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Home My WebLink About0076 EMERSON WAY - Health 76 Emerson Way, Centerville a v- 1 II �µECVLIFpC SAYII OZm UPC 12543 o- No.53LOR `bsr.cow HASTINGS, Mtd COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF ' DEPARTMENT OF ENVIRONMENTAL PROTEC % \ ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 A ' DEC,t�I``^E,6 u�O WILLIAM F.WELD TRUby COXE Governor Secretary ARGEO PAUL CELLUCCI �llH DAVID B.STRL Lt. Governor .Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: L �wt¢-c,�r� t C;o,..�ve��l�`, Address of Owner: Date of Inspection: %2 toATe (If different) Name of Inspector: Company Name, Addresstanp e umber: 1 CERTIFICATION_;>,N ITSTATEMENT / 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Eval tion By the Local Approving Authority F 11Q Q&�� s 1 1 Inspector's Signature: Date 1Z1 1 The System Inspector shall submit a copy of this inspection report to the Approving Authority ,within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) w %.Printed on Recycled Paper ' r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 1 Property Addressc 4"J � _ _ Owner: � Date of Inspection: ; B] SYSTEM;CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the dis ibution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The syst will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due t 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 Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALT Conditions exist which require further evaluation by the Boa of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DET MINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND/AFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is wit/eaeet of a b dering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE OF LTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONINGANN THAT PROTECTS THE PUBLIC HEALTH.AND SAFETY AND THE ENVIRONMENT: The system has a septicd oil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septicsoil absorption system and is within a Zone I of a public water supply well. The system has a septicd soil absorption system and is within 50 feet of a private water supply well. The system has a septicd soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a wr analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fromcility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm- 3) OTHER j (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: f Owner: Date of Inspection: D] SYSTEM FAILS: I have determined that the system violates one or more of the following f ilure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should b contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge.or ponding of effluent to the surface of the gr nd or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outle invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below inv rt or available volume is less than 1/2 day flow. Required pumping more than 4 times in the las year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, sspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is with' 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is w' hin a Zone I of a public well. Any portion of a cesspool or privy is ithin 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 If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile orga c compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to lame systems in addition to the criteria above: The system serves a facility withla design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to g Y Y g public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:,` Owner: Ak Ij Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the components system have been pumped for at least two weeks and the system has been receiving normal flow rates y during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. ,The system does not receive non-sanitary or industrial waste flow. 4 The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: 'FLOW CONDITIONS RESIDENTIAL: Design flow: allons Number of bedrooms: Number of current residents:,[ Garbage grinder(yes or no):_ t!0 Laundry connected to system (yes or no)'�t~S Seasonal use (yes or no): .10 Water meter readings, if available: Last date of occupancy: S COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title.5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)__t,JLj If yes, volume pumped: Gallons Reason for pumping: TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: kmr &, " l G 1. Sewage odors detected when arriving at the site: (yes or no) Q (revised 11/03/95) 5 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 �W eSdK) Owner: Date of Inspection: SEPTIC TANK: S (locate on site pl n) Depth below grade:_a� Material of construction: ,,concrete _metal _FRP—other(explain) Dimensions: I OOQ o,w Sludge depth: el Itp Distance from top g of sludge to bo ttom of outlet tee or baffle. 34 Scum thickness:0 k Distance from top of scum to top of outlet tee or baffle: Ids Distance from bottom of scum to bottom of outlet tee or baffle:—I i, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, str ur I integrity, evidence of leakage, etc.) by u GREASE TRAP:v (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: Nv (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: eallons Design flow: eallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ N� (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, eviden of leakage into or out of box, etc.) PUMP CHAMBER: IJC� (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and a/urtenances, etc.) (revised 11/03/95) 7 P , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A dress: ZG --to eJ Owner: Date of Inspection: �Z��OlS to SOIL ABSORPTION SYSTEM (SAS):�g (locate on site plan, if possible; excava ion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 4�t(� leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hyd ulic failure, level of ponding, condition of vegetation,etc.) �3�1_L__' 9 YUG �i4MS cs� �+�► �aNc9-tict %(4�.c CESSPOOLS: (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: S Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: l (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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: T. Owner: Ac-tt-CD Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' nc 1 ,Az.- DEPTH TO GROUNDWATER Depth to groundwater: '� 1 Z, feet (� method of determination or approximation: f)o GQOVNd V,OO a►c- G �.�;n0K (revised 11/03/95) 9 TOWN OF BARNSTABLE �. UT �. LO --A.LION I SEWAGE # VILLAGEti� — ASSESSOR'S MAP &LOT G INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PAWVffPDATE: 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feq of leaching facility) Feet Furnished by a E. 3 � `t TOWN OF BARNSTABLE LOCATION &2erJonSEWAGE # __qL— jrW VILLAGE �, ��P� V i l ASSESSOR'S MAP & LOT �( r INSTALLER'S NAME Cz PHONENO. A & B CANCO 775=6264 SEPTIC TANK CAPACITY J' O®O LEACHING FACILITY:(type) (6 0 D (sue) NO. OF BEDROOMS- PRIVATE WELL O UBLI• WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No f l o 3s' No. .j. ............ Fx cdo.,_.............. t THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE v �vrcme�= Apptiration for Dispuiai Workii Toustr r ' = ..Dm :� Application is hereby made for a Permit to Construct ( ) or Repair (fin Individual Sewage Disposal System at: � i?Vif ......?.. ..._ .l�r .l�,S i? ?.................. `.------•--•--....•... .....CK-. ---- --------------------•.......-•----•---......-- Location Add ess or Lot No. plh ---------- ... ..•..--••- ---------------••-•----------...-•----......••--------•.._....--•------•--••--•-••--......._.---- Owner Address _ a •.. ° �-tea....... .l -�. - .......................................... �....... ................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms___..3...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ..............:............. No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------......------.-------•-------------------------------------------------------------.......------------------. 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........................................ Test Pit No. 1----------------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........................ a' •------------•---------------------------------------------•-----••---------------•----------------------------- ----------------------------------- -......... 0 Description of Soil........................................................................................................................................................................ x U Nature of Repairs or, A Leratio _—Answer when applicable. _.. :-_ '�. 00 Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Enviro al Code—The undersigned further agrees not to place the system in operation until a Certificate of Comp been issu the board of health. �1.� /2 Signed -- -------- -------- ----------------------------------------- "-9 ApplicationApproved By ... .. .. ...... ....... ......I.... . .... . . .. ... . .. .... .. ... .. .......................................... e... ... g Application Disapproved for the following reasons- ----- ---------------------------------- ----------------- --------- -----------------------............................. ------------------- .................. ------------ -------- ------. ..................................... Dare PermitNo. ' 6 .......................- Issued ... ... .. . .I-............................. No.�.[/"6 Fss, 0.:................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE _ Appliratiou for Btspuiial Workg Tonstrur#iurc Prrinit 1_2 Application is hereby made for a Permit to Construct ( ) or Repair- (k--) an Individual Sewage Disposal System at: 7 (� _L hr,E(ZSo►.a w�� CepZ-� Rvr�' .......... .... ...... ....�.................................._......• .................................................... N ............................................ cation o - ddyes Lot L.1 Nara F1!0 -----_.....---••-•----•----------------------•---•--•-..._....•-••-_............ .................................--............................................................... Owner Address -------------•-•- Installer Address UType of Building 3 Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther =Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ---------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. x 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. 1................minutes per inch Depth of Test Pit._____--.-_-____-- Depth to ground water........................ f 4 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ a .•••-••••••-••••••--•--•----••••-•••••••••-•--•-••••••••---...•••••..........-•-•-------•---•-•................•--......---•••• •------ .--------- 0 Description of Soil..........................................................................................................................................•........ .................. x UW -------------------------- ---------------------------------------- ----------------------------------•-•••-----^ = p Nature of Repairs or Alterations—Answer when applicable'.___ �OC> .......................................................... 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'furiher agrees not to place the system in operation until a Certificate of Compliance-has been issued'by the board of'health. ---- - _ Signed . � - ........ �..----................................................ ....L..".../.9-,/........ Application Approved By ------------------------------- ---------------------------------------- / . /__.!....1.- t Application Disapproved for the following reasons- ----------------------------------------- -------------------------------------------------------------------------- -------- ...... ..... a ......................................................... -------------------------------------/..... /- ------------------------------........ / Dale Permit No. rl/ -- ............................ Issued l.- ............- L THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ger#tftirate of C antylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( v) by--- - C�P.C -.. - ----------------------------------------------------- ------------------ --................................................ 'S."• Installer "7 Vv��: rL SC> 1�aA C 4F ti i(F R at ...... ? ........................................././�„L..�...-------- -----------------<----....-------------------- has been installed in accordance with the provisions of TITLE 5� f The-��tat,e'�•�nvironmental ,ed as described in the application for Disposal Works Construction Permit No. .. �" �Wit!___.} _...... dated ��7...........�._:.�.............8............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ( �- / ^ /lull 1 J [ � . ` ,. ..�- DATE---------------------------------------------- - Inspector .1---�----T-. .............`.::.... ....... .........------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 4 N ................... FEE. ...................... 11ispostt1 Work.5 T nstr ion amit Permission is hereby granted...... . __._..0/9 N CrJ ............-• ••••••••••••-•••••••••••-•---•••••••........••••••..........•............. to Construct ( ) or Repair (:--), an Individual Sewage Disposal System at No...... (o i IM L (_2, 57 0�J W R`_� .._.....C.�N r` ................I i` .._..: Street 3 � �,y7� as shown on the application for Disposal Works Construction/Permit-No ...�...t_}Dated.._.. ... ............................ DATE...... Board of Health -----•••.------ ...; -•-••••-- FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS