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0010 KEARSARGE AVENUE - Health
10 Kearsarge Avenue, Centerville =226 - 193 1 r-- G-71) No. ....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / e!�r'•-----OF.............. : ------------------- Appliratinn -fur . 1 Works Cnnntrnrtinn Vrrntit )PpliaationJis hereby`mad for a Permit to Constr t ) or Repair ( } an Individual Sewage Disposal tan sy Nae t �G/z' �l' �.�.�s ------------ --- ---- --- ........ ..... - -- ------•• ---------------------------------------- Loca� -Address /n� 3� orb of No. •.... . ..... ........................ •-:....... {'.t'k ........... ------... -----. ---•--------...-..... t/........................ Owne Address li a � s Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms__ ..._ Expansion Attic ( ) Garbage Grinder aOther—Type of -Building _ __' . _!______________ No. of persons.-______................... Showers (3) — Cafeteria ( ) Ga Other fixtures -------------------------------- W Design Flow....................__ ._.__. __gallons per person per day. Total daily flow__.... . -• gallons. •----- WSeptic Tank�.iquid capacity/tF__._._gallons Length________________ Width---------------- Diameter........._ ..... Depth................ x Disposal Trench—No_ ___________________ Width..._.r./._._ ------- Total Length-_---_-__-____-__-_ Total leaching area--------------------sq. ft. __ �C_Y_----_ Depth below inlet.................... Total leaching area-----.___.-------sq. ft. Seepage Pit No...__.__Y___ Diameter._ Z Other Distribution box (k_� Dosing tank ( ) O h a,O e 2 -2- 2 - 7-7 Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- a a Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water........................ �14 Test Pit No. 2---_............minutes per inch Depth of Test Pit-------------------- Depth to ground water__._-.---__-----__- �. -• :-----••--.. Description �f Soil_4 _ �eta _ �(, ------ . . ._..._--- ----------------- . �> -------- --- -------------- ------------ --- 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be iss by th bard health. Si -ed..-- . .-- -•-- ..... • - ---- --------------------------------------- Date__ ------------ Application Approved B _ PP PP Y .......�- >--- ---------------- --------- ----�1` --1--------- Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------- ••••-•-•-•-------------•-----•------------•----------------------•-------•-•--------------•-----------•----•------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ! ---OF....... .. ��.�P�..... ...... .:..:.................:................. �rrtifiratr of Toutphatta TI IS T RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) y c.�ma."�;:4z -� --------- - b .... .. - I at...... - _.!1����.__ '�✓.ems:__ to sta`lle 66.r-'_.;rl 4.y` 'c ���t has been installed in accordance with the provisions of AA gI XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit N . -- -----_--------- ---------------- dated--.. ................................. THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / DATE --------- -----------f------------2-2----------------- Inspector--L-„ -- J TOWN OF BARNSTABLE L� :nrTION�� SEWAGE # /,9 4 VT.LAGEW ASSESSO 'S MAP& LOT /9 3 / 5 C-'7URS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACELITY: (type) PIZ 62 (size) 1606 P". ,DAA NO.OF BEDROOMS BUILDER O OWNER PERMTTDATE: 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 -, ���`� r3` �� ' i O �$� i �� � a� \ ,�o �� ! .r TOWN OF BARNSTABLE LOCATION /`SCd 2. QU2 • SEWAGE # VILLAGE is / �A��S��SESS S MAP & LOT-VVq`� s��70, NAME&PHONE NO /'��O tt D'-� O�S 76f e31 SEPTIC TANK CAPACITY �S-00 LEACHING FACILITY: (type) ��"`�S ��l (size) /6"0 �2ax NO. OF BEDROOMS BUILDER R 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 �4110 `ICL- et O she ,i CATIO/N /� , SEWAGE PE=�IT N0. VI L L G E /7fSe/ INSTA LLiER'S NAME & ADDRESS L B IJ U D E R OR OWNER DATE ,PERMIT ISSUED DATE COMPLIANCE ISSUED- //�.� A G �. �• ` i 2� 7 I. ��, � �S U ryG� _. No.........--•..a ... `�`� Fx�............ry .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H L .OF............. ................ Appliratiun -fur Uigpuuttl Works Totustrnrtiun Vautit Ampplication is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ,ste IV ........... ---- ................................ -- ----- .............................................. Loc on-Address or No. `. -- ...... ....IC---- ------------•---.....•..................•. ......• *- A#' !!!! ! 9f... ...... 4t Owner � 4 Address (( � a . ----- ----•--.......................................................... !AMA Installer Address CQ� Type of Building Size Lot............................Sq. feet g— P ( ) Garbage Grinder (0 Dwelling No. of Bedrooms Ex ansion Attic Other—T e of Building �_______________ No. of el sons..____ Showers — a YP g ---------------- (.�) Cafeteria ( ) d Other fixtures --- --... . ..----•--- W Design Flow.................... . ..... _..gallons per person per day. Total daily flow....... -----__--__--_----._...._--gallons. WSeptic Tank&eLiquid capacity/ .____..gallons Length---------------- Width------------ _._ Diameter--------- ...... Depth...._...---.---- x Disposal Trench—No._______ - ���id i__.._ ...------ Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No........ Diameter..� ...�__- Depth belo inlet.................... Total leaching area-----------------sq. ft. Z Other Distribution box ( Dosing, tank ( ) +�. •yi " ► aPercolation Test Results Performed by----- ------------------------------------`-'.............................. Date.......=-----------------------------.... Test Pit No. 1................minutes per inch Depth of "Pest Pit..._.__.___._....... Depth to ground water.__._.._..._...._.__.... rX4 Test Pit No. 2................minute�ser inch Depth of Test Pit_---__.-_-_-___-.._- Depth to pra*�r r groun ~d --------------------- ,,water-_--...__-___---__- " 11 DDesc f Sodo - --- - ----------- UWj -- -- . --------------------------------------------------------------- Nature of Repairs or Alterations Answer when applicable._------------ ---------------------- --------------------•------•--------- ---------------------------------...................................------•---•--------------- --------------------------------------------------- - Agreement: All . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with . the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in ;toperation until a Certificate-of Compliance has b . iss d b th aid health. x Sit ed... ' Date Application Approved By. .... ,_ _- ---- --•-------------------- -,�- ��»--------- Date I' Application Disapproved for the following reasons----------------------•-----------------•-------..._. ....-------------•--••---------------....----•--•---•---•-- .............•-----•-----•---•--------------••-------•--------•--•--•-------•-•-•------••---•--•-•----------•-=-•-=•-=---------------------•-----------. -------------------------------•--------.------ Date PermitNo........................................................ Issued---------------_------------ Date THE COMMONWEALTH OF MASSACHUSETTS ' BOARD F HEALT /. ............OF..... .................... 6WIrrtif iratr Of TOmplianta'' . eS TO RTIFY, That the Individual Sewage Disposal System constructed or Repairedby. " . • -- . r P. In4tall _ has been installed in accordance with the provisionsTZ&1 XI of The State Sanitary Cade as des ibed in t e application for Disposal Works Construction Permit N 7 .... _ _��----------------- dated...6-6.40-_ .................... -..THE ISSUANCE OF THIS CERTIFICATE-SHALL NOT BE CONSTRUED A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE---------�-----X•�------------�......-•--•------ Inspector------------------ --- ....................... THE COMMONWEALTH OF MASSACH TTS - BOARD QF HEAL H OF j / f.........`. . .... ..... ......... ........................... ----------------- ----------- //�...M No..-- ........ y FEET I .. �i��u�tti rk,� un�tr�trtiun �rrmit � - Permission is hereby granted ... --- --•. ................................ to Cons F r Repair ( an Individual wage sw •ys m • r at No •-- �?l �lk 1F 4/�l �f -. . stree as shown on the application for Disposal Works Construction Pe t No.__ - ated____ ---. .............. ..... . --- ......................... oard of Health DATE.................................. --------------------------------------------- 41 FORM 1255 HOBBS & WARREN, INC:, PUBLISHERS „ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' y � o 3g` �s DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: •¢ l vXIV i Ur '�"1"ej • aac� 19 BORTOLOTTI CONSTRUCTION,INC. 0 765 WAKEBY ROAD,MARSTONS MILLS,MA 0264 ~ S EF 508-771-9399 508-428-8926 FAX: 508-428-9399 TOWN OFBARNSTABLE HEALTH DEPT. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION C PART A 9 � TIFICATIO�NN 8 L Property Address: /10 , Date of Inspection: ffy'7 nspector's N e: Owner's Name and A dress: / v J CERTIFICATION STATEMENT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal �}'�tems. The System: I Passes Conditionally Passes Needs Further Ev ation By h ocal Aproving Authority Fails Inspector's Signature: ate: 1/l1O�9� The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY- A)SYSTEM PASSES: S/ I have not found any information which indicates that the system violates any of the:failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM << PART TIT CERTIFICATION(continued) Broken pipe(s)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 C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which"require'furtlier-evaluation by The i3w&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 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 a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that-the system violates one or.more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged 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 -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 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 a large system in addition to the criteria above: The design flow of a 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 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 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 atleast,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. I/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. _a CAII system components,excluding the Soil Absorption System, have been located on site. ✓The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. _ ,,Zfhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- :.r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION s. FLOW CONDITIONS RT. NT'L _ Design Flow: allons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use:A)d Water Meter Readi gs,if ilable: Last Date of Occupancy: COMMFRCIAL/INDUSTRIAL: Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of it►for ation: rh. System Pumped as part of inspectio d If yes,volu pumped: gallons Reason for pumping: TYPE OF SYSTEM: !/Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): P OXIMAT AGE of all components,date installed(if known)and source of information: Sewage odors detect when arriving at t site: -4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: � — Depth below grade: Material of Constriction: l.Iconcrete metal FRP Other (explain) Dimisions:>0,,<-',Yb' 1ls� Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 3✓ Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid , level in relation to outlet invert,structural integrity,evidence of leakage, i� � /I�i a (a �.n�2 �,r ixl�f Q .�irt� r'�}�.✓l [,� /,� �,�ii ./1��d. GREASE TRAP: 00 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: 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.) TIGHT OR HOLDING TANK: 20 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: Depth of liquid level above outlet invert: Comments: (note if 1 el and distribution isqqual,evideYce of solids carryover evidence of leakage into or out of box,etc.) / PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):_ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number:Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil,signs of h draulic failure vel of ding,condition of vegetation, etc.) O CESSPOOLS: k)U 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 soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - r � i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 3y 38 � N' DEPTH TO GROUNDWATER: I Depth to groundwater: 17 Feet ^ Method of Determination or Approximation: 5. -7- ,f BORTOLOTTI CONSTRUCTION, INC. / SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM V Address Prop e L Map arcel Owner Date of Inspec} ll 9s-- PART A — CHECKLIST 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 COLUMES 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 SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,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. HE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. Ls' THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL No of Bedrooms � -No of Current Residents Garbage Grinder ycs Laundry Connected to System Seasonal Use NON RESIDENTIAL: Cafcufated flow) _ WATER METER READINGS,IF AVAILABLE: GALLONS Pumping Records and Source of(Information: SYSTEM PUMPED AS PART OF INSPECTION? U IF YES,VOLUME PUMPED = IQ GALS Reason for Pumping: °A- vG TYPE OF SYSTEM: Septic tank/distribution box/soil absorption system o� Single Cesspool Overflow Cesspool vv Shared system (if yes,attach previous inspection records, if any) G cq y Other(explain) 41. 1 J aA A�pp/r/�4yxiymaQt / e age of all components. Date Installed,If known. Source of information. *� ` SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - SYSTEM INFORMATION (Continued) SEPTIC TANK:- Depth below grade: Dimensions: i Material of construction: Concrete Metal FRP Other} Sludge Depth If Distance from top of slud99 to bottom of outlet tee or baffle 37 Scum Thickness Distance from Top of Scurry fo top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle `Z Comments: DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: r n ! O /� - tl/ff2 I? 1,16 PUMP CHAMBER: Pumps in working order? Comments: SOIL ABSORPTION SYSTEM AS IF NOT PRESENT,EXPLAIN: TYPE: Q �,�(�• ments: wn� 'Sf S //T Aj C/fJ f p`o�• —ems(�' (p r v� //CJj �� t? — i� D'— S C.✓ej mP ctLl CESSPOOLS: Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Q Materials of constructlon Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' N � o 3g` �s DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA , (Indlcate Y—yea N—no ND—not determined.Describe basis of determination.H"not determined",explain why not.) Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Al Required pumping 4 times or more in the last year? Number of times pumped —Al Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiftration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? Within 50 feet of a private water supply well? I Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? 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,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION, THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK O I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY r rT, , i � i �I i I f I i • o .i rU h \Q I /G, C . GC o L l i I ON r- LA -1 11.1 3,E k' t� .`C 1. E7 , VI A5�. Zc� 1` TZ I' c r-- \T ta <a Kc�U N© 17 GU N Fc> �(S TO `Tt 4 a.: .A F} -,�.... ...r....