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Home My WebLink About0139 FULLER ROAD - Health 139 FULLER RD.,.CENTERVILLE A = 189 002 No. 42101/3 ®RA �;pc, "R.' ! colt o'': U 10°I° o � o I .. Commonwealth of Massachusetts I89-0oa1009_- p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins r tf Owner Owner's Name information is Centerville ►/ Ma. 02632 August 21 2020 F' required for every 9 , page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 45 ILI4 D on the computer, use only the tab Thomas Roux key to move your Name of Inspector cursor-do not use the return Company Name key. 89 Mayflower Lane Company Address East Wareham Ma. 02538 City/Town State Zip Code s 774-678-9066 S14531 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3 4,011 v Z6 zozo Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��. 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21 2020 required for every 9 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"ConditionalPass"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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21, 2020 required for every 9 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ON ❑ ND (Explain below): 3) 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 failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21, 2020 required for every 9 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a 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 private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21, 2020 required for every 9 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 '/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 water supply 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owners Name information is Centerville Ma. 02632 August 21, 2020 required for every 9 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has 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? ® ❑ 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? ® ❑ Wasthe 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: ❑ ® 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(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21 2020 required for every 9 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): No design Number of bedrooms(actual): 3 DESIGN flowbased on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): +330 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • �' 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21 2020 required for every 9 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21, 2020 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 28 years, house was built in 1992. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +100'to any wellfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 f Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21 2020 required for every 9 , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'L x 5.67'W x 5.67'H Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts (24 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21 2020 required for every 9 , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 per day t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is required for every Centerville Ma. 02632 August 21, 2020 page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Fuller Rd. Property Address , James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21, 2020 required for every 9 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Pit was located and inspected. It had about 2'of water in it at the time of the inspection. Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21, 2020 required for every 9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit was located and inspected. It had about 2' of water in it at the time of the inspection. 12. 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 ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21, 2020 required for every 9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21 2020 required for every 9 , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately rv,�Jiv� S -FiD RD 0,S e A 3V, 0 B S e 2 ` 87 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21 2020 required for every 9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +10'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A test hole would have to be dug onsite to determine the actual groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 139 Fuller Rd. Property Address James Collins Owner Owner's Name information is Centerville Ma. 02632 August 21 2020 required for every 9 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . - - a DEPARTMENT OF ENVIRONMENTAL PROTECTION OA r _ A 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 189 PAR 002 Property Address: 139 FULLER ROAD CENTERVILLE RECEIVED Owner's Name: SALOME,BILL Owner's Address: 139 FULLER ROAD CENTERVILLE,MA 02632 OCT 16 2001 Date of Inspection SEPTEMBER 27,2001 Name of Inspector:(please print) JAMES D.SEARS TOWN OF BARNS j MdLE Company Name: A&B Canco HEAL_SH DEPT, Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 3" Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 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 tot he 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 1 A s Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 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 distribution box is leveled or replaced 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 explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(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 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. The system has a septic tank and SAS and the SAS is within a Zone 1 of 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 private water supply well". Method used to determine distance "' 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. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below invert or available volume is less than''/�day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (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. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. 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) 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. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "ves"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Fonn 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 Check if the following have been done. You must indicate"yes" or"no'as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X 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 X 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X 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(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 1999 83,000/2000 65,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A—PUMPED AFTER INSPECTION Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1986 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 16" Material of construction: X 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) Dimensions: 1,500 GALLON PRE CAST Sludge depth: 3" Distance from top of sludge to the bottom of outlet tee or baffle: 27" Scurn thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.OUTLET BAFFLE.TANK AND COVERS 16"BELOW GRADE.NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A 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: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 S Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 TIGHT or HOLDING TANK: N/A (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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 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.,): DISTRIBUTION BOX IS 16"X16",2'BELOW GRADE. ONE LINE IN,ONE LINE OUT. BOX IS CLEAN AND SOLID.NO SIGN OF OVERLOADING OR SOLID CARRY OVER SEEN IN BOX. PUMP CHAMBER: N/A (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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits, number: 1 leaching chambers,number: 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.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT. PIT AND COVER 20"BELOW GRADE.WATER AT 2' IN PIT. STAIN LINE 2"ABOVE WATER.NO SIGN OF OVERLOADING SEEN IN PIT. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXlocate 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): Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Y A Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i fieuNT 0 . 0 3 -y Title 5 Inspection Form 6/15/2000 10 L Page 11 of 11 _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 FULLER ROAD CENTERVILLE,MA 02632 Owner: SALOME,BILL Date of Inspection: SEPTEMBER 27,2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 30.5 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: Observation site(abutting property/observation hole within 150 feet of SAS) X 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: GROUND WATER BARNSTABLE BOARD OF HEALTH,G.I.S. GIS GROUND WATER 42.5'ELEVATION 12.0', 30.5' ADJUSTED 2.4', 28.1'. 6N _ A D.7' Title 5 Inspection Form 6/15/2000 11 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: 3"2-3 - Fill in please: APPLICANT'S YOUR NAME/S: 5< MMI BUSINESS YOUR HOME ADDRESS: l3 t Fv� 1..�e- Rom• \r r � TELEPHONE # . Home Telephone Number - a as —2-Gl - 1-2— NAME OF CORPORATION: NAME OF NEW BUSINESS A TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS t3�1 q-�l�- � K� C�r�1-�Eizvst.l� MAP/PARCEL NUMBER l $ 'b0 [Assessing) I`�� a2.632 When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and Licenses required to legally operate your business in this town. 1. BUILDING COMVAth R'S OFFICE This individui orFn dPny(�Aire it meets at pertain to this type of businessNIUST COMPLY WITH HOME OCCUPATION RULES AND REGULATIONS, FAILURE TO z i ature** COMPLY MAY RESULT IN FINES. OMMEN pw 2. BOARD OF EALTH / e.r This individual has been informed of the permit requireinIs p . ai thi �e of business. (�A11S12 G(JMPLY WItH ALL � HAZARDOUS MATERIALS REGULATIONS Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS [LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Date:S /26/ fo TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF'BUSINESS: 4 BUSINESS LOCATION: k3q INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT .PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: cf:?-S - 91-t o t MSDS ON SITE? TYPE OF BUSINESS: Pea.-z " ,--t-- INFORMATION / RECOMMENDATIONS: Fire District: 1,4-0c►.�R FZ-� v�tT S'�� cJ-�1 o N z:�-o & �'% 'f' �'R G' Mir Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents / Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Apt ant's Signature Staff's Initials pp- ASSESSOR'S MAP Na- PARCEL 9 ff LOCATION �3`� SEWAGE PERMIT NO. P I L L A G E I N S T A LLER'S NAME i ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED �a-c. DAT E COMPLIANCE ISSUED r 117 Fimic 77..SO` THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .__..70_WAj.................6F......!M2/,5'?i4 4e Appliration for Uhip sal Workii Tnnitrnrtiaan reran# Application is hereby made for a Permit to Construct (>ej or Repair ( ) an Individual Sewage Disposal System at: --.............. �2_.��_�._._:-.� !U r�R V..��------- -- ....---- =�-----z--------------------------------------------- Location-Address or Lot No. --DALE'_ (�lZM9/11.K 153 NICK® �1.. 1��- LRcL -o5-n 2y/Z4 ..... (�- ner Address ---•-----------••---------•---------------•_ Installer Address Type of Building Size Lot-_ _5 9e!h Sq. feet Dwelling—No. of Bedrooms.._._._.._3............................Expansion Attic ( ) Garbage Grinder (N q p., Other—Type of Building ............................ No. of persons.......42................. Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ w Design. Flow..............._-'�___............_....,___...gallons per person per day. Total daily flow..........33.0:=.______.___..__......gallons. W Septic Tank—Liquid capacity a gallons Length__ -V. �`idth._'4'.:-N Diameter__.__.__'.=;__yDevth.-'�-__-�� T Width__._... ----------- SeepageTotal Length.................... Total leaching area=_: x Disposal Trench—No. Fg g sq. ft. .. Diameter..___. .Q__---__ Depth below inlet_150.. Total leaching area:_. 5_ _...sq. ft. Pit No.____.._I.....-..._ 1 - Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by.G.A�...01).5qt: Cn�SU.T tTs_ Date...._s6_Q_`'1�-.&-------------- ,aj Test Pit No. 1................minutes per inch Depth of Test Pit... �J.�P Depth to ground at'er - 0z Test Pit No. 2....... -....minutes per inch Depth of Test Pit 1_ Z ..... Depth to ground water :, � N t�C9 T P I- -a--9S- M EAR U-1 -s-AnFi�_. A b ...-•---__----•--•-----------------------'----- .=' Desc�iption�of Soil_`� ..__8 �V /CYF(Af � /N -_SZr9T/F/�� p n �, .S 0` ' ROGER x 64 --9a• V�jE. JUM S - ,,6AM� � /5( DE ��Pt'�lM T�Vl, ....................................... �.- � a� V ................... __ I ._._ _.j.__._.._ ___. �__. ..___.j��__._._.___ __ _..____ ;,_a.Q1v` ?e'rbV1C� S.. w Sfifrl:S�M�_.J�J -TRAct #z �J"13f1 � ..I� DpS?IYI Sri�2f9)1F1E , . t:. o. csac r UNature of Repairs or Altera on —Answer when applicable_SANA AND CK,AV'EL �lV r_ i ---------------•---••-----•-- Agreement: The undersigned Pgrees to install the aforedescribed Individual Sewage Disposal System in Cora nce w h7� Qf the provisions of'I 5 of the State Sanitary Code—The undersigned further agrees not to pl ce the syste in D'b operation until a Certificate of Compliance has bee i b e o d of health. to ApplicationApproved By......................... -•---•• ----•--------••-- --------•-----•--•--- Date Application Disapproved for the following reasons---------------------------•---------------......----------------------------------------------•-•--•--------•--- .............................................. ..................................................._...................................................................................................... Date Permit No. Issued--------------------------------------------------•---- Date . "' THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Applirafiaat for Disposal Works Tomitrurtion Prrutit Application is hereby made for a Permit to Construct ( >6 or Repair ( ) an Individual Sewage Disposal System at: C. = . .. .` ,+ ......_-------- -------------- Location-Address or Lot o. tKNIK ........................................ Owner ................................Address Installer Address Type of Building �D Size Lot_ 42�%tti:Sq. feet Dwelling—No. of Bedrooms................. •_____________•.__-_.._----Expansion Attic ( ) Garbage Grinder (N aOther—Type of Building ............................ No. of persons_...._._�................ Showers ( ) — Cafeteria ( ) dOther fixtures ......................... ..............................................................................................=- W Design Flow................. ....................gallons per person �r day. Total daily flow_.._.._....3-�*�--Q.....................ga�llons. WSeptic Tank—Liquid capacity_1000gallons Le.ngth__8__."-_(P__ Width._""f'.'_-•./!;yDiameter________________ Depth....•r+"___ _. x Disposal Trench—No..................... Width....... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------r-.-______- Diameter_______ 0..... Depth below inlet.._ ..o__.._. Total leaching area....ZA�._sq. ft. Z Other Distribution box ( � Dosing tank ( ) `-' Date----•- Percolation Test Results Performed b .C/.�. _._ �l ��' G® ? - � � ____------.. by..CAM... - ,.a Test Pit No. 1....."-^""'___mmutes per inch Depth of Test Pit____ _ ------- Depth to ground water-!":"--,,'_ Test Pit No. 2........2....minutes per irlch Depth of Test Pit.....t 1>2. .._ Depth to ground water....... t%A%OFl, � x `1 x 5 s ' } " o�f it ..W ..........-..... --- --- ®' -O Descrjooil_. -a. ER � A / ------------------------ MICHNI4..E ------------------------------ __.` A------------- U Nature of Repairs or Alterations—Answer when applicable_. A AN1,� C1;AYGL •—•., \ Agreement: ,� = The undersigned agrees to install the aforedescribed Individual Sewage Disposal System i ordance wit the provisions of iiT p 5 of the State Sanitary Code— The undersigned further agrees not to pl e the system n operation until a Certificate of Compliance has beebsuf by e board of health. _ ned • -••-----------••-•-••-•-•----••--••---------•-•• .......................... Application Approved BY...••------...--- ......-- .... - ----------- ---•--...----•---•--- 111 z'C-�....... Date Application Disapproved for the following reasons-----------------------•--------------------------------------•----------------••--------------------------•--•. ...............•--•••-----•-••-••••--••--•---•-•--•----•-••------••--•••--....-------••---...----------•-•--••••••-•••••-••-•----••--------•--------•-------------•-••-•-••---•------------•---••--•---- Date Permit No..-.: = -. Issued---------•-••-----. Date THE COMMONWEALTH OF MASSACHUSETTS --- "' BOARD OF HEALTH t�......,�.........oF...................:......... � ....�:......... ....................... TatifiraU laf TlampliFattrr THIS �jTO CERTIFY, Tha Individual Sewage Disposal System constructed ( ) or Repaired ( ) byl- G� -•-----•--------------------------•-...... ..................................................................... � i Installe at y __. ---...- _L ------ has been installed in accordance with the provisions of 5 0' the State Sanitary Code a de e in the application for Disposai Works Construction Permit No..._ ......_�...9..j.... dated----.__- .1_.� —` .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI ION �Pj, FACTORY. f/ DATE 2 ..........• Inspector --....-G�•... THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF._.,,HEALTH W'oJ _ � -G— ..............................I...........O F................. ....... 9j...._ F>EE..: ....... liMp sal lgjarkii T wit panfit. Permission is hereby granted-------- - '- - ------------------------------•--...-------------•---------..............------ to Construc ( ) or Repair ( .--an I dividual...Sevrrage �o al Sy t at No.. o t G.... ----- r.� �t� � -.............. Street L as shown on the application for Disposal Works Construction-P_enait-Mo.__�`��i ed ------- ...................... -- - - - y� I . Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS f IF'wa.,. 1 ASSESSOR'S MAP W.I. PARCEL= � ' LL ®A T ION 139 SEWAGE P RMIT No. VILLAGE �Q(� INSTALLER'S NAME A ADDRESS - , Vt i B U I L D E R OR OWNER ' 1 l DATE PERMIT ISSUED DATE COMPLIANCE . ISSUED ; Z J 1 l d �Oil q' j � '1� I I . I -_ � I I - I I �I I - I� I � I I I I ? 11 . I . I - . . I 1-1 I - I I I . I - I I I I � I I I I - I I I I �. 1 ,7, -I I I I . I . I I I I . I I . I I I I I I I I I �, . :� I I I I I ; , I I I I I I I,,, . I � I I I . I .. I . I I I I � I I -� I � . � ! I I I I I 11 I I I . .I I I I I , � I I � I I I I I I I I , I I I, � I I I - I . I I 11 1: I I I I �. II .I I . I I I I � I I I . . I I � � I I � � . I I I I I I . , I . � I � I I . i I . . I I I I 11 . I I I . I I I I � � I , I � � I . � I �I � ,I I .1,I I I I � I I - I I I '. I I I I I . I . I . I . I � I I I -11 �. I I I j I I I I I 1 I . � � I I . I I I I I I I � � . . I I � � . � I � I I, � I � I � I I� . I I I � I I I I � � I � I I . I I .I I I I I � . I I I �. -, I I I I I I � I I I I I � I I I I I I . I I - I ,I I I .11 -__ - I 11 , , . . I I . . I � � � �11 11 � I " - ' "I ", � I " ^ . em - � . I I I I I SEPTIC TANKDETAIL- 1000 GAL I - � DISTRIBUTION BOX DETAIL: I . LEACHING PIT DETAIL: I � , ., REVISIONS.. � I I - 1. I 11 '' I I - I I I 'Ii SOIL ' TEST PIT* DATk . INDICATES . I I I � I I . 11 :-��_%, I I I I . w I I INDICATES V I � � I � � I I I " . � I I I 11 .� 11 " I I I I PERC. - OBSERVED I ,� I I I Z_ I NOT TO SCALE � I � NOT TO SCALE NOT TO SCALE NO. DATE � I 1 . I . . ' � I I I I � I I I I I I I I 11 11 �', I � 11 I I I TEST , ,' GROUNDWATER I . . I � I . I lt� ,� . I . I I �, 11 I I . � I� I I I I I � - I I ,� � � � NOTES: I.',SEPTIC TANK SHALL BE STEEL 4. INLET AND OUTLET TEES TO BE CAST [RON OR " NO. OF OUTLETS: -5 I MANHOLE COVER . LOAM Ek SEED I I I 11� � I �11 ,�.�I I� I..�', 11� I i � I I 11 � I Z) OR PAVEMENT I I I I � � I I - I I I I I I REINFORCED CONCRETE. SCHED." 40 PVC. TEES TO BE CENTERED UNDER � BROUGHT TO FINISH GRADEI F I 1. I 11�1 11 - . I TP4t I I 1, - � TP _# Z TP TP I . . - I - ,, I __ 1k] (I I 1110 � - . I I � � 1 .� 1� . -- - I I I I MANHOLECOVER. . 7F 1 7 NOTES- " ��:i ,///, 111 ( 11 [ w � � III ki , -_ 7/7� .1� I I I ,, , I 2. SEPTIC TANK TO WITHSTAND H-10 LOADING . I _j__j____I ' I . .� I I I �. I .. GRD. EL. -79. 5 GIRD. EL.07-3 � GRD.,EL. ' I GRD. EL. I I I I r-- I. DI'ST BOX TO WITHSTAND H-10 LOADING 2"MIN'.OF I*'i I I "I I , I I I . ' � 11 w . I UNLESS UNDER PAVEMENT, DRIVES OR . I I I - I � t I I . % I � � � - I I I TRAVELED WAYS,WHEREIN H-20 LOADING I _� 11 � 11 L I I I . 1 I I I .. I . 0 -GW. EL. - 7911a 0 W. EL. I 6111 - W. EL. I I _GW. EL. I I I I I I UNLESS UNDER PAVEMENT, DRIVES OR TO 1/2" �� 12 MIN. F -,� 1. � � I I I I . �: _j E N H-20 LOADING WASHED 4� . I � I . I 1, I . � STONE � � .1 - I I I I w I I � . . �I rmo -ropsot" I I I � I I I I. I I I - SHALL APPLY. 11 * ' I �i I i.-_ . � � I � . � I I I - - I I I I I - , I I I 3. ALL PIPE CONNECTIONS AND CONCRETE � MANHOLE COVER I is I DIST I � , I 1. ;, � 'I- � k�o1z SVIS ;O) I � �A��Z:�- - , -, t, � - '. I . I I . I - i I I I BROUGHT TO FINISH GRADE BOX � I-__ 2. PROVIDE INLET TEE OR BAFFLE WHERE SLOPE OF :-) � A,�t� ,) 1b,, / - � I I I I I �� I I I . I CONSTRUCTION TO BE WATERTIGHT. I 1 I PVCINLET PIPE- L3 M CZ3 E= t= r-1 r-1 C:3 C3 -Z : I � I . ., , �. t I i 1fA,F_z)iU�k_ I I . I - , . -, I I - I I 11 I I - 11 ; I I I INLET PIPE EXCEEDS 0.08 FT/FT. OR IN � 0 a .. - �, , . I 1< I . . - I � . 11 I I I I I I . I � llqppK,11.111%_,<�'11� w1111\x4k.w � � . cp&7�v '1� . I I I I . I ., � " 6D�;:: a c= = r= C3 1 I I . I I . 11 I - I I - . I 0 � to . I � I I 11 MIN. "' � � L___r___�__._j . . w ..'� �� , , 1� GENERAL NOTES: 11 1 ,.� S-r r-A*T I C-i LrD � - Fim c I I I i I I PUMPED SYSTEM. A - �bl � � , 1 84 5 I � I I I I 1 12 � 1 a I % 1 3. FIRST TWO FEET OF PIPE OUT OF DIST 4 I--' C= = C3 .�.�"I � NOTE: I I I I I I I SAMID � - , - I I I I I COVER - n� 0 LEACHING PIT TO I I 1'� I I - I - I . I I 7: I - ,�F , 10 D-�- 6�,- � � I I L I I � - . . , . . - , .r " . - BOX TO BE LAID LEVEL. I- I - . tp � WITHSTAND H-10 LOADING � ; I 11 , . .. �/z I I I . I I I I I ,, . I - � . .� �.. . � . , 'Y 1. . ... A I . I (L 9 011.1, , 0 C3 =3 = = = C:3 M 0 _ . , 1. THIS PLAN IS FOR DESIGN AND I . . - ,�--`-,. r . I I � I I .. . . . I �r. . ... . ..,., . - -. * . PLAN VIEW w � � I I I I . I I I . � I I " -To � . I � 8 - 6 1 � . � m .. - -�--..- I . ;� �..6 A �� q,, jjg. � � I 1 49, 1 - t, , , I 1� , . � 11 .... 11 ... - ... .,�� ....- I 0 V PRECAST ,.. -_ UNLESS UNDER CONSTRUCTION OF THE SEWAGE , I � I .0 - t3.3 - - I - 0 ., --��- 5-8 - tACt) UK I RE' . � . .: ,- . I . � 4 - - -7 1 1 1 . MOVEABLE-\ � �,� PAVEMENT,DRIVE OR . �� , I. I vegfe P im 6 � � I I � I I I ;NORMAL WATER LEVEL � -2 I I Uj � 3/4"TO 1-1/2" -_ 0 C3 m r__1 = = CZ) 0 cl �: . 11 ,�� DISPOSAL FACILITY ONLY. I I I � I I I . I �_ 4 #0 - COVER I I I I I I I �I 11 I I I I '.--_j ____7_ . .4. - > r- :�. . , I Z_ � I � I I �I � I - , I � I - � - ... I 1 /0 . . � I I DOUBLE '.- � LEACHING PIT , ,... I 1�b� I H-20 LOADING SHALL I ., I I Ird � , I . t ff ?.-. � �_ . �11< . A '.) 2- ALL CONSTRUCTI 11 -I I P-we "I I �� I I - s-MA-r j F i IF t) I I I I I I I I : - L�+ I :-% I' I r__1 0 41, WASHED - 0 = m = r-" = r_1 = 0 - . CP APPLY. I I I � I . I I .. /4 .. Uj - . . MATERIALS . I � I I � I I I I I I I � I I I � I . . , 4 1 .. PROVIDE �'. r � ' . , . .. I STONE �.: . 10 I . � I - ZTMAT I Ft 0> � � I - , I -� I� - , I I I I I . � I . .1 � . I I ��-,�.:-.-..--.� ::I_%-, LL_ ... I U I I � . I I I . � I INLET TEE i .i., � WATERTIGHT . I LL_ I I * ,I D.E.O.E. TITLE 5 AND LOCAL BOARD . � I 1 . � ., - 1�-. I I 11 (no fines - - o� . I � ,� . I I . A- 13 C3 C] 1=1 r__1 1=1 C:I 00 - 0 4 . OF HEALTH REGULATIONS. I I . �� j, . '� SAM b I . I I , JOINTS(typ) .1 :"I Uj + . I I + tl . AM 1> 1�, , ' I, � . - �� I. -A 1�' . - - V q I . , I . _f ,5'.j� --;,, ..I 1.!� D 0 � � :z� � � 'r . I �, I I - ft ... . L-If -SEE 1. .m - kt ` � I I , I I I I .. I S ,-. . , ., . I I _11� .. .1 :1 � � I . I - I I . , I I ,A.� 1� I I . - - I I I 11 . . ; , I . 4'_O"MIN. OUTLET ; . .� . 3. ALL PIPES LOCATED UNDER PAVEM I I I 84 � -7.Z.'B - km I 1. I I ,I SEPTIC : A . LIQUID DEPTH -P TEE :�* NOTE 2 1 1-11, I.- �- CO r3 ' . . ENT I ' � ,, : . , � . b I �I TANX I�.. � .1. _. - --4 0 M = =3 =1 C= C3 I - I I . I . I I I -to I*., .z / ) P 114) r= 4ft 21�� _! . 11 a I A ,, L OR TRAVELED WAY SHALL BE �, � � I � I I .. .* I k, i I 4"OUTLET I �, I aw, MMU-5b SAAM '� � I I �. I - I I - , . I(D I . I I (DI . . . .. - oil �11 �140- - ":�6c 1, . 010�2. . - , 1 7 71* � I .4 f.- . 1-= '. - A )O I 0 ,� n%!a O/ I . SCHEDULE 40 OR EQUAL. I I . " I I 41-P I I I I I ... I i-i 't_ 1::. 1 T , V - - - I -_ 2F_ . I I � � I . I .I , :�j I -2- I I - I I I� VEASE �1.1 "P V"e�L I , I I I . I .:, .1 . ,.. 1. 2 1. /4-"/\,Y/ //"//,\�// I .1 . . �I 11 I . 11 , - , - I �1, - - I � . - " I - I I . � .. " i -_ .....L-------- 1,.,� - .a- 6"IMIN. � I I I I � I , V6)ZY 'r-jAJ47 I I I I � L - - -__j .I - i � � I . .. '.�. . 4:-.'..:�.-� ...:'..... . . . . .0 Z -r 6' DIA. Z ' I I I " I'll � 11 I , I ""I I I 11 ':*! '" :,.",-,0,'._�_ ---! .::�:.::�'_.i,.*�:.4i..",,.' ..,.A, :' ,�,_�-:��, '. .6 . .. - V'.".: I I I I . � . I .� ,- ; I � I I 'rO Ft4E - 1� I I � i. I .1�.,; I ... - I - . - A--BOTTOM ON I . r . . I 11 . -,,I I I I I I - I � - I .1 . .,a,;). L.�� _ I I. I I I I . �� 3 - cc:� , I I I I . - I 11 I I I I � - I I I . I I 0-t) BOTTOM ON LEVEL STABLE BASE gj;-,�P I I i��'��S2��'C;) LEVEL STABLE - 0 1 1 1 1 11 I.I � StRA�T i ri I 11 1� I I I 11 I � 11 I I I -5'.ra -_ , -. 'L - !_QtL�� /0 DIA.� . I � I I 11 I� � .11 �,�. I 4AN t> $V Tf:�'f;�� I I I - � I I ,. � I `/11 I CROSS-SECTION "_______r'7',1_-'111---'_ BASE I � I I" I �, � 11 / I � I.- � I No W610 � - I � I 1 .1 I I r PLAN VIEW I ///�F//t__//4__ CROSS-SECTION VIEW ;11P5 ;�5_1_�, . �i I . r I I I I I I . I .� I I I I L I I I:I I I L I , I I I . I- or 'SIf.-r I , 32� '� I., w..�. . � I � J I �I � I CROSS-SECTION 1. I , 1� 11 I I I I I I I �. I I 11 \ �, I I 1 1 1 1 1 1 1 1 1 � I I I . - I I � . I . 11 I I,. 1. I 1, I I I I I . . ,� 11 1 1140 WA-jf,&- I � ,I , 1 I I I I � . - __ _ _ I I I , 1, .11" .. � � 154!!- &C.'s , I' � I - I I . I �11 I I I CONSTRUCTION NOTES:' I � I I :11 , I . I I I DATE,' . I 'll . I I DATE: � , � DATE: I �, I I . I 11 11 I , I � '. I I � 11 I I I 5G, 11 � . I I . I I I I I I � INVERT ELEVATIONS: I � I �, 11 I 1 61 1 fd , 6116MG I I I � � � I I I I L I I I I I I I I . I I I I I . I I I I I I . . I I i � I . I I/ � ) I . I I I I I � "'C' ""/ L I � TEST -BY' � TEST 'BY: e, I . TESTBY: I TEST BY: I �1. I I I � � . 09,50 1 1 1� I 111.�, '/I * , I r I I I I I I I I 0 L4 S.")�.�NlpwlxW . � . � I I . . I � I INVERT AT BUILDING L' I I I I, ' ' .",1// . . &AI/P.Mkon I I .I I I I I . I I .. �, " I , � I 11 I I � I I I I I'�:� " I I � ' �1 I WITNESSED BY: , WITNESSED BY:' � WITNESSED BY: WITNESSED BY: I I I I I I . TANK(in) 6930- � I I I ,� �. INVERT AT SEPTIC I . - ", I I I � I I � I �, I � - I � � , I I -.1 I I � I I , i I �. I � I I - I . I I , I I I - . I I � ) eq. 05 � I I � I 11 .� " I , I I I - "I I I . INVERT AT SEPTIC TANK(out. . 11 . -, I � I . I PERC. RATE: I PERC I.I RATE:- . I PERC. RATE: - I PERC. RATE: , I 'N'�,_ I � I : I I . . I I�. . L I I I I I'I', � I � � I I 1 88,93 I . -, . . I I 1 12- , I . � I I I � . INVERT AT DIST. BOX(in) I � I :-, .. - , ` MIN.ANCH , 'MIN./INCH I - MIN.ANCH ' � MIN.ANCH I I ; I � � I � , II I I I I ,,, I 11 I I � I � �L 11 I I � I . 11 11 I I L . I - I � i . . I � 6?)J;Z� I . I . � I I I � � I I 11 I 11 . I I I I I � I INVERT AT DIST. BOX(out) I . . . � .� I � I I I - I I I . . I . � I " I I . . � 11 L 1, � � I I .. , - � I I I I I I I 11 I � I I , . � � � I � 1. I . - - ___ I � I � I - I " , . - 11 . I r . � INVERT AT LEACHING PIT 816.47 � I � - - � I - I � I Z11 11 11 I I � I . I I : %c) I � . I � . . � I ' ll " I I 11 I 11 I . � I I . I I 1, � I ;�� I e I � � � 11 I I I I . . I � . I � I 1 I I . I' ll ; . I . 11 , I I I CA I I I . . � I � . I I I I k 11. - DATUM. � - 11� I I � � . � . I . . BOTTOM OF LEACHING PIT 82,160 , I � 1. "I 1, ,� � I . I I � � I I . . I I I I I I � I � - . I ; � � I I I I � 11 . 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