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HomeMy WebLinkAbout0057 LAKESIDE DRIVE EAST - Health 57 Lakeside Drive(East), Centerville =252 - 097IIt w COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIR PROTECTION < ONE WINTER STREET. BOSTO O8 00 ,1 Rfc�ivE0 WILLIAM F.WELD p TRUDY CO)M Governor S EP 2 6 1997 ,p Secretary ARGEO PAUL CELLUCCI TOWN OF B11Nsra DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISP $;V!YSTEMEINSP.E IlbN F@� Commissioner PA T A � L,��(�slc�a ERTIFI TION 9 Property AddreJss: J� I� N v' `�e--Addr of-Owner: e�l Date of Inspection: 9 -Z3- 9-7S (If different) Name of Inspector: I am a DEP approve sy m inspector purl nt to ion 15.340 of Title 5 (310 CMR 15.000) Company Name: -, C Mailing Address: U Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Lo I Approving Authority Fails Inspector's Signature: Date: Q" 2 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Aj SY PASSES:, 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: Bj SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the world Wide Web: htip:/lwww:magnet.state.ma.usidep ej Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: A� E:.ct,ss t ) Ce�.`p—\ "� Owner: K Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl 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 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. - The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 o: 10 1 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: K 0�� Date of Inspection: Cf DJ SYSTEM FAILS: You ust indicate ei:!,er "Yes" or"No" as to each of the following: oKus 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. Yes No. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. JAny portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. JAny 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: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST . Property Ad ress: ek, Owner: t q_� Date of Inspection: C1 _2 3 —1-7 Check if the following have been done: You must indicate either "Yes" or"No"as to each of the following: Yet/ No �/ Pumping information was provided by the owner, occupant, or Board of Health. �/ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. V Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)J (revised 04/2S/97) Page 4 of 10 I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Add ? L a•)re. "cQ44.— Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: '93 0 g.p.dJbedroom for S.A.S. Number of bedrooms: 3 Number of current residents:0 Garbage grinder(yes or no):- Laundry connected to syste (yes or no):� Seasonal use (yes or nol: � Dv U� Water meter readings, if av Iable (last two (2)year usage (gpd): 0 Sump Pump(yes or no):�"� a Last date of occupancy: \ COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)� Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)_ If yes, volume pumped: tzallons Reason for pumping: TYPE 0�-65TEM ►O 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/2S/97) Page 5 of 10 ;- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A dr�' �k f �- � J Owner: Ki?.-`l l� Date of Inspection: 9 - Z3—'7 7 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron 40 PVC_other (explain) Distance from p,�vate water supply well or suction line Diameter�_ Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: / Material of construction: _✓concrete metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: �O Sludge depth: I` L f I bt( Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: �( Distance from top of scum to top of outlet tee or baffle: �lt Distance from bottom,of scum to bottom of utle or baffle:_ How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, de th of lirwid leyel in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottorn of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Pavia a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I y SYSTEM INFORMATION (continued) Property Addre s:I L �T C�� EIS` ) C -1tks" l e Owner: K e—k` Date of Inspection: Z3— 9 -7 TIGHT OR HOLDING TANK:�I (Tank must be pumped prior to, or 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: gallonstday Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX- (locate on site plan) Depth of liquid level above outlet invert:�� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBERIL (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION (continued) Property Ad ress7 L Owner: Date of Inspection: -2.3' 1-7 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-q-FA&w tJi�,��ssurt leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ADvD Dry 5i l CESSPOOLS: (locate on site I la� p ) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:J-4 (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 ' F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) \\ Property Address.' L- C.Ka- Owner: Date of Inspection: c l SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (revised 04/25/97) Page 9 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION (continued) 1 Property Address: Owner: d� l Date of Inspe ion: ca 2-3_c', - Depth to Groundwater q Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records /Check local excavators, installers %/ Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) 1--7 �. -�"V-' v',tr, �a,�S of v-rr (revised 04/25/97) Pago 10 of 10 !� • vP 14POV t^erQ �s a v9 � Oc w a . . 6 BORTOLOTTI CONSTRUCTION INC. TOwaOr 199 765 WAKEBY ROAD,'MARSTONS MILLS,�MA 02648 HFA�rH FPIT'�B(E , p 508-771-9399 . .508-428-892(► FAX: 508428-9399 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `' 9 PART A CERTIFICATION Property Address: Date of Inspection: Inspector's Name: er's Name and Address: O rd 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 systems. The System: 1/ Passes Conditionally Passe Needs Further E ation B th oval Aproving Authority Fails Inspector's Signature: Date: !j 36`/�7 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)SYS�'EM PASSES: V I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.3 3. 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 a? PART A ', 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 HEALTHt Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1)SYSTEM WELL 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 ihan 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 a 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: VPumping information was requested of the owner,occupant,and Board of Health. J�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. t/As-built plans have been obtained and examined. Note if they are not available with N/A. —The facility or dwelling was inspected for signs of sewage back-up. ___,_,,The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. !/All system components,excluding the Soil Absorption System, have been located on site. V 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. 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. -3- i f� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) V-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. / FLOW CONDITIONS IrVAY. Design Flow: 0 allons Number of Bedrooms:v Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal User Water Meter Rea gs,if available: Last Date of Occupancy:{A nA/ a& 0 COMMEERCIAIJINDUSTRIAL6 /AU 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 information: System Pumped as part of inspection:_ If yes,voluM pumped: V gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If es,attach previous inspection records,if any)/) Other(explain): APPROXIMA AGE of all components,date installed(if known)and source of information: •Sewage odors deter ed wheh irriving at a site: ,0 e~ =` •.°. }:•' -4- - SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C 'GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: 1,--co�ncrete metal FRP_Other (explain) Dimisions:Z0,6-'X Le'X uf' Sludge Depth: Scum Thickness:. Distance from top of sludge to bottom of outlet tee or baffle: 3 y 1i Distance from bottom of scum to bottom of outlet tee or baffle: 14FOW Comments: (recommendation f©r'pumping,condition,of inlet and outlet tees or baffles,depth of liquid lawl in lation to utlet invert,structural integrity;evidence of leakage,etc.) q2f; Q_ /,57,b ,l/�l.i .� GREASE TRAP: 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 TANMLb 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 level and distribution is Canal,evidence of solids carryover,evidence of leakage into or out of box,etc.) 61� azL 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) SOEL ABSORPTION SYSTEM(SAS): V (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: 12 Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Commen note condttion of oil i s of hydraulic failure level of ponding,condition of vegetation, ( b'n y Po g g i CESSPOOLS: 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- 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. s ° DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of Determine'ono Approximation: -7- c 3 4%p l�lt���oy Fw�sl���o ,. Thy Q �s /s to e Do�r►�e �j►.� mad wry do w�l/ba,�,co raw ce-th "y �ryh�S a cID'" 7 No....l :. 3./..... '��i� Fxs..... d. ..... THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH SUBJECT TO APPROVAL OF BARNSTABLE CONSERVATIox .......... ......OF...................a.A~_ 'T1Q�1�e�_............... C Appliration for Biipoial Morks Tontrn.rtion 1krutit __. . Application is hereby made for a Permit to Construct (1.-<or Repair ( ) an Individual Sewage Disposal System at: •................ ,ai'_1__�Q......-�..0GSAVV.1 2t, A.../ ..P--c ?a..T.4 l'e . * tGt...P'Z.A C.• ..Location-Address or Lot No. �Ll.._..:.... .�r ...,rS to".40.24 f4.................... ................... ----..........--•-•-------........................... W wn Address ..............��--_.... l.R..l�. ..................... .....................----................. .......------ Installer Address •t d Type of Building Size Lot..."dda".Sq. feet aDwelling—No. of Bedrooms...............%3.......................Expansion Attic ( ) Garbage Grinder (MQ) Q" Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- Design Flow....................rrs............gallons per person per day. Total daily ............3-3.4...................gallons. Septic Tan —L'�d p 'y1X4&galons L.e ngth✓&.—A. Width. p 1 er...:............ Depth....4-3 Dispo o.ca._3...._._.. Width.....j6._r........ Total Length_. �y� _. � ^ ng area...le-;?......sq. ft. Seepage Pit No..... _ Diameter.................... Depth below inlet.. pal etc"`'ng � .. p �...._s��ca ,� area..................sq. ft. Z Other Distribution box ( ) Dosing tank ) o GROSSwaAh!Cj ' ti Percolation Test Results Performed by....... .. }�',� ...._._.. ........ Test Pit No. 1....... ._minutes per inch Depth of Test Pit....... _�a.Fl� and water------- f=, Test Pit No. 2......A...minutes per inch Depth of Test Pit../ Sad fib`' ound water—... --_-_.----. ---------------------------------••---------•-----------------------......... ............................................ Description of Spil.......77�'T....1?!�". Z-4--4............................................................................................................ W ......................�....". ..`......'4CU4.,f.J........E.�_..-4._... . .. . ...--... .dr or '0 5; --/X.OlWjj+'...................------------. ---------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- V Natur of Repairs or Alterations—Answ r 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 Code—.The undersigned further agrees not to place the'system in operati until a Certifi f Compliance has been issued by the b�oahealth. Signed....... •-----.... ..................... �� W/....... Date lication AlAveY "•-.l4 t-----• �- 6- �t� Date PPlication Disapproved for the following reasons---------------••-----------------------------------------------------------------------=--......------•-•------- ---------------•----•-----•-•------•------•-------------------...........--------._..........------.......---------------------------------------------------------------------------------------------- Date PermitNo...................................--------------------_ Issued_....................................................... Date No. .'.....,,..._f ' > Fims............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..4. ,V. .........OF................... Appliration for Uispao al Works. Tonotrur#inn Frrutit 49 Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System at: Location ddres or Lot,,oNo F,----.... �:•d: .....I...!...--•------•--•------- ..........--................................. -- -• ....................... wn Address ............... ............. ...................................... . ...2,t_ uG ......................... ...---..................----•--=-•=-.........................-•-•-^............•................. Installer Address •� d Type of Building Size Lot... feet V Dwelling—No. ................Expansion'Attic ( ) Garbage Grinder (NQ) a of Bedrooms--------------------------- - aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----------------------------------•----•---------••-----•--•--------•----•--•---••-------......-----••---............•--•.._.......----•-•-••-_•---- W besign Flow.................... t` ------------gallons per person per day. Total daily flow...........3--1.4...................gallons. W Septic Tti "4 d capach4'�tgallons Lengthlo_.' . Width--.S ='-Z� r Depth.... ..'„ . x Disposal —No. e ..... Width...... Total Length.-.,2-7..' _� at9.f W area...7�Jf�.......sq. ft. Seepage Pit No_________ ________ Diameter.................... Depth below inlet......... _��` otal area..................sq. ft. Z Other Distribution box ( ) t Dosing ttaank� ) ,' go NORMANA Percolation Test Resu]W Performed by...... =g -.....e_..._. - �- GRO_ a e _ _. = :_ ✓_.._...-. ,a Test Pit No. I....... r _:minutes per inch Depth of Test Pi ........ ..._ ti 2J05� water.._._.12..,.......... 44 Test Pit No. 2....._�:.minutes per inch Depth of Test Pit__ ti>.__. Ago t&Tt� d water........ ............... a -- ••-----•------••----•--------•---------------------------•---• .... f._l I bi k �� E D Description of Spil.....__7�9 1' - W . ... ...1 .t'r _.c...._............____.____.__._.________________ ______________________------------•----_-----. •---••-----•-------------------------•••--•-•--•----•---------•-•---•-------....---------- •-------•-••--...--------.....---•••------••-------•--•----••---•----------------•------------------_.... UNa irs o Alterations:Aw en aPPli ble------...--••----------------•------------------•---••---•--------•-----•--••-•-----•--------•• ........................................- ---•----._.:_.. _.. ....... ...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the pr ions of'I'LL:, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operatowe n until a rti- e. f Compliance has been issued by the board of health. /Signed.._.. .............._;� '�f.............- -•---•----•----- - c . 2 w � tiny'"' ate plication Approved By.. `.. a... a.... ! ,� ------------------ Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------ate-------------- •------------------•-----•-----•-•-•--------•--------•-••-------•-•-•---•.........._....-----•-------------.........-----•-----------•••--------...-•---••-•-•-......._...•---•••--•---•-•----......._._ Date ., PermitNo.......................................................- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T�✓Cwy'.........OF........... 17Z. 4..4�...........-•---.. (9rdifirtttr of Toutplitanrr THIS IS TO C RTIFY, That the-14dividual Sewage Disposal System constructed t-,) or Repaired ( ) by--------------_--•--------`, '' °``' •-----........................................................... ......................................... # Installer N at.............. '''... r� --...--. ----- ------- = PW:............ ---------------.......------------------------------------------- has been installed in accordance with the provisions of T 'LEE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit N .fit _.�3�................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........................91A)Al-................................ Inspector.......&/� F-----------•-•-------•-----•-...--•---...-•---••--- _ b THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ...............�aeoWgiiV......OF............ .!/49 04 6........ ....... FE&_�.................. MisposaFndivid�uail ork� #rudI Mul �rntit. Permission is hereby granted. --- ----------------•-....--•--•--•-.......•--------.............--•-•••-----. to Const u . or Repair an Sewage Disposal System JJ , at No _ .i� ~� Street as shown on the application for Disposal Works Construction Permit No..................__ Dated.......................................... Walth DATE.----.---..... ..- . ....." ............................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS UNITED STATES POSTAL SERVICE OFFICIAL BUSINESS PENALTY FOR PRIVATE - SENDER INSTRUCTIONS USE TO AVOID PAYMENT OF POSTAGE.'SM Print your name,address,and ZIP Code in the specs below. MILMAIL • Complete items 1,Z,and 3 on the reverse. ®m • Attach to front of article if space permit% otherwise affix to bark of article • Endorse article"Return,Receipt Requested" adjacent to number. RETURN TO BOARD OF �HEALTH1 TOWN OF A BARNSTABLE P. O. Box 534 (Street or PA.Bags HYANNIS MA 02601 '. (s ty,State,and ZIP coati) I i m ®SENDER; Complete items 1,2;:and 3. �4+ Add your address in.tt:a"RETURN TO"space on � revesa� -05 L_The following service is requested(chech one) XKKShow to Whom and date delivered............_Q ❑Show to whom,date and:addresss of delivery..._...4 El'RESTRICTED DELIVERY ® Show to whom.and date delivered............_4 0 RESTRICTED DELIVERY. Show to whom,date,and address of delivery.$_ {CONSULT POST MASTER FOR FEES) -Z ARTICLE ADDRESSED TO: 7° Mr. Norman Grossman 412 East Falmouth Highway East Falmouth Ma. 02536 in 3. ARTICLE DESCRIPTION: Lz REGISTERED NO. I CERTIFIED NO. INSURED NO. =' 0019848 (Always obtain s",mature of-addrlis-sae or.agent) is. l — m 1 have received the article described above. ?g SIGNATURE ®Addressee OAuthosized agent 4. DATE OF DEI IG. Y l� V9/ 5. ADDRESS ompl; only if e, 6. UN ABLE TO DELIVER BECAt3j£: CL£R *CPO:I979-3W-459 i • THE t0 TOWN OF BARNSTABLE OFFICE OF i HAEUST OBLE, Maaa. BOARD OF HEALTH ape, 0S9. \�0 367 MAIN STREET E0 NAY a' HYANNIS, MASS. 02601 June 8 , 1981 Mr. Norman Grossman 412 East Falmouth Highway East Falmouth, Ma. 02536 Dear Mr.. Grossman: The Disposal Works Construction Permit No. 81-231 for Lucile Spencer, Lot 139 Lakeside Drive West, Centerville, is re- voked. A review of your plan reveals that the proposed system engineered by you does not comply with Regulation 15.02 and 15.03 of 310 CMR 15.00 of the State Environmental Code, Title 5, Minimum Re- quirements for the Subsurface Disposal of Sanitary Sewage. You are directed not to proceed with any construction on this lot until you have performed soil tests and percolation tests that .fully comply with CMR 310.1500 of the State Environmental Code. Please contact us if you have any questions. Very truly yours , n M. KeY'-1 irector of PublId Health JMK/mm SENT VIA CERTIFIED MAIL cc: Building Inspector Norman Grossman, P.E., F .L.S. 226 Holly Point Road Centerville, Massachusetts 02632 August 25 , 1981 Mr. Ron Gifford Barnstable Board of Health . Town Hall Main Street Hyannis , MA 02601 Dear Ron: This letter is to inform you that I have inspected the on-site sewage system on Lot 139 Lakeside Drive East, Centerville, Massachusetts and that it was installed substantially in accordance with plans submitted to the Barnstable Board of Health. Very truly yours , Norman Grossman, P.E . NG/gs LOCATIONS SEWAGE PERMIT NO. VILLAGE i I N S T A LLER'S NAME i ADDRESS BUILDER OR OWNER - DATE PERMIT ISSUEDzz` : DAT E COMPLIANCE ISSUED �O M o . I TOWN PF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESS R'S MAP,&/LOT }8,�yoR,SNAME&PHONE N0.2Ta--1/& SEPTIC TANK CAPACITY /5W W.ga LEACHING FACILITY: (type) (size) NO.OF BEDROOMS v w BUILDER 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 leachin facility) Feet Furnished by L g; J � / << al (o a� , i saz alALL eZ-el ✓. `ND & //V ARL'P A4eAA1 S&.A LC"VEL., BA vela nN v. 5 c f G 5• OA ro44 f�L A N 1 ~ (Z ,�1 r�N Q LL /1,�E5 ,a /N/M vA./ o� �e `, ^ ' / , ^� - f/r✓LESS UTf�IE�Yti'/3c".` „S�'E'G/F'/�,°"I�• � PRECAST LEACHING CHAMBER C4�..-ALL SZ-PTIC rA AJ*- s, 40/.57W/04)r/OOk/ BOX .511A4L ACV -COR 14-241 WAikErG 4.OARS FD 4 X 8 — L FLOWDIFFUSOR AI Viv.5 /7 404 F /4lA 7'40A11A l- AJeA rN '� ,, � I' �, I � r� a C� )• . ,�'�'/V((14� L- � �` yr uorE J � rtJ'r 1NI.���7 �Let�i4TiUNS aF TX�`MCfl�'s OR I � 0 � { f 1 2 I( • ' f+ I i Cl•4c:�t j%!.L fc%7 �I.AY �.' tiA�tlD'f�i ce.4 i Ir \ - -----= -- --- _- - I -- - -- -_- t '` ! v,, 1 �•^r-- ----�-ld' I `7 \ j i ter - - - - - " - I - - -- --- - - - A �C ��E7�/ e/L. 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OA TU 4r1 A N,e N ,o`1776,4 A tom- L/1,1,ES A iN lAJ MVA4 0,4� % /A'poT f//V4,ff55 07-,ge,CW/5G` .5A'EC/,=/0A9 TN I ,'+� •, "" "� _. .._.. �.. ��� _ ,4L L f'/f'G"� TO AVO /N E" 5Y5 7-E&W SHLL A t; o 4A;7- 1',e / dE' .SGN�D(,/�• 4D PIPRECAST LEACHING CHAMBER i mill --- I - _ FD 4 X 8 — L FLOWDIFFUSOR" - I. � .�/U�G�G� �a� 14•�4) Wf lE,r/- 4 0A©S i ;.'SLOTS At AIU Un/,5',(,/1r14'fGl- A4ATee'/!4- , t-Ad4f r.Al /N�/�' 'r �LCV,4 rlUNS o` TX�"NGN O/C' 4 � • •� "�- � - - - - - - - -,- .. - - -�- - - - - - - Z f,`/4 Cf-///1!� C/CjL l"� J�C�.4C' ��,',�►i''�/l/!,;d�!,?�' !D � .4 itl 4,7 0 0 1 14 o c' A/!z- 4e.117-.Al z,4Y, I••6 ..5A/70 GItiA �G ,r M P 4r Lff • (NI � �•� � �� � 7 fir- - - - - - - L _ _•_ _ _ " -- _ --_"__ _ /-E,fV' f %l �. iF� 1. ,';0%• f • I'�•I�„�� , / •� r< 1 ,. / ` I ' ' ! I I ' _ �•L��'fj L �''� �.' 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PRO RO 5ED 5467WA6Z: D1:5P0,*AL 5Y51 e f B E.,e O c 0<FIO ,�oo M 5 — ;s F•+'/ 57- 4 Or 1 5 L 4c,�z 42�zCS6/J5 PF,2 B�D,POD/k! _�rl --- -,4 LL t2t15 , ' T 2 5drt/ P DAY Uif'�DA 5 S �r / LEAC,4//,VG P,PO ViDIE70 352 G i7t� pF'oSFL' 'DO �� FxPi4</S/Ord/ SLAG ,4 5 iCIOTEU UA T E A L -7 ) L VI I J � Colic - � PL O -- _— 14,)a4,:,ciAN ' .<'�' �� 3��(G/it1 E�,2 itj0 AMA N v`iP0 3 S M•4 A/ f?E ?E~��i .� �G ," ; '�� y t ZZ� MOLL y �4/til7 ROAD k C MA 5 5. 1r r-)7- Uc3 T !k.) PL o:�3 t3 FL,& i