HomeMy WebLinkAbout0059 ENSIGN ROAD - Health 59 Ensign Road, Centerville
AMA
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UPC 12534
No.2 1�5 LOR
HASTINGS UN
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TROY WILLIAMS L y
SEPTIC INSPECTIONS &A r/.7
Certified by MA Department of Environmental Protection 6 z000 (508) 385-1300
19 Hummel Drive04v®,c r
South Dennis, MA 02660 8 �
C COPY
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary .
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: s� Ea S H �( Name of Owner Ho, y o ( ' ZZo
CA 4-Lr- ; 11< Address of Owner
Date of Inspection: 9/18 /oo oz6 3�
Name of Inspector:(Please Print) Troy Williams r ,'.I 1 c /tif w-
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Nanne: Troy Williams Soti Insnection4
Mailing Address: 19 Hummel'Drive. So. Dennis MA 02660
Telephone Number: (508) 385-1300
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 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 Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: ti, l�J� r.. Date: 9// /00
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 ttm
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
revised 9/2/98 Papr iorii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(contimsed)
Nay Address: 59 Ensign Road,Centerville,MA
Owner: Donna Rigolizzo
Date of Inspection:
September 18, 2000
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDRIONALLY PASSES: N/A
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.
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank, whether or not metal,is 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 complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system 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 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
revised 9/2/98 Page 2of11
r,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
59 Ensign Road,Centerville,MA
Property address: Donna Rigolizzo
Owner:
Date of Inspection: September 18, 2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:IV119
Conditions exist which require further evaluation by the Board 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 DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3ofII
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
59 Ensign Road,Centerville,MA
Domia Rigolizzo
Property Address: September 18,2000
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what.will be necessary to correct the failure.
Yes No
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 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.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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-then 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: N/19
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ofII
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
59 Ensign Road, Centerville,NM
Property Address: olizzo Donna Ri
Owner: g
Dace of fnspection: September 18, 2000
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant,or Board of Health.
None of the system components have been pumped-for-at least two weeks and-the system has been-receiving vnormal flow
rates 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.
_ 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. For example, Plan at B.O.H.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable!
(15.302(3)(b)]
- _ The facility owner land occupants,.if different from owner) were provided with information on the proper maintanance.of
SubSurface Disposal Systems.
revised 9/2/98 Page 5ofII
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 59 Ensign Road, Centerville,MA
Owner' Donna Rigolizzo
Date of Inspection;
September 18,2000
FLOW CONDITIONSRESIDENTIAL:
Design flow: //D g.p.d./bedroom.
Number of bedrooms(design): Number of bedrooms(actual):-S
Total DESIGN flow--?flow--?c3 0
Number of current residents: f
Garbage grinder(yes or no): AIQ
Laundry(separate system) (yes or no):A/o; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no): /Vo
Water meter readings,if available(last two year's usage(gpd): 00 = 4000 c
Sump Pump(yes or no):�
Last date of occupancy: O c c., s i.
COMMERCIAL/INDUSTRIAL:/V114
Type of establishment:
Design flow: apd ( Based on 15.203)
Basis of design flow
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 jtECORDS and source of information:
Systefn pumped.as part of inspection: (yes or no)_VO
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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed Of known) and source of information: N S�a./I<c� �•2$ b
a in c
Sewage odors detected when arriving at the site: (yes or no) /VO
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(confirmed)
Property Address: 59 Ensign Road, Centerville,MA
owns:
Date of I,upecaon: Donna Rigolizzo
September 18, 2000
BUILDING SEWER:
(Locate on site plan)
Depth below grade: /49 n f
Material of construction:_cast iron Z40 PVC_other(explain)
Distance from private water supply well or suction line N/n
Diameter q
Comments: (condition of joints, venting, evidence of leakage,etc.)
F`I u I. A n c c II .. ,Jl 1 I :., — y�y// .. Lf' :n c .I�5'u...L1 r, 1-
NO..nL yj'!A s /o t..1 N �u I( /OW 7 hr .� L +V 4'u-I..{c C.+ -/'-1n ) ft-
SEPTIC TANK
(locate on site plan)
Depth below grade:26 r� �c-.3 r'• S c✓.
Material of construction: ✓concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:__
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 02 9
Scum thickness: NUNi-:7
Distance from top of scum to top of outlet tee or baffle: Nos0•+�
Distance from bottom of scum to bottom of outlet tee or baffle: Nu S<- o w.
How dimensions were determined: Pro 4
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structuroHntegrity,
evidence of leakage,etc.) Pt/C- 1 7101 i h I e- o N c r< c
� r c./ur �, r o n .� d c✓. /1/D � dt�..,
'Jet at
GREASE TRAP:_ t�,,9
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Ensign Road, Centerville,MA
Owner: Donna Rigolizzo
Date of Inspection:
September 18,2000
TIGHT OR HOLDING TANK:_N/A (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Materiel of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions: __._..._. _. .._.
Capacity:_gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:--,,/
(locate on site plan)
Depth of liquid Ievel above outlet invert: 2 u
Comments:
(not/e�if level pand distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
7>>�l�. I �/ 1 0. �n s� t. i d r/ .n t l r—c C c v W /1 1y�o G J e
C !] C c.. ,i y u t ✓ O✓ G`�/,� `/
PUMP CHAMBER:N/,
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Pygt8OfII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(con*wed)
Property Address: 59 Ensign Road, Centerville,MA
Owner:
Date of Inspection: Donna Rigolizzo
September 18, 2000
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type: leaching pits, number: ) — 6 L + w' rt R!S 74v v, .
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number,length:
leaching fields, number, dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
�II i W«S
Cti N c-In w o, r s fu r , i
/1 ✓� c..�Qb tea,1: � s L. Ic✓ A W a- ! i
N,� J Y-" /N C a-� c -� - /+ NU e J',,.A G 1�r.1c._L YC N v tr'O- I �]g.i Y/✓ C�✓ i��'U E�l e✓� C
CESSPOOLS:2_-Y1,9
(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 (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://'1.9
(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 9/2/98 Page 9ofII
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address' 59 Ensign Road,Centerville,MA
Owner:
Date of Inspection: Donna Rigolizzo
September 18, 2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Q��k•
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revised 9/2/98 Page 10 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Ensi n Road, Centerville MA
Owner: ,
Date of Inspection: Domia R1golizzo
September 18, 2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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revised 9/2/98 Page 10ofII
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CO'�4� ONWEALTH OF N ASSACHUSETTSEXECUTIVE OFFICE OF ENVIRONMENTAL AFFADEPARTMENT OF ENVIRONMENTAL PROTE ON )plyN 199ONE NVINTER STREET. BOSTON. NIA 02108 61 29_-54X1A
E
1YILLIAV F W'ELD
Governc• Se.retar`
ARGEO PAUL CELLUCCI D.AVID B.STRUHS
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: ' � RCN -���� Address of Owner: *w1�.�vtpw. c.�
Date of Inspection: (If different)
Name of Inspector: / � �o ;5,A Ew�,,tv
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) ��v
Company Name:1121 a r i4-!'c Eol rf'rr l+1 0" P
Mailing Address: Pa Arnx -E-339 L f H ASf;!oPe-0— H I9- (=7 2C4LC/ � �o)
Telephone Number: rSG tJ Ct �— /4i= ZO
CERTIFICATION STATEMENT
I ceru� that I have personally inspected the sewage disposal system at this address and tha! the information reported belov, is true. accurate
and complete as of the time of inspec,o-.. The inspection was performed based on my training and experience in the proper iunction and
maintenance of on-s,te sev,age disposa systems The system:
Passes
_ Conc t-onai;\ Passes
tieecs Furne• E%a!uat o Sy the Local Approving Authority
_ Fa.-s
Q
Inspector's Signal.,—. Date: 72S L9.__7
The S\•s,,e- Inspecto• sha!' submit a copy of this inspection report to the Approving Authority within them (30) days of completing this
inspection. If the system is a shared system o, has a design floe of 10,000 gpd or greater, the inspector and the system owner shall submit
the repon to the appropriate regional orifice of the Department of Environmental Protection. The orig:na! should be sent to the system owner
and copies sent to the buve,, if applicable, and the approving authority
INSPECTION SUMMARY: Check A, B, C, or U
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.
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.
Indicate yes, no, or not determined (Y, N, or NDi. Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. I he system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(rev;.Sed 04/25/97) Page 1 of 10
DEo on the Wond wise WeD htto bwww magnet state ma usmer
^ o_.,.— Paro,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner ,H•.
Date of'Inspection:/`
BJ SYSTEM'CONDITIONALLY PASSES (cont,n.,a
_ Sewage backup or breakout or high static water level observed in the dis ibution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution,box. The syst will pass inspection if(with approval of the
Board of Health;. Describe observations:
broken pipets) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to b ken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipetsi are replaced
obstruction is removed
CJ FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which reouire further evaluation by the Board of H alth 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 DETERMINE THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY ND THE ENVIRONMENT:
Cesspool or priv% is within 50 feet of a surface water
Cesspool or pri%, is �+)thin 50 feet of a bordering v etated wetland or a salt marsh.
2) SYSTEM "'ILL FAIL UNLESS THE BOARD OF HEALTH (A D PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT P TECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The systerr has a septic tank and soil absorpti system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorp ion system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absor tion system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil abso'ption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well ater analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that cility, and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to deter ine distance (approximation not valid).
3) OTHER
/
(revised 04!25/97) Page 2 of 10
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DJ SYSTEM FAILS:
You must indicate either "Yes" or "No' as to each of the following
-
I have determined that the system violates one or more of the following failure tterra as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be cont ed to determine what will be necessam, to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an over oaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or s rface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution boa above outlet invert d to in overloaded or clogged SAS or cesspool.
Liquid depth it cesspool is less than 6" below invert or avail le volume is less than 1/2 day floe,
Recuired pumping more than 4 times in the last year NOT ue to clogged or obstructed pipes:.
Number o'times pumped _.
Any portion of the Soil Absorption Svstem, cesspool or p ivy is below the high groundwater eievation
Are port:on of a cesspool or privy is wither, 100 feet of surface water supply or tributary to a surface water supply.
Ant ponion of a cesspoo' or prwy is v,ithin a Zone 1 'a public well.
An,. pc^io-- c�a cesspool or pri\,-.• is within 50 feet a private water supple well
Any por:,or. o-*a cesspool or prvoy is less than 100 eet but greater than 50 feet from a private water supply well with no
acceptable water qualm analysis. If the well has t3een analyzed to be acceptable, attach cop. of well water analysis for
cohiorm bacteria. volatile organic compounds, a onia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate e:he "Yes` or "No' as to each of the followin
The io!ioA:rS cr:e,,a app;,. to :arge systems in additior to the criteria above:
The system serves a facilir, with a design flow of 10, 00 gpd or greater (Large System; and the system is a significant threat to
public hea!th and safes and the environment becau one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surfa drinking water supply
the system is within 200 feet of a trib ry to a surface drinking water supply
the Svstem 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.
t+
(revised 04/25/97) Page 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property dress:
Owner: �(<
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or 'No" as to each of the following:
Yes No
— Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving ncr-rra
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this inspection
As built plans have been oo:a:ned and examined. Note if they are not available with N/A.
— The fac:lm or d%%ehing was inspected fo, signs o'sewage back-up.
The system does not receive non-sanitan• or industrial waste flow.
— The site %as inspected for signs pf breakout.
— All svFtem• components. excluding the So!l ADsorpt:on System, have been located on the site.
The septic tank rnanhoies were uncovered, opened. and the interior of the septic tank was inspected for condition of
baffles or tees. matena.o' construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and locat on of the Soi! Absorption Svstem on the site has been determined based on:
X — The facdit� ovine' ;anc occupants. r d:fteren: trorh owneri were provided with information on the proper maintenance of
Sub-Suriace Disposal Svstem.
— Existing information Ex. Plan at B.O.H.
- v
Determined in the field :r am of the failure criteria related to Pan C is at issue, approximation of distance is
unacceatabie (15.302.3::b`?
(revised 04/25/57) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FOR,10
PART C
SYSTEM INFORMATION
Propem dress: I
Owner: Gv,
Date of Inspection:
I,f FLOW CONDITIONS
RESIDENTIAL:
Design iiov. fZO o.d./bedroom for S..A.S
Number of bedrooms
Number o-'current residents:
Garbage g•; der (yes or no.,:-
Laundry co-•^ected to system (yes or no`
Seasonal use (yes or nv0-0
Water meter readings, if a a lable (last two (?: year usage (gpd): 11,3M
Sump Pump Ives or no):
Last date o' occupancy (�
COMMERCI4L'INDUSTRIAL:
Type of establishment
Design fio�% galions,,da\
Grease trap present. ryes or no_
Industria! \\aste Holdrne Tani: oresent. ;ves or no
Non-sanitan waste dscnargec to the T:;,e 5 system ;yes or no_
\later meter readings, if a�ailabie
Las:Pate o: o cupanc.
OTHER: Describe
Last date of occucanc.
GENERAL INFORMATION
PUMPING RECORDS and source of iniormatior
System pumped s par; ch inspecoon: ;ves or no
If ves, volume pumped eallons
Reason for pumping
TYPE OF SYSTEM
Septic tank%d15trbunon box•�soil absorption system
Single cesspool
Overflow cesspool
Pro.),
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site. (ves or no) �
(revised 04/25/97) Page 5 of 10
SUBSURFACE SE�NAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
v
Property Address:
Owner: L(g,
Date of Inspection: � (G�
BUILDING SEWER: f�
(Locate on site plan) �(\J
Depth below grade:
Material of construction: _cast iron _40 PVC _other (explain`
Distance from private water supply well or suction Ii
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:Q,(/�,
(locate on site plat,
bt
Depth below grade
Material of construct,o concre:e _me:a _Fiberglass _Polyethylene _othenexpfarn
If tank is metal, list age _ Is age confirmed o� Ce^,.ficate of Compliance _(Yes,No
Dimensions QIPA
Sludge depth cif— q
Distance from top c!`,swage to bottom of outie� tee or ba^ie
Scum thickness: y
Distance from top of scum to top o� outlet tee or ba^ie H
Distance from bottom of scum to bone-n of outlet ee o, bare
How dimensions Here determined
Comments
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid ley -Lin relaton to outlet invert stru ur,
integrity, evidence of leakage, etc. ( �U �f`
�.
C; O
GREASE TRAP:
4
(locate on site plan'
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle.
Distance from bonom of scum to bonom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
:ntegrity, evidence of leakage, etc.i
(revised 04/25:91) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properh Address:iJ� st'*y3
Owner: V—
Date of Inspection: !
�a)C;
TIGHT OR HOLDING TANK: Tank must be pumped prior to, or at time, of inspections
(locate on site plan,
Depth below grade:
Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions.
Capacm: gallons
Design floe galions.•da,
Alarm level Alarm in working order _ Yes, _ No
Date of previous pumping
Comments
(condition of inlet tee. condition o�alarm and float switches. etc.)
DISTRIBUTION BOX: ""
(locate on site plan
Depth o` hcuid level above outie: ime"
Comments
mote r leve' and tnbunon is eraual. evider> of olds rr)Over, evidence of I ge into or out of box, etc.)
\�
N r -
PUMP CHAMBER:
(locate on site plan;
Pumps in working order: (Yes or No,
Alarms in working order (les or No,
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Pro pert) Address: �.
Owner: d
Date of Inspection:6Rz`an
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible: exca,a ion not required, but may be approximated by non-intrusive methodsi
If not determined to be present, explain:
Type:
leaching pits, number. �{
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimension.;i.
overflow cesspool, number
Alternative system
Name of Technology.
Comments.
inote condition of soil, signs of hydraulic failure, level of ponds cond t n((��f fgetatio , et .. '
`%. ) Z ,
•r
CESSPOOLS: _
(locate on site plan.
Number and conf,gura:-on
Depth-top of liquid to inlet Inver,
Depth of solids layer
Depth of scum layer.
Dimensions of cesspooi
Materials of construction.
Indication of groundwate-
inflow tcesspool must ne pumpec as par, of inspection;
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
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.)
(ravaged 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR:M
PART C
SYSTEM INFORMATION (continued)
Propert. Address: ! -T,— �)
OKner: EA CC'
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
LEI ' J
1.
-7 � ,75
04'25!9") Page 9 o: 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropertN dress:
Owner:
Date of Inspection: tk \ci
Depth to Groundwater: Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
in m
Observation of Site (Abutting property, observation hole, basement t sump etc.)
Determine it from local conditions
Cnec'K %%ith Iota' Board o' nea!tn
Chec'K FE..MA Macs
Check pumping records
Check local eaca•:ato,s. installers
Use L SCS Data
Describe in .our.o.Nn. %%oro�no%% �o:, estao; shed the 6-+ighi Groundwater Elevation. (Must be completed-
Page 10 of 10
LOXCA ION SEMI;A G E PERMIT NO.
"y-t 0 tea;
VILLAGE �.k.
INSTA, LER'S NAME A ADDRESS
6UIL0EIll OR OWNE
.:DATE PEIt III IT ISSUED
w 4,4-8 -
DATE COMPLIANCE ISSUED
r ,, .,...
. � � � ,
j
� � -
�,� ��
t.
.�
No. ....�i'3�3-z.� as.3. .._............_.
THE COMMONWEALTH OF MASSACHUSETTS
� BOAR OF HE H
-----.....� ..........OF..... . .Afvo...`..� ..............................
Appliration for DtspuuFal WorYwTumitrurthin Vanfit
Application is_hereby made fora Permit to Construct ) or Repair (` ) an Individual Sewage Disposal
System
�-at: t Y . . lon Addres �—� ... or Lot -- -------- ------'---•----------------------. � :...... 4:9�.. - J.0... ................... ..............�s ���...... ................
...........: .�_::.... ---.... --= �- a .....................................
In to le � q �;V Address }} �r
Type of Building s `/ Size Lot....`5-11.1.....Sq. feet
U Dwelling—No. of Bedrooms.................:......... Expansion Attic ( ) Garbage Grinder (
�+ ---•---------
'� Other—T e of Building .. No. of persons............................ Showers — Cafeteria
Q' Other fixtures -------------------••-----_-•-••__
W Design Flow.................... .5.............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 to� )
`" Percolation Test Resuljs. Performed by-------- __. .__ L... �..................... Date........................................
._ .
Test Pit No. 1_C'. .minutes per inch Depth of Test Pit____ (�.__.__ D h to ground water_. j/C .....
Gr, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --- .............
'r-Description of Soil----.....0........ - ............
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 ii:ILE 5 of the State Sanitary Code—The undersigned further agrees n t place the system in
operation until a Certificate of Compliance has b n issued b boa db eal
P P Y
Signed :.. ...•-•-- ....... .._-••... --•- ....... ••........
Date
Application Approved BY-------- ..= / . --•----------------•-•--•---
Date
Application Disapproved for the following reasons:................................................... ............................................................
-•------------••-•---------------•------------•----•-------.......-------------------•---•-•--------.......--------------•-------•---------•-----•------ ................................................
Date
PermitNo......................................................... Issued.......................................................
Date
2 2-L :• ` F s.... .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD-OF HEA TH
,� lirn#i,an for Iligpn,oal lUlnrk Tomitrurtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at• �-
.. ,) t�Ar
I L Location- ddress/
....................... .......
--•• - --••-=r•—�-• ---- -------"----------..�.......•. .......--- -- ---k ----- I =
s f� Address
� ns a11er 'St Address (/
Type of Building 7 Size Lot-_-_-� . .-•s-j•-- .... feet
U Dwelling—No. of Bedrooms.................. ---------------Expansion Attic ( ) Garbage Grinder
Other—T e of Building No. of persons............................ Showers — Cafeteria
dOther fixtures ---------------------------- -
W Desi n Flow........................ .�•- gallons per person per day. Total daily flow..........__ > _._.............._
g .3---3•------------g P P P Y• Y -- -... 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
aPercolation Test Resul Performed by._....__ _. _..... --- -! ~a�_.... Date........................................
a Test Pit No. L. .2_.minutes per inch Depth of Test Pit____ _____ Dej�th to ground water...P. t!i:Wj '.....
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
i {........I -•••••......--•-•• -- -••.........................................................
ODescription of Soil.........Q .. Q .1'.'A......�1s.... ------------•--•-...-•-•-••--•••-----•......--•--•-•-•.............................
V - ` <'- -` ...._.._ __._�11�n�!' -- -----------------•--•---------------------------- ------•-----•-----------------•
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 TTTIE 5 of the State Sanitary Code— The undersigned further agrees n t place the system in
operation until a Certificate of Compliance has b n issued by�te;.board-6f fealtlY: -fir`-�5 .-.Signed._:._.... �' �° - ' -- -... •-------- • ..........................•.
` i Date
05
ApplicationApproved BY........1----�-.--�-/•'-•'-"-'-"-�-�-• f-/...��!l:,_/.� __..-F-----•------•.................. ......................................................
Date
Application Disapproved for the following reasons------------------------•---------•--•---------- ............................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LT
.......:......................OF..... N.✓.`... .............................
(Inrtifiratr of Tontlifianrr
THIS LS 0 CERTIFY, That In :v�al Se age Disposal System constructed ( or Repaired ( )
. .�4_:..
--
Y--------...: .............. - .
�a
Install
frG,.a. vl..._
at v - ----••. -_ -
has been installed in accordance with the provisions of _
TIT F� 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No____
G✓ ..__` L
__________,a..�........... da.ted------------------------------------------------
_____
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATI• FACTORY.
DATE......................................... ------- Inspector------------------4A.��___--•------•-•--•-------•---•---................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR `D( OF HEALTH
Z to .............OF.......1), .c..................................
C Z
No......................... FEE.._.....................
i �a tt1 inn � uaIit,rantit
Permission is b4reby granted...-i--- -••-----•-•- S `' .: _fk---........ .......... .................... ....
to Construct )f or Repair.( ) an Individual Sewage Disposal Sy tem
at No...............'.'. .'S. .�_r I d.... C! �;t' 1�
Streeett
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
iy- ---........-•-----------------^ ..--------------------------------------------------
Z-- Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
-oo
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LEGEND
EXISTING SPOT ELEVATION OxO �P��� oFAj s CERTIFIED PLOT PLAN
EXISTING CONTOUR --- 0 ——— 0=3 A T �y� Lo �� /9 c-•vs�c.• 2 , ..
FINISHED SPOT ELEVATION s
FINISHED CONTOUR 0 r..-
ca RS No.10951 I N
O
APPROVED BOARD OF HEALTH 9 .\ 1 .` =i t XpU s`
DATE AGENT SCALE: � �= 461 DATE ' z--
LOREDGE ENGINEERING CO. IN Gr�c�'N.ak���-� •
CLIENT I CERTIFY THAT THE PROPOSED
EGISTERE REGISTERED JOB NO. 81013 BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
ENGINEER SURVEYOR DR.BYI .A � '��'' OF BARNSTABt E,/-MASS.
712 MAIN STREET CH. BY,
� ,
H YA N N I S, MASS. Cxl 02 82 ` 'x'_ ..
SHEET_ L OF 2- DATE ! REG. LAND SURVEYOR
20 FT.` M/N. NOTE /F E/TNER THE-5-F, C TANK OR
�_Ei4CH/NG P/T ARE /YORE 7WA,V /2"46ELOit/
ID Orr. M/N.. �RAOE� 24'D/AM ETER CONCRETE COfiER
.SJ�AL4 BE ,9R0UGH7- TC GRAUE.`-`+,✓ EXTRA
: C4AeCRLTG -vc- P/pz 44r,4vy Cif S•T /RO/Y COVER S'NACL 3E USE,o
O M/_N. P/TCN
;�. C—��✓; 9�• . CDYER.S �B PER f..T /F/N DR/VEh/A 7�
2 J M iN. GO/V C�'E TE
A i ��_ G ,�oE CU ✓ER CL EAN SA/V 10
t/pu/o BEVEL - • . _ . .���
�4 — 2*LAYER
w
MIN.P/TGV `• aF 1/B -�
lOO y GAL. o •a o P o
�'- D/ST, o e 1 • e • • • • • ► o •4 WASHED 5710NE
/4 Pit fr SEPTIC TANK , t t • • • . . . , •
BOX .314
o v . • 1 .8 • r 11 • � ' �•• �
a , -
" • • DMPTJ+� • • 1 1 o y✓AStIEO STONE
I v
•eta I / • 1- i • • 1 ." CO o
: P/T C^%'r`t 1 rY • v e r • • • • • • • r D • v PRECAS T SE.EPAG E
!N!/e�tT CLE{/�IT/DNS ¢70 G/� o • • r 1 . . . . e •v P/T OR eVLJ1Y-
. . 7ff
/NYERT AT DU/LD/NG 99 FT. S4 7 CI o
INLET :SEPT%C TANK �•S FT- /° FT O/.4J�J. C SEE TABULATION
OlJTLET SEPTIC TANK 96•6 FT-
INLET OISTR/BIJT/ON BOX 9�•� FT SECT/ON OF GROUND Iar,4TER -rA4LE
O TLETD/STR/B&JT/ON box G Z IF
/NLFT LEACHING PIT. 96•o FT SEh/AGE A/SPD%S'A L. SYSTEM
TABULATION E
LEACH//VG PIT flIMENs/oN A Z- P'T.
DESI6IY CR/TER/A sc,� /4 6
NtlM8ER D/c BEDROOMS 3 D/MENS/ON C ¢ F77 E
47AReA4GED/5PO5AL UNIT fJouC SO/L. LOG
TOTAL ES'T/t447"ED FLOW 3 .3'y o,4L.1DAY SO/L TEST Ak/ SO/L 7ES7-**2 SD/L TEST `
/SLUMBER OF 4-ACN/N6 .o/TS � ELEY. 979 //O� / 7 f" J"ELEY, pATE• OF SOIL TEST g ( �
S/DE LEACHIMC, PER PIT l Cfd� SQ. FT. G= _
O RESULTS H/ITNESSED
9OTTOM LEjACH/NG PER P/7-__Z9__ $Q- A LO PtRCOLAT/OlV itATE / Lt�5 S
TOT.4G LEACH/NG,4REA SQ- FT. wBs�/� PEleCOLA77/ONRA7,FIkZ lNA41' M/N.1/NCH
RFSERIVELE4CWI Y6 AREA SQ. FT.
ZH Of At, �N OFM4s
O� x"4m
H v R E y
� 2974 v ,o ,p No.iossi.�o��. �, EL DREDGE ENG/NEER/lVG G'O /NG. f
LJ
7/2 M/1/1V ST. • HYgNNIS, MASS.
NO SUR�� rS�ONAi NO GR0YIN0_YY�4TER ENCOUNTLrREO 'Y3 P l'
CL/ENT: .e DRTE:3/� �z
l:'a .1 R GRO UA/O Lv.4TER AT EL.Eev
- JOB No �2.� r/ sHE,ET7_ aF- _ _