HomeMy WebLinkAbout0072 CROSBY CIRCLE - Health 72 CROSBY GHCLTE,CENTERVILE
A-187.023 00
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UPC 12534
No.2�153LOR
HASTINGS, MN
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No. 3L4 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ves
PUklC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Migpogaf *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(x)j Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 72 Crosby Circle Owner's Name,Address and Tel.No. 7 71 —8 2 7 7
Assessor'sMap/Parcel Centerville, MA Eric Riedell
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
Wm E Robinson Sr Septic Sry
PO Box 1089 , Centerville, MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no)
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 sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 septic consisting of
1 500 gel 1 can tank, D—hox, a I H-20 GtnnPpac-kPr1 maxi mi7arG
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 Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this d Health.
Signed 27 Date 6�-V2
Application Approved by Date 7
Application Disapproved for the Yollowing reasons
Permit No. _7 3 Date Issued
--------------------------------------- �r■
No: ' t• . ) c-/ Fee$5 0.0 0
THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer:
UBLX HEALTH DIVISION - TOWN OF BARNSTABLES MASSACH,USETTS es
y- ftplication for Migogat *pgtem Corigtructio:n Permit
Application for a Permit to Construct( )Repair(X4 Upgrade( )Abandon(? ) ❑Complete System ❑Individual Components
Location Address or Lot No. owner's Name,Address'and Tel:No. 7 71 —8 2 7 7
72 Crosby Circle _
Centerville MA Eric'Iiiede11 �`--A
Assessor's Map/Parcel ► -
Installer's Name,"Address,and Tel.No. 7 7 5-8 7 7 6 Designer's Name,Address and Tel.No.
Wm E Robinson Sr Septic Sry
PO Box 1089, Centerville, MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot'Size sq.ft. Garbage Grinder(no)
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 sand
r. Nature of Repairs or Alterations(Answer when applicable) Title 5 septic consisting of
1S00 gallon tank*, D-box, a 3 H-20 stonepacked maximizers_
Date last inspected:
r r
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 Code and not to place the system,in(operation until a Certifi-
cate of Compliance has been issued by thi rardof Health. I "'I-
Signed -ze, / Date t4-7'
Application Approved by Date 7
Application Disapproved for the ollowing reasons
Permit No. Y / - 7 T3 y Date Issued
--- — -- — --- -- — -----
H-0OMMALTH OF MASSACHUSETTS �'- _ �i --'
Riedell BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site,Sewage Disposal System Constructed( )Repaired( X) Upgraded( )
Abandoned( )by _"
at 72 Crosby Cir, --Centerville has been constructed in accordance
Jill with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 7, 731 dated
Installer W E Robinson Sr Spt Sry Designer
The issuance of this permit shall not be construed as a guarantee that the system ill function as designed. '
Date Inspector
v
———————————————————————————————————————
No. / 7" 73 f "'Fee$50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Riedell Migp�ogal *pttem Construction Permit
' Permission is hereby.granted to Construct( )Repair(x )Upgrade( )Abandon( )
System located at 72 Crosby Circle
Centerville, MA
Installer: Wm E Robinson Sr Septic; Sry
and as described in the above Application for Disposal System Construction 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 permit.
Date:�� - �! - Approved by` �'�
•
NOTICE: This Form_Is To Be-Used For the Repair-Of Failed
S-M ie-Systems only.,
CERTIFICXT.ION aP SKETC11-AND-APPLICATION OR-,. .
DISPO�A-L WORDS CONSTRUCTION PERMIT-(WITHOUT
ENGINEERED-PLANS)
I,. William&..Rohinsaa S.r._.' ,hereby certify,thatthe.applieation..for..disposal..wprks
construepon per-nut signed by-me rated ���� `j`� � concerning the
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property-.located_at.- 72-.gosh ..C.i ele._Center.yiHe,-At&,_ meets-all-o�the
P
following-,cxitzria:
* There are.no,.wetlands.withai-.100-feet of.the-propowd-leashing facility
* There areno-private.wells within150.feet-of the proposed-septic system-
There-
* is-no-increase..in-flawandior.change.-in...use..proppsed.
* There aj:e_no variances-requested-orneeded
•
* If-the-proposed..I=hing.facility will..be..located with-250 feet-of any wetlands,the bottom of.the-,
proposed ip .hinu.facility will-=bclocated-less.than_fourteen(1.4)-eet.abovethe MgxiM„m..ad*ied
i'
groundwater.table elevation_...
Please complete.the.following--
�
X}_Top.of.GroundElevation..(accordingto_the.Engineeriug.Division..G.1S:-reap). _ 0
I
B Observed-Groundwater Table_Evaluation(according to.Health Division well 1w)-i L 1>.� 7
SIGNED: � DATE.•Jj �`�
I ICENSED•SEPTIC SYSTEM, INSTALLER IN THE T4WP,�O BARNS'TABI E.NUMBER. 60.
(Attach a skctch4Aah..of-the promsed-system-Also-if thelicensed_installer posesses.a.zertiiied.plot..plan,
t1�is-plan-shorrldbe-subn�ted}..
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TOWN OF BARNSTABLE `
;,LOCATION �r7�
'?a S Cy C► Z SEWAGE A �� I
VILLAGE '" ASSESSOR'S MAP& LOT
>{rNS.TALLER'S NAME&PHONE NO. ��,`� /�'' �-' ?
: . .:-SEPTIC TANK CAPACITY l.S
LEACHING FACILITY: ((type) ieh 3 (size) -
,'NO.OF BEDROOMS J
;.BUII,DER OR OWNER
'.PERMTTDATE: Ion `�4I"mil 7 COMPLIANCE DATE: .' S` g
°'$eparadon Distance Between the:
.'Maximum Adjusted Groundwater Table and Bottom of Leaching Facili Feet
;Private Water Supply Well and Leaching Facility (If any wells exi
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands st
within 300 feet,of leaching facility) Feet
urnished by`
Cf
i� TOWN OF BARNSTABLE
LOCATION / Y�o s�Y C SEWAGE # `
VILLAGE ASSESSOR'S MAP &LOT IMP
b 2�
INSTALLER'S NAME&PHONE NO. a 4 I Z "' `7 (y
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 3 '/�s'�d io& Jz 3 (size) f/'a27- ;L
NO.OF BEDROOMS
BUILDER OR OWNER C/41l/
PERMITDATE: 1A ` 240/''Z COMPLIANCE DATE: ,
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facili Feet
Private Water Supply Well and Leaching Facility (If any wells exi
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
i Furnished by
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,per
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 72 Crosby Circle
Centerville
Owner's Name: Sharon Riedell
Owner's Address:
Date of Inspection:
Name of Inspector: (please print) Wi 1 1 i am E_ Rohi nson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5—8 7 7 6
CERTIFICATION STATEMENT
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
training 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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature. Date: ��
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthmr
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
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Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Crosby Circle
Centerville
Owner: Riedel l
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syste 'Passes:
V I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
expl in.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
uns und,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
exis ing tank is replaced with a complying septic tank as approved by the Board of Health.
*A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indi sting that the tank is less than 20 years old is available.
ND explain-
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 a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
9
distribution box is leveled or replaced
i
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND xplain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Crosby Circle
Centerville
Owner: Riedel l
Date of Inspection: -d /
Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is falling to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
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.
LThe system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
rivate water supply well**.Method used to determine distance
*This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
acteria and volatile organic compounds indicates that the well is free from pollution from that facility and
t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
ilure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Crosby Circle
Centerville
Owner: Riedell
Date of Inspection:Z-/' -0
D. System Failure Criteria applicable to all systems:.
xou must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ E Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the 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 portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
( Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I 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 necessary to correct the failure.
E. L rge Systems:
To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd•
You st indicate either"yes"or"no"to each of the following:
(The f ]lowing criteria apply to large systems in addition to the criteria above)
yes o
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary,to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If y u have answered"yes"to 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
sign ficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.3 34.The system owner should contact the appropriate regional office of the Department.
4
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 Crosby Circle
Centerville
Owner: Riedel l
Date of Inspection:
Check if the following have been done You must indicate`yes"or"no"as to each of the following: -
Y No
7_ Pumping information was provided by the owner,occupant,or Board of Health
_s-,—/Were any of the system components pumped out in the previous two weeks?
Has the system 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 available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site
L/ _ 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?
3/ _ Was the facility owner(and occupants if different from owner)provided with information 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:
Yes/'no
Existing 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(3)(b)j
5
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 Crosby Circle
Centerville
Owner: Riedell
Date of Inspection: , o
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR.15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: dv A
Does residence have a garbage grinder(yes or no)/L
Is laundry on a separate sewage system(yes or no);i [if yes separate inspection required]
Laundry system inspected(yes or no):/Lo
Seasonal use:(yes or no).A U
Water meter readings,if available(last 2 years usage(gpd)): 2000 66,000 gal.
Sump pump(yes or no):�/O 1999 71 , 000 gal.
Last date of occupancy: L— d
C MERCIAL/INDUSTRIAL
Typ of establishment:
Desig flow(based on 310 CMR 15.203): gpd
Basis f design flow(seats/persons/sqft,etc.):
Grease ap present(yes or no):
Industri� 1 waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water I eter readings,if available:
Last da a of occupancy/use:
OTH R(describe):
GENERAL INFORMATION
Pumping Records
Source of information:J9 / 7
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TY F SYSTEM
eptic 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 maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components date installed(if kno )an ounce of information:
Were sewage odors detected when arriving at the site(yes or no):_
6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Crosby Circle
Centerville
Owner: Riedell
Date of Inspection: (:—l`l—o
DB DING SEWER(locate on site plan)
Depth below grade:
Matelials of construction:_cast iron _40 PVC_other(explain):
Dista ce from private water supply well or suction line:
Co ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ locate on site plan)
_( P )
Depth below grade:�_
Material of construction:_✓concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) C � � q, �G ,L r`
Dimensions:
Sludge depth: I —X ' ' I '
Distance from top of sludge to bottom of outlet tee or baffle: L� y
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: `l
How were dimensions determined: 6 F4?.*— r-4o4 X
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.): j/J ///►`
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum t,ickness:
Distan a from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as rel ted to outlet invert,evidence of leakage,etc.):
7
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Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Crosby Circle
Centerville
Owner: Riedell
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: /(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:(1
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): 6 1
CHAMBER: locate on site plan)
PU ( P )
Pump in working order(yes or no):
A] s in working order(yes or no):
Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
~ Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address72 Crosby . Circle
Centerville
Owner: Rie ell
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
'leaching pits,number:leaching chambers,number:
leaching leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer: -�
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PR (locate on site plan)
Mater' is of construction:
Dime sions:
Dept of solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 0fII ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Crosby Circle
Centerville
Owner: Riedell
Date of Inspection: g' I
SKETCH OF SEWAGE DISPOSAL SYSTEM
al system including ties to at least two permanent reference landmarks or.
Provide a sketch of the sewage disposal y g
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Crosby Circle
Centerville
Owner: Riedell
Date of Inspection: '- 1
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water .i feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
-,"'Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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TOWN OF BARNSTABLE
LOCATION 6X C) SEWAGE # -
VILLAGE_ ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type).,?—,A ,d ,6 ,9z ,j (size) //
NO.OF BEDROOMS
'BUILDER OR OWNER
PERMITDATE:� ���b'�l �/ COMPLIANCE DATE: m I
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facili Feet
Private Water Supply Well and Leaching Facility (If any wells e)i
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands �Stf
within 300 feet of leaching facility) Feet
Furnished by
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SHORELINE TANK SERVICE, INC.
87 Pond Street
Osterville, MA 02655
(508) 428-5529
Mr. Eric Riedell March 10, 1997
72 Crosby Circle
Centerville, MA 02632
For: Removal of (1) 500 gallon underground fuel tank.
Includes:
Necessary permit.
Excavation of tank.
Fire Dept. inspection upon removal from ground.
Cut and clean tank.
Transport tank to an approved facility.
Backfill site to grade.
i
Total $950.00 n
SHORELINE TANK SERVICE, INC.
87 Pond Street
Osterville, MA 02655
508-428-5529
Storage Tank Removal Receipt
Da te: F _ � ?-----=
Type: oit_- ------=-
Gas-----------
Other__________
c �« I --- __. ----------....____-- ----- ---- -
Address-----2,.C1:2s�_4--C,1SA�-------------------------------------
------------��-'.rT/2v�// f 17A�----------- -•--------------------
-i�;�lliC.$l'Le: SOO C�AIIG�-------------•----------•--....--------•----•---._.__-•_
Oats: Removed; l_��.L���,� t'1-------------- --=_--_--
-�c - Dig Safe�E_��6�013�7._--•-
'funk Transported To: i a l Old Falmouth Rd. Wlt O
(Temporary Destination) -
Final Tank
Inspector:----- --
Comments:----------------------------------------------------------
-------- ---------------------------------------------------
--------------------------------— —� __ p ruXT.e'li oy,
------------------------------
---------------------------------------------------------r..
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t h Oepartment -'
isy3.nO# . t, iJ 6 ++ `
z Undergrood tank at 2 CR03��C C I R
1 u 7 C,.t
Toil
Our rgr.Qt,4 Aodicate that ycijr under co n . feet -0eMOcat)
Storage rek , ver years rangy +�*C been r �= ;+a.►t�d .ys......
,.
required V t
You, are .lir#'cted to ro:ioue t.,"- s tarok 5flyty (60) ot�s , �; y;
from the nsfo . of th#ts t 00(;0M
raft c YOO ank fs removed* -pteas furr��� s�+ t�►i.s of fi a evit�enc*
3r, the fOrtt` n aerai t from y tizsr i Ocal f flre depart���t: ;
wi-thin n1p t rt.(90i rJays of rec0pt of til$s , not ,��
you gay t hoer n or viaec
re4uzstin tOMO a re ice IVed by the loard of "eat 0,
.k � n seven C;Y dj)ys aft or .th is artier f z _.�trved_
t .er 'Order 0�f :":die
r e c or d f Amo!-to
L616IATION - SEWACk PERMIT NO.
VILLAGE As
,e / - to
INSTA LLER'S NAME i //ADDRESS
IS
BUILDER OR OWNER
DATE PERMIT ISSUED � �..� ,
DATE COMPLIANCE ISSUED �� -
r
f .�..
r -� --
,t
�t �
���
����
No.---•-•.......��'Ti.... ps F ...... ...............
....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
OCR / ...............OF..........J.s,/Q1?5 '.f71. ....................
.......
ApplirFafinn for Elispos al Works Tvn,�Irnrtiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................cam'b ... �r.. / .. �n �.r_arc l/ ------------------------------------------------------------------------•---•--................_
Lo ion- dress
...... 1 '1.._�.._.. 1._ .1 Lot.No.
5 � � .�._..............................................
.r....U....e...........•--•---------1............
O ner errress.. . f--------
Installer Address
U Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.........._._______.__._... Showers ( ) — Cafeteria ( )
a Other fixtures .................................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------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.......................................................................... Date........................................
,aa Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil....�14 92.... ......... . .U. 1...___.___._.._.
W --------------------------------------------------------------------------------------------------------------------------------------------•.... .--------------•
UNature of Repairs or Alterations—Answer when appli le_atTI-Q-6.)-_-.--an.`2___-_ zQ�j.
2g-q.11DA �'�4� ._01�. U --..................................... ..............................................
ireement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITia 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu by the a of health.
Signed.6�Xl _:------•-•------ ................................... _'... .............
Date
Application Approved By....... ----•-••------------------•-- _`_
Date
Application Disapproved for the following reasons.:--------------------------•••-•...............................................................................
-------------••----•-•-•--•-•--------------•-------------------•--------------------------......------------------•---------------------•--•----•-------------......---------------------•-----..._.._.
Date
PermitNo......................................................... Issued................................
Dat
No.............. .... Fus...... .....�...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,.
. Appliration' for Mipasal Vorkfi Tomitrnrtinn ramit
Application is-hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
................ !°'€ .L . f `N ••.e t-11111 . -•-•----.........................-•-•-- -•-• -••--••----••••••-......••-•-•-•-•--..........
Location dress or Lot No.
/ p�
.... :.� i. _.... �i ,"P-,5,', ----------•----.......................... ..........................._. i 4W. ..9._..--•--------••-•---.............................
O ner -Address
ash
Installer' Address
d Type of Building Size Lot............................Sq. feet
.-�U
Dwelling—No. of Bedrooms......% ;:........ * ....._ .Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building _ No. of persons......... ------------- Showers — Cafeteria
dOther fixtures ------------------------------------------------•---._....------------------------------ .............................................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............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......................................................................... Date........................................
d Test Pit No. I................minutes per inch Depth ofr Test Pit.................... Depth to ground water........................
G� Test Pit No. 2................minutes per inch Depth of Test Pit-_____._----__._.__- Depth to ground water........................
t - ---
DDescription of Soil.... •._ . . :.. ....._. - ..-----••--•---------------------------•-------------...._....... •-.....-•--••............•-•----
V -•---------------------•--•--•-•-----------------...-•----------------------------------------------------•-----•----------------....•--•-•-•-•••-•--
W -------------------------- -•-----••••-•--•-••--•-•-----••---------•----•--------------•-•-•-......-------••••-•. -- --
U Nature of Repairs or Alterations Answer when applicable 0. w l 1 J%ids /'! ' _.:.d
-K--------- ----- - ----- -------- -------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1.;;:. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a C-rtificate of Compliance has been issu by the a of health.
Signd. -•-•• - - -------•--•--------------•----•-- -- -------.••• •-------
`'' //l ` Date
Application A ro ed B ff�// 11
PP PPS Y s --• ...GL !hCr ,. I�+ Date '
Application Disapproved for the following reasons:-----•-------------------------------------------------------•-------------------------------------............
----••---------------••-••••••...............---•••.......................•...----••-------••----••-••-•--••............................................
Date
`Permit No......................................................... Issued_............................. .......................
Date
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ....J`"'tr�l�t.......o F..........: ,. ..... ,try
10rrtifirtttr of ;f�.unt�rlt�tnrr
THIS�/�S TO E FY, That th na:vldual Sewage Disposal System constructed ( ) or Repaired
at.._�._t ! ... .... :_._._:6 Inst V
.. .............a--------------------------------
has been installed in accordance with the provisio1 of TI 5 of The State Sanitary C e as desc% din the
application for Disposal Works Construction Permit No___ ________ __ __
`'� ......--•••••. dated----- = 2
'THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® �A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......`....�. { ` .......................... Inspector--_._ .............................
: THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r�
No. �� ` .......... FEE.........................
ga l or v nitrnrttiv amit
Permission is herebygrant ... ._._.. ...
„ ........ --
to Constru ( . ) or spa- ( ) an nd' ual ewage sposal ystem !
at No._„•-Z !t=:..... . -•-• .....
Street `
as shown on the application for Disposal Works Cori ` Per o___s ated.... ....................................
Board of Health
DATE. •.. �� .......................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS