HomeMy WebLinkAbout0032 CARRIE LEE'S WAY - Health 32 Carrie Lee's Way
A= 168-008-003
Centerville
5 M E A D
No.2-153LOR
UPC 12534
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pplicatiou for Migonl bpttem Con!Aruction permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ®Individual.Components
Location Address or Lot No.3) C/7(f! ��S A Owner's Name,Address and Tel.No.
Assessor's Map/Parcel c v v (,V,i I V d ?7
��� b i ^(m A
Installer's Name,Address,and Tel.No. t l Aeesi�er's Name,Address and Tel.No.
0r)-can '(Sumfus Soo-3&-/
Type of Building:
Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank _Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ox reeAt r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Cade and not to place the system in operation until aCertifi-
cate of Compliance has been issued by th' oard of Health. 4
Signed "-14 Date
Application Approved by Date l
Application Disapproved f87the ollowing reasons
Permit No. 1, Date Issued
— ———————————— -' —z�— ——————————
No. U � � , �' + Fee �es
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Rppricatton for M.5pogal *p tem Construction Permit
-Application for a Permit to Construct( )Rgair(- )Upgrade( )Abandon( ) O Complete System G Individual Components
Location Address or Lot No. Owiier's Name,Address and Tel.No.
Cry«t� � e.@3W��! `:.:
Assessor's Map/Parcel (� n^ 4,(Igner's
)U'Sb1p4lMA
�,e tr�e,f V� VInstaller's Name,Address,and Tel.No. Name,Address and Tel.No.
660,20n eUrof U-r 4
= So 9-3&L/- r
Type of Building: ,
't Dwelling No.of Bedrooms %3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank _Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) &y repAt f
Date last inspected:
Agreement:
r
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordaknce with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thi Board of Health.
Signed�io ( ,I Date
' Application Approved by + Date
Application Disapproved o�r the following reasons
a
r
- Permit No.�/ / C�— i 7 Date Issued
--------------------- -----------.-------
THE COMMONWEALTH OF MASSACHUSETTS rs
' BARNSTABLE, MASSACHUSETTS BOX rQ- A% �
Certificate ofa C.Ompriance
THIS IS TO CERTIFY,th t the On-s' e S,ewag. D'spp aI S tem Constructed( )Repaired(/ )Upgraded( )
Abandoned( )by C _ a? II I ---)
at 3a C A C 1 tA I has been constructed e;�d i ,accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.2 U I -12/ dated U l.�rP /t
Installer ,11 Rum)"(1,= , Designer
The issuance o/f t `s b nrut hall not be construed as a guarantee that the sys emr fun t, a d ign d1.
Date h inspecter
------------------------------------------
No. _�O I L/— l Fee �U
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mtgpooat *pztem Com5tructton Vermtt
Permission is hereby granted to Construct( )Repair(�Upgrade,�(" )Abandon( )
System located at � t't^1 CA � 61 (! /Arkry
and as described in the above Application for Disposal System C:ncstiuction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions: ; , ,
Provided:Construction must be completed within three years of the date of this pe t.
Date:__ I l.�.2� 1 V Approved by 1 /J A (.
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal^System Form -Not for Voluntary Assessments
°M 32 Carrie Lee's
Property Address
Estate of Louis Dipalma
Owner Owner's Name
information is
required for every Centerville MA 02632 4/18/14
page. Cltyfrown State Zip Code Date of Inspection
1
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When
filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your is
cursor-do not James Ford
use the return Name of Inspector
key. P
P ,
IV
rze Company Name "
P.O. Box 49
Company Address
Osterville MA 02655
CltylTown State Zip Code
508-862-9400 S 12482
Telephone Number License Number
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B. Certification
a
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my trpining and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The!system:
® Passes ❑ Conditionally Passes ❑ Fails
,t
❑ Needs Furthe valuation by the Local Approving Authority
5/5/14
Insp or,s Signature Date
The stem inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,00d gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer,if applicable, and the approving authority.
****This report only describes,conditions at the time of inspection and under the conditions of use
at that time. This inspect!6n does not address how the system will perform in the future under
the same or different conditions of use.
510
t5ins•3/13
Title 5 Official Inspection(,m: Sewage Disposal System•Page 1 of 17
9,
` I .
Commonwealth of Massachusetts
Title 5 Official nspection Form
Subsurface Sewage Disposal' yytem Form - Not for Voluntary Assessments
32 Carrie Lee's
Property Address i
Estate of Louis Dipalma
Owner Owners Name
information is
required for every Centerville IAA 02632 4/18/14
page. City/Town :sate Zip Code Date of Inspection
B. Certification (cont.)
d
Inspection Summary: Chet;k-.A,B,C,D or E/always complete all of Section D
t:
A) System Passes:
s,
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 orl,in`310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments: w
k,
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.
i; . ,
Check the box for"yes", "no"`or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explai".:';
The septic tank is metal an. Over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that'the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
�t
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1,
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i.
Commonwealth of MassAehusetts
Title 5 Official' Inspection Form
Subsurface Sewage Dispos�, l System Form -Not for Voluntary Assessments
°M 32 Carrie Lee's
a
Property Address
Estate of Louis Dipalma
Owner Owner's Name
information is
required for every Centerville A IA 02632 4/18/14
page. City/Town , State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired:
I ;
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed.pipe(s)or due to abroken, settled or uneven distribution box. System will
pass inspection if(with'approval of Board of Health):
El broken pipe(si.
ate.:replaced ElY ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass insped.tiori if(with approval of the Board of Health):
❑ broken pipe(s),a're replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is [Required by the Board of Health:
❑ Conditions exist which ra�uire further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass uriless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the sy.stem is not functioning in a manner which will protect public health,
safety and the environment:
' S '
k
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or priv;yjs within 50 feet of a bordering vegetated wetland or a salt marsh
i�
(Sins•3/13 4'; Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
t
t
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Commonwealth of Massia6h:usetts
Inspection Form
Title 5 Offici
o Subsurface Sewage Disposll System Form -Not for Voluntary Assessments
32 Carrie Lee's 1.
Property Address
Estate of Louis Dipalma !
Owner Owner's Name
information is
required for every Centerville MA 02632 4/18/14
page. Clty/Town State Zip Code Date of Inspection
B. Certification (cont!)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the sygtem is functioning in a manner that protects the public health,
safety and environment:
t
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a Septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a's�ptic tank and SFAS and the SAS is within 50 feet of a private water
supply well. t;
❑ The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to detern`ihe:distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other: '
ti.
I
3�
6i
D) System Failure Criteria Applicable to All 'Systems:
You must indicate"Yes" br,`,No"to each of the following for all inspections:
I
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogg-A'$AS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to ph overloaded or clogged SAS or cesspool
El ® Static�quid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid!:,depth in cesspool is less than 6" below invert or available volume is less
thanday flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
• 6;
Commonwealth of Massachusetts
W Title 5 Official, Inspection Form
Subsurface Sewage Disposal system Form • Not for Voluntary Assessments
°� ,•• 32 Carrie Lee's
Property Address
Estate of Louis Dipalma
Owner I:
information is Owner's Name
required for every Centerville MA 02632 4/18/14
page. Citron:: State Zip Code Date of Inspection
B. Certification (cont.j
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any potion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any bort'ion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any*ion 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 p private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
❑ ®. The system is a cesspool serving a facility with a design flow of 2000gpd-
10;000gpd.
El ® The system fails. l have determined that one or more of the above failure
criteria.exist as described in 310 CMR 15.303, therefore the system fails. The
system.owner should contact the Board of Health to determine what will be
nece"pry to correct the failure.
E) Large Systems: To be c66sidered a largo system the system must serve a facility with a
design flow of 10,000 gpcilito 15,000 gpd.
„q ,
For large systems, you must'indicate either'yes"or"no"to each of the following, in addition to the
e.questions in Section D. j;:
Yes No
❑ ❑ the sy��tem 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
g sensitive area Interim Wellhead Protecti❑ ❑ ( on
Area=.IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"; �any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed.under Section D shall upgrade the
system in accordance with 310.CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
u-i..
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
t t
ii
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal Oystem Form - Not for Voluntary Assessments
e,,'• 32 Carrie Lee's
Property Address
4 'P
Estate of Louis Di alma r.
Owner Owner's Name
information is 3; i
required for every Centerville MA 02632 4/18/14
page. City/Town o- State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
' F
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has tliersystem received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® Were as built plans of the system obtained and examined? (If they were not
availall� note as N/A)
® ❑ Was tire;facility or dwelling inspected for signs of sewage back up?
f .
11
® ❑ Was tl'e•site inspected for signs of break out?
® ❑ Were all'system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the'facility owner(sand occupants if different from owner) provided with
informarti4n on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existinq�information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approxiMation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information `
Residential Flow Conditions:
Number of bedrooms desi •p`.' 3 3
( 9.) Number of bedrooms (actual):
DESIGN flow based on 310,C,MR 15.203(for example: 110 gpd x#of bedrooms): 330
ii
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l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
tit.,...
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I
Commonwealth of Massachusetts
Title 5 Officiar lnspecrtion Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 Carrie Lee's f'
M I
Property Address
Estate of Louis Dipalma I
Owner Owners Name
information is a ;
required for every Centerville MA 02632 4/18/14
page. Cityrrown ;. f State Zi Code
P Date of Inspection
D. System Information
Description: F; r
�i
I ° I
ii
Number of current residents! 0
Does residence have a garbage grinder? ❑ Yes ® No
i,
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) t El Yes ® No
;
Laundry system inspected?, ❑ Yes ® No
Seasonal use?
t, ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
I
unavailable
Sump pump? r El Yes ® No
Last date of occupancy: t unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
i ,
Design flow(based on 310 CLI 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc:.):
i;
Grease trap present? 1
❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
R
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M a 32 Carrie Lee's
Property Address
Estate of Louis Dipalma
Owner Owner's Name
information is
required for every Centerville s MA 02632 4/18/14
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:.;
Date
Other(describe below):
4�
li t
General Information
Pumping Records:
Source of information: unavailable
Was system pumped as pa.rf,of the inspection?
® Yes ❑ No
1
If yes, volume pumped: 1000
jr gallons
How was quantity pumped;determined?
Reason for pumping: maintenance
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)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenancil
e contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
` Commonwealth of Massachusetts
W Tale 5 Official, Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
M 32 Carrie Lee's
Property Address
Estate of Louis Dipalma
Owner Owners Name
information is
required for every Centerville MA 02632 4/18/14
page. Cityrrown State Zip Code Date of Inspection
i,
D. System Information (cont)
Approximate age of all components, date installed (if known)and source of information:
installed on 7/7/83 -per design plan
Were sewage odors detected When arriving at the site? ❑ Yes ® No
Building Sewer(locate onsite plan):
Depth below grade.:
feet
Material of construction:
❑ cast iron ® 40;PVC [l other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
r ..
t i
Septic Tank(locate on sitei'plan):
Depth below grade: ?' 12"
feet
Material of construction: a
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑ other(explain)
i+
i.,..
If tank is metal, list age:
+' years
Is age confirmed by a Certifrcaie of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gals.
Sludge depth: ,.
2"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 or 17
6
y,
iF
Commonwealth of Massachusetts
Title 5 Offid '
01 Inspection Form
Subsurface Sewage Disposal Sys y tem Form -Not for Voluntary As
sessments
32 Carrie Lee's
•IM 9
Property Address
Estate of Louis Dipalma
Owner Owners Name
information is
required for every Centerville _MA 02632 4/18/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 4"
6"
Distance from top of scum ito4op of outlet tee or baffle
�� 12"Distance from bottom of sc'urn to bottom of outlet tee or baffle
How were dimensions deteFmined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present.The liquid was even with the outlet. The tank was pumped after the inspection
The inlet cover was 12 below grade.
� i
C
Grease Trap(locate on sit6 plan):
Depth below grade:
feet
Material of construction:.
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain):
N/a
Dimensions: I
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of sc6m�to bottom of outlet tee or baffle
� I
Date of last pumping:
l, Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
t '
• � is
Commonwealth of Maspachusetts
Title 5 Official,'! Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1.
°�M a 32 Carrie Lee's I`
t
Property Address
Estate of Louis Dipalma
Owner Owners Name
information is
required for every Centerville MA 02632 4/18/14
page. City/Town ,
+ ;late Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
ai
Tight or Holding Tank(tai k.must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal 1 ❑ fiberglass ❑ polyethylene
❑ other(explain):
N/a
I
Dimensions:
Capacity: `
gallons
Design Flow: I'
gallons per day
Alarm present: ' ❑ Yes ElNo
e
Alarm level: — Alarm in working order: ❑ Yes, ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
t
Attach copy of current purr�ping contract(required). Is copy attached? ❑ Yes ❑ No
t;
t .
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Officiats Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�A. 32 Carrie Lee's
Property Address
Estate of Louis Di alma
Owner Owner's Name
information is
required for every Centerville _NIA 02632 4/18/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
Comments (note if box is leyel.and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or:out of box, etc.):
The D-box was broken down.A new D-box was installed. see permit#2014-126. The cover is 2"
below grade.
E
�i
Pump Chamber(locate on`site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition Qf,pump chamber, condition of pumps and appurtenances, etc.):
n
i.
I!
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
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t5ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 Carrie Lee's
Property Address
Estate of Louis Dipalma ti
Owner Owner's Name
information is
required for every Centerville MA 02632 4/18/14
page. CitylTown State Zip Code Date of Inspection
D. System Information (-cont.)
Type:
® leaching pits number: 1-6x6 with 1'
stone. per plans
❑ leaching chambers number:
❑ leaching galleries number:
i
❑ leaching trenches number, length:
❑ leaching fiefs' ` number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of tTchnology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The pit was dry.There was ho signs of failure„ A camera was used for the inspection
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Cesspools (cesspool mustfbe'pumped as part of inspection)(locate on site plan):
Number and configuration N/a
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 El Yes ❑ No
l5ins•3/13 F; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
I "
r
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal system Form - Not for Voluntary Assessments
ti.
MA.
32 Carrie Lee's
Property Address t
Estate of Louis Dipalma
Owner Owners Name !
information is '
required for every Centerville _NIA 02632 4/18/14
page. Cltylfown g, State Zip Code Date of Inspection
D. System Information,
cont.
Comments (note condition,of soil .signs of hydraulic failure, level ondin co
of
etc.): P 9, condition of vegetation,
a '
f
i
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.): ;
N/a
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t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i'
i..
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�M v 32 Carrie Lee's
Property Address
Estate of Louis Dipalma
Owner Owners Name
information is
required for every Centerville page. Cltyrrown MA 02632 4/18/14
State Zip Code Date of Inspection
D. System Informati6n (cont.)
Sketch Of Sewage Disposal�System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
i�
® hand-sketch in the area below
❑ drawing attached separately
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
s;
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I .
i Commonwealth of Mas;'achusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal;System Form -Not for Voluntary Assessments
°M 32 Carrie Lee's
Property Address
Estate of Louis Dipalma
Owner Owners Name
information is
required for every Centerville _NIA 02632 4/18/14
page. CitylTown Skate Zip Code Date of Inspection
D. System Informati6n (cont.)
Site Exam:
❑ Check Slope ; ,
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 25'
feet
Please indicate all.methods used to determine:the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date'of design plan reviewed:
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Using topo andwater contours maps
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS tlatabase -explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report, pleases see Report Completeness Checklist on next page.
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
1
i
. ' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
32 Carrie Lee's
Property Address
Estate of Louis Di i alma
Ow
Owner - Dip
alma
s Name
information is
required for every Centerville _NIA 02632 4/18/14
page. Cityrrown State Zip Code Date of Inspection
E. Report Complete6es,s Checklist
® Inspection Summary: A,'B, C, D, or E che(.ked
® Inspection Summary (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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t5ins•3/13 +.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
�
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BOARD OF HEALTH
���. ° �
� ���«�����ou�ww^� ��m���xuxwoo�� 4�»u»�m�» ���«�w����u��mwo� �����4��
. ~ �-
Application is hereby made for a Permit to Construct (��/~or Repair ( \ an Individual Sewage Disposal
System at: 4 \ � �_. _~��
kA
Installer Address
Type of Building :3 Size LotAZA-1...I......Sq. feet
Dwelling—No. of Bedrooms................ Garbage Grinder (V
Other fixtures
---.--.--'-..-----------_--_----.--.-' . - .
Design I�uvv-.-.---.\�� ��-- o6}ooa per person per day. Total d�6/ flow-.--'��.'~���....--'.....��1000�
ScpdcTxok--Liquid* loua Length................ Width................ Diameter--_-_.. Depth................
Disposal Trench--No. .................... Total Total f t.
> Seepage Pit 0u'--'-_-'' .................... Depth below Total ft.
� Other Di��6o600 �x ( ) Do�o nk
~
^� ft/colu6 � Res
ults Performed by.- . - -' Date-L-����� ' ---_-
Test Pit No. l-----.miuutcoyec��b Depth of Teo PL� .-..--'Mthtog7ouo6 wutc ------
rT4 Test Pb No. 2................minutes per inch Depth of Test Pit.................... Depth toground water.-----...--.
1:4 -'-'.-__._-.- __ __
0 Description of
-------------.._--'_.--''-----'—.-_-_----_'_------'---_''----'-------_----'____-
U Nature of Repairs or Alterations--Answer when '-.-----.---_-'----'-'-...-._-_.---_-_-
--------''-- ----'-----'----'----'--'-'-'-'—'---------
Agrcnneot:
/ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
� the provisions of I 'APILj 5 of the State Sanitary Codo—The undersigned further agrees not to place the system in
opccu6ou until u Ccz66cuzc of Compliance has been issued bv the board ofhealth.
'��'����.. '
Application Approved B ^���'....----------------__---------------' --- ���.��'��-
' te
Application Disappro hefollowing reasons:...............................................................................................................
-
.........................................................................................................................................................................................................
� Date
Date
No.__ : _.:. Fxs... //..�..
.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c.`• n.............
Appliration for Diiipoittl Workii ( ontitrnrtion Frrutit
Application is hereby made for a Permit to Construct (L,,)'or Repair ( ) an Individual Sewage Disposal
System at:
-
,�L:� .1. ........:. � ._•__' �)�.1�1� ...._. . Y�' L ��j .._
.................... .' ...........................
Location•Address or Lot No.
A .O,er Address
a ,��_. ^'•4*'f t'......... �^ -�� �� ?_i.-!�..d` d�_..::..—:.: •/ ,J._l..�T nn............................
Installer Address t
CQ} Type of Building Size ......Sq. feet
Dwelling— No. of Bedrooms.................. ---------------------Expansion Attic (k)l Garbage Grinder
Other—Type of Building No. of ersons____________________________ Showers
Aa YP g P ( ) — Cafeteria ( )
Q' Other fixtures ........................................
Design Flow__________________ ................__._____.__.____gallons per person per day. 'total daily flow............ ................gallons.
W ,
WSeptic Tank—Liquid capacityli)t}.)_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..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by........ ir�t... !______..:. �_, �` :�---....._.... Date___Le,z.n.1_:'. +—".............
aTest Pit No. 1________________minutes per inch Depth of Test Pit.............J... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-•------------------------•---------•--•--•----•---•-•-............------•-------•------..._--------.........................................................
p �,
Description of So><1........�-----�----------�.:�-r�--!�--•---.....:�_...:.............=U=--`--�-�'i-�`-�• --------
U _ !� - -•--••--•-----••-••.........................
W ..._........._......................................................................................_...................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.
---------•-•--••--•------•--•------•--•------------------------•-•---------------------•------------•-•-----------•.--------------•-•--•---•----•-•---•_..___.._._._-._._.....--•-•••••--------.....----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of Health.
,Signed
Application Approved By�......._..
Date
Application Disapproved f orthe following reasons: ...................
---•------------•------------------------------•-----•-••-----._......_..-----------------......_......----------..------------------••-----•---------•---------...-----=-•------.__••-••-••---•__....--
Date
PermitNo......................................................... Issued_.......................................................
Daft
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... .........OF.......... S... ..,..............
Trrtifiratr of f anplittnrit
THIS IS TO CERTIFY,..-That the Individual Sewage Disposal System constructed ( or Repaired ( )
by....... ........... ...........................:.................._..._..._._...._.._.........--------._....---------------------•------.._..._......
Installer ll`
at. . _---- -�Xn
has been installed in accordance with the provisions of TI. I� 5 of.The State S�nitary Code as de*eribed in the
T F
application for Disposal Works Construction Permit No.........__.:.._" __../____________ dated_..:_____�._..��___.....................
THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE
/
CONSTR GUARANTEE THAT THE'
SYSTEM N7F7FTION SATISFACTORY.
DATE..... .............................................................. Inspector.................. _•-•••-•---•--•----••---..........-----••••-•--THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HI=ALTH
w.. ...........OF............... �.C�� e.............
No.....,............................ FEE........................
lgiiipaoal Vorkii Tomtrttr#ion Vprrnti#
Permission is hereby granted.____._._ ����__ ?,n.. ............... _._____............_.......
to Construct ( or Repair ( ) an Individual Sewage Disposal System
atNo........�._ .......... ---•-•-•-••-• - C= ..-------------1- •-•-- •-
Street
as shown on the application for Disposal Works Construction Permit No............. �`Dated___,......... .....................
-•---•-------•-----•�---- L-.�.�
DATE....................................:; aa d�/•-•-•----•--•------- l Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON [
�I..�,�►.►G�.C-. FAM�L�( - ;3 BGORnoM
I 1Jo GATtBAG& "6wNDE2
�i DAILY ;=LOW c 110 A 3 = 3306.PP 1,1°
�I SEPTIC, TASK = 390X15o% = A9iG.Po
I u5E- ►000 GAS... �, J
Y
o%5Po5AL PIT v5c 1000 (SAL.. N LC,;-
IV
BOTTOM AREA- , ,�j 5F, �` Az A „pSP.o M
1. 0
-ToTA�. �F.51 GN e 42-5 (�.?D. `18.3 `r 9F.1
'TOTAL pA 1 l.Y FL OVV =
N r.,a. I
PE2c0I..A.T►ON GZATE - I''IN 2MIN o�L�55
IFou0tbAT1oN
It lip _
Y�P`SH OF �� III
0f M'RS's ALAN tiG 4-1. i
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l RICHARD �, o W. 98.2
A K JO E
( 9AXT.ER n No. 2 0
Na 24048 o C,
�Qlg7�R� Q• '^ E i
WA
TE'�T P�oBs '�s9B To FND=loo.op
,I LOAM q 1000 lN�.
SUBSOIL D1ST. IIJV. GAL sg
56PrIC
I DSO I N�/. 9:J'G TA►1 K
I,..EAG41
P IT INV. INV.
CL• wlTu 95.2 95•¢
WASNG D l
670 N E
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PRUFIL� L044-T►0N
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I C E RT%F Y Z N AT THE i-G7V�J�1�T7oI� 5�10�rYN
}1EREo1.1 C,OMPLYS WIT4N"THE S1p6L1t-1 � �� !
AuD 6ETe4GK Rr6QvIR.fcM6NT� o�FZ1�E- i
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LOCPTED WITNIIJ TN6 GLOaD PL.AI
DATA G-23•f33 Ct � - gAXTEcz.e N`(E 1N�.
REG I Sz icQ6rU'vAu�5 u izv EYoL'S !
W5
7%415 PL&► J 15 NOT' r T� o1d A KJ 4>6 -9-VILLE - MA�s•
IW5-T'RuMENT SUeVEY �-TNE o17-F5ET5 SuouL C
NO-T e,& USED'T0 C7E'TE��I►.lE �.c-r �-11-IE.� APPLIGA►JT• It-t4
J
LOCATION SEWAGE PERMIT NO.
y�VILLA
INSTALLER'S NAME i ADDRESS
IgAllex z r7y/9 r
d U 1 L D E R OR ONIN ER
e 5114!r14
DATE PERMIT ISSUED � �� � — 33
DAT E COMPLIANCE ISSUED -41
3$ r 41,
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