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HomeMy WebLinkAbout0273 HUCKINS NECK ROAD - Health 273 HuckinsNeck Road, Centerville A= i No. 42101/3 ®RA 4 ESSELTE 10% O O @ O • i Commonwealth of Massachusetts Executive Office of Environmental Affairs . �U� Deportment of , ' �J�b Environmental Protection William F.Weld Governor Trudy Coxe Secretary EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 41 c 1( 'Z Address of Owner: Date of Inspection: -7/is/i 6 (If different) Name of Inspector: %?o,o G a-9 ena i ASSESSORS MAP ft Company Name, Address and.Telephone Number: Po Qo,c 1167 n-211.ri, �'� n, �� wZGvS CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is frue, 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: ��.?,� �,�CL.x; ` Date: '711 r The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection'-' If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to :he system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check AJ)C, or D: A] SYSTEM PASSES: Y I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: /, YOne or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) 10 The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-5500 r. �J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 017 3 ]C 1 N e CK 9-43 Owner: S 4 e ut p b I..s S jJ Date of Inspection: '7 D] SYSTEM FAILS (continued): N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N1 Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. N Required pumping more than 4,times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped N 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. tit Any portion of a cesspool or privy is within 50 feet of a private water supply well. N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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: 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 li 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. I (revised s/i5/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: //Pumping information was requested of the owner, occupant, and Board of Health. ,,,"None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ZAs built plans have been obtained and examined. Note if they are not available with N/A. _JZThe facility or dwelling was inspected for signs of sewage back-up. /The system does not receive non-sanitary or industrial waste flow V"'The site was inspected for signs of breakout. ZAII system components, excluding the Soil Absorption System, have been located on the site. i/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. il"The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. v The facility ov.rc- ia': occ,_'pa-!S, if dinere^t from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: �L20 gallons Number of bedrooms: 'D- Number of current residents: v Garbage grinder (yes or no):_IAf S Laundry connected to system (yes or no):e Seasonal use (yes or no):A Water meter readings, if available: Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: Qallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_yLS If yes, volume pumped. /2, gallons Reason for pumping: ya E 0 i3 r. te- TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 1 of )4411I (firc 6:k0 I Sewage odors detected when arriving at the site: (yes or no)N--" (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: Owner: Date of inspection: SEPTIC TANK:v (locate on site plan) Depth below grader_�- Material of construction: _concrete metal ,_FRP _other(explain) Dimensions: 7-4 /Q, t. Sludge depth: ea il' Distance from top oftludge to bottom of outlet tee or baffle:_ 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: `16� Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural -)x integrity, evidence of leakage, etc.) . n . L-c - GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sn ^i to bottom of outset lee or baffle Comments; (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.: (revised 8/15/95': 6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distrbutic;-. i; ecu !, e%;dence of so!ids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/1S/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION (continued) Property Address: 1 C"C is e-CAr s2'� Owner: z. R c h i ti s o w Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' A ►3 c t3 r 6 c� DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: I7 U�� /�•z L �� 1"i (revised 8/15/95) 9 d� f' \ A ` `'°' \, F L _� � v oil No.- A.::f�........6.. Fizz...... ....... -•<-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 O+cJ.�I............ .......OF.......364.R.hJ S !4.Ii �= Appliration for M-4poant Worse Tongtrurtion rani# Application is hereby made for a Permit to Construct ("✓') or Repair ( ) an Individual Sewage Disposal System at: La—, ���..._. .I�CK�.c�l. .__.IUCS.K__. �.....C'.H:1�V1L�� ocation-Address or Lot No. ---------------------------------- ...IC__9X f9V.1LL( ....f�j9.$S Ow er Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms---....�u1.,0..................Ex Expansion Attic�--� g— p ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons..........--............--.. Showers ( ) — Cafeteria ( ) 04 Other fipures ------------------------------------------------------•••----------•-•----------------------•-•----•-----••- Desi Design s 9 a�r---------------------- W g ..........gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity.!',520L2.gallons Length-------_------- Width.......----.---. Diameter--------.--.-.-- Depth................ W 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 ('4) Dosing tank ( ) Percolation Test Resullt�s! PIC ormed by.......................................................................... Date........................................ Test Pit No. 1----_---------minutes per inch Depth of Test Pit.................... Depth to ground water---".---..-.-----.--- l.%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.---...............----. ...-......-.................................................................................................................................................. 0 Description of Soil. rs....I.;Z••.FT ----- x W UNature 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 TITHE 5 of the State Sanitary Co The un ersigned further agrees not to place the system in operation until a Certificate of Compliance has been ued th oar ealth. Signed --- --- ---- -- ••--------------------•--------- Application Approved BY �! Date - •----------------------------------•------------•------------------•-----------•- - Date Application Disapproved for the following reasons---------------------•--------------------...---------------------------------------------------•-------....----- -------------------•---••---•------------...........----••••...-•-------...---------•---•---- ---------------------•--•--------------------------------- -------------- Date PermitNo.... ............................. Issued....................................................... Date 6 t/u 1.2� . .cFimz THE COMMONWEALTH OF MASSACHUSETTS ...., BOARD OF HEALTH 1.ouJ . ....................OF...... !gQla.S'1`�> .:Q� 1.?:....._.. Appliration for 11hiVosal Workii Tomitrnrtiun rrmit, ��au ,Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: --------------------------•............-• -L....... P----.4 VM lu .. ocation-Address or Iat No. .!9�> �r?l l.la•' I!�s •-•--------------•------•--------• -•C.G'�N_t't .t t_L......�i. S Ow er Address Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......-- .ul....................Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ............................ No. of persons....................._______ Showers ( ) — Cafeteria fixtures ........................................................................................................ � J_S a-a-----------•.......-----••---`- Desi n Flow _____gallons per person per day. Total daily flow.. WSeptiict Tank I'�iglrid;'capacity_/ _OO..gallons Length................ Width................ Diameter-_.__-__-____._. Depth................ x Disposal-Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit N4 --------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( 4) Dosing tank ( ) , Percolation Test ResulZf Wormed by--------------•--•-...-------•----......-•---•---•-••....----•--- Date Test Pit No. 1______________-minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Test Pit Now 2................minutes per inch Depth of Test Pit.................... Depth to'ground water......____..____.....__. O - .+-�-^' ........................................ Description of Soil----•--'�--._.d..>r?....I-°�•-•--�T'-----��...-•�--•-�=-p-f-V-h�-----a-Alf•t�----------------------------•-•---------.._.......---- x W UNature 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 TITU 5 of the State Sanitary Co The a ersigned further agrees not to place the system in operation until a Certificate of Compliance has been sued th boarr�6fjliealth. -- ................................ Approved By �_�-------------------•-- �.y' ........................................Date Date Application Disapproved for the following reasons-..........................................-------------------•----;---------------------------------....------•. [ Date PermitNo....IV......... -1.............................. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH aGe.!. ,ei Jl.[a s r/5 6!c= t. z Trrfifiratr of f�nmplittnrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) �,�Gtkt — dv by-•-------'--------• . ........-......................................................--------------------------•------------•--...---......------------------ ...----- -----•---•-------- D % r Insta er' fCsd t1�lC e at................••--•--•-�=-6 {vo/�«s vt '- ,' -_/ �`..' .. --- - --_----------- -------_-- has been installed in accordance with the provisions of TIT P 5 o The State SanitaryCo.e as described in the application for Disposal Works Construction Per No"..`. ..... .G1...._.._.... dated... ...........' THE ISSUANC OF THIS CERTIFICATE SHALO. NOT BE CONSTRUE® GUARANTEE THAT THE SYSTEM WI�e F /ACTION SATISFACTORY. DATE .1 <./..� .lfx` _..��`. . .................................. Inspector. ------ -•-•---•-•----•----- THE COMMONWEALTH OF M. ACHUSETTS BOARD OF -HEALTH / ..........................................OF..................................................................................... No..... f'•6-� FEE........................ Disposal lVorkii %Tnni#r i.on rrmi# Permission is hereby granted............ .........................•---•••............ .. . !�1J_iGC�'�.'........:..�� ..'� �.to Construct (W ) or Repair ( ) an Individual Sewage Disposal System .� Street Ix el as shown on the application for Disposal Works Construction.Pe'rmit No..................... Dated.... _ .��.. 3...,. . ............ ... --------------••---••--------- - ------ -••------------------------------------------ ((// Board of Health DATE �r i.•� t =....................... .. _... K FORM 1255 HOBB�yS,� & WARREN.fINC PUBLISHERS «„ � . TOWN OF BARNSTABLE LJCATION7_ _ I ur�'-w+ I1J R� SEWAGE # VILLAGE_r���b�.`.w ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY O O LEACHING FACILrrY: (type) b fi" (size) (rs o NO.OF BEDROOMS BUILDER OR OWNER _9 71,1 ..��m PERMITDATE: COMPLIANCE DATE: Separation Distance Between-the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .r A U Lf e �o p � � o ;✓ v ` 73 LOCATIO SEWAGE PERMIT NO. VILLAGE. rL INSTALLER'S NAME i ADDRESS 120 Beer 6. Due Co 1 LI L t, NOgRi 4A&Wt S U I L 0 E R OR OWNER Bo G Ceo&.11 k DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �, • iAog a 150o Gsr P A,- ToT4ay-- 24 ,A- To '9. 13ox 1 _ -T-a P, s,X e' w To I 8_ To Qovc - 3a piT— 43 A 1 � 1 -�� L - --- A&-L eA.GV 15�i aJ A2g 14 rs A.ei_ U' �G��5Prlccd ,�►t..� l..►VES A ►•t,v,w�� of 1—L_.� � ` /� , � � � _ t�.��.ES� Sri,-�"C►.�t�E SP�JC�fftED. 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