••--•-----•.....--••--•••---•--••........................••-•-
Locate n• s or Lot No.
/� ram LOW C•_ --
4 r�
W Owner Address
Installer Address
UType of Building Size Lot- -`.6- -----Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion A is ( ) Garbage Grinder
pa, Other—Type of Building- �''Y/! No. of persons_._._.... -......-.-- Showers ( ) — Cafeteria ( )
QI Other fixtures ------------------------ - -
W Design Flow----------- per person per day. Total daily flow........... ---------------
WSeptic T.Ink—Liquid capacity;! allons Length................ Width-.... Diameter...........-.-.- Depth.__._.._..--_
x Disposal Trench—No.--_._-.---_-_.-.- Width-------------------- Total Length.................... Total leaching area--------------.-----sq. ft.
Seepage Pit No---------/------- Diameter.....--..5.*sSi Depth below inlet...... ............ Total leaching area........------__-.sq. ft.
z Other Distribution box (C-4- Dosing tank ( ) 010-- -- S= / .-• T 6
aPercolation Test Results Performed by -------- ---------------------------------------------- Date
Test Pit No. 1................minutes per inch Depth of "Pest Pit------_-_--_-.--._.. Depth to ground water......------..-....._:..
f� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water......------------------
--
f - 1.
. --r OD ----- --
,---------
Uescrt Description of Soil__
U Nature of Repairs or Alterations—Answer when applicable...._---
------------------ . .
--------•---•--...-•---------------••-•----------- ----------------�---- 4 .. 1 "'
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further of to place the system in
operation until a Certificate of Compliance has been iss y e boardlte
J3 .
G" --- - --,,�--�---
ed ---------••.. ..- . ------------------- - -
��� Date
Application Approved BY /" � ----- --_-------------- ------ ----------------------- ----------------
V Disapproved for the following reasons:..........................
------•---•--------------------------•---------------------------Date-----------•--
-----------•-------------------•--•----------...---......------------......-•-------------------•-------------.-...-------
------------------
Date
PermitNo........................................................ Issued...............................................
Date
I
THE COMMONWEALTH OF MASSACHUSETTS
---•� BOARD OF HEALTH
-�'�
....................................oF............ . -^ .....................------..................
urtif irate of f�nutpliatta
THIS,J,S' TO CERTIFY, That the judwidual Sewage Disposal System constructed ( <r Repaired ( )
G/ �on .
by .................................
�. Installe
at = �d_--------------P 5 i c '�
has been installed in accordance with the provisions of Art' e� 'I of The State Sanitary Code as described i the
application for Disposal Works Construction Permit No..._ ,Z."J�'.-.-- dated ...��.---x�l.�.!!t--7740.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SAT FA TO
DATE Inspector. ' ------ . . •--•...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7L
FEE--- ............
Binpusttl Nwkfi TIonstrurtiuu Vamit
Permission is hereby granted .... ( 0 a,------------•�c---------------------------...................
to Construct �r Repair ( ) an Ind�ividd I Sewage Disposal System
at No.------- ---•s -------- ,��r`!•-------••-� OJT_
reet /
as shown on the application for Disposal Works Construction P r it No.. .... ...... .. Dated_...�� -
Bd of ealth -
DATE......... .....•-•-- ---- ------------• -------------------
-• oar
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS