HomeMy WebLinkAbout0015 LONG POND CIRCLE - Health 15 .Long Pond Circle
Centerville
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ASSESSOR MAP 209 PAGE 93
BARNSTABLE REGISTRY PLAN BOOK 273 PAGE 99
LOT AREA: 23,200±SF PER RECORD PLAN
FLOOD ZONE: C
2500010005C REV 08/19/1985 SITE PLAN- PROPOSED ADDITION
SEPTIC SYSTEM LOCATION APPROXIMATE
FROM HEALTH DEPARTMENT RECORDS 15 LONG POND CIRCLE
CENTERVILLE, MASSACHUSETTS
�OFSs90 SCALE: 1" = 30' DATE: 3-22-10
DAVID tiG
3 N
o No.39403 DMAD C. THULIN, PE, PLS _
y
211 MILL ROAD
!� BEAST SANDWICH, MASSACHUSETTS 02537
�CSUFD (508) 888-2345 FAX (508) 888-7259
PREP. FOR: MACBRIDE DRAWN BY: PST I CHKD BY: DCT
JOB No: 10-010 REV. _
�� 9 SHEET 1
Commonweafth of Massachusetts r
Executive Office of Environmental Affairs
Department of o f
Environmental Protection t
WIIllam F.Weld a c <
Govornor
;
Argeo Paul Celluccl
u.Gammor NRd B.Struun
C 5�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ g
PART A
CERTIFICATION
Property Address: IS- c��^�` c r"'`
Address of Owner.
Date of Inspection: //-oZ S'c/7 (If different)
Name of Inspector. ,o Q,
Company Name,Add z�6d"Te�1ephonPNuAmCr. 1
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
— Fails
Inspector's Signature: Je Z , a Date: //-���97
. . �;'�v
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:
A) SYSTEM PASSES:
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.
BJ SYSTEM CONDITIONALLY PASSES:
One 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)
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 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500
A '
iJ Printed on Recycled Paper
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:-
Owner.
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES (continued)
1Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) 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 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 within 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
♦r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner.
Date of Inspection:
DI 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 effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less 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.
a
El LARGE SYSTEM FAILS:
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.
the system is within 400 feet of a surface drinldng 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)
The owner or operator of any such system shall bring the system and facility into hill 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 11/03/95) 3
4
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner.
Date of InspecUon:
Check if the too wing have been done:
v Pumping information was requested of the owner,occupant, and Board of Health.
Pmg req Pan , h
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
�Ybuilt plans have been obtained and examined. Note if they are not available with N/A.
LI�' facility or dwellingwas inspected for signs of sewage back-up.
system does not receive non-sanitary or industrial waste flow
e site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
dThe 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.
ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or
,approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Addresp.
Owner.
Date of Inspection:
11- a-7—r1'1 -
FL0W CONDITIONS
RESIDENTIAL:
Design flow: J ons
Number of bedrooms:.
Number of current residents:
Garbage grinder(yes or no):4--04i
Laundry connected to system(yes or no):4,8� v
Seasonal use(yes or no):_A
Water meter readings, if available:
Last date of occupancy:—
COMMERCIAL/INDUSTRLkL:
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: y
System pumped as part of inspection: (yes or no)A/0
If yes, volume pumped: gallons
Reason for pumping:
TYPE qVtkSTZM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yea, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: 6 •Fitly+ �a' B
Sewage odors detected when arriving at the site: (yes or no)_ffO
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
p SYSTEM INFORMATION (continued)
Property Address: v
Owner. (1
Date of Inspection:
SEPTIC TANK
(locate on site plan) .
Depth below grade:L
Material of construction: o to_metal_FRP—other(explain) `
Dimensions:
Sludge depth:
Distance from top
of sludge to bottom of outlet tee or baffle:_
Scum thickness:
i
Distance from top of scum to top of outlet tee or baffle: 17
Distance from bottom of scum to bottom of outlet tee or baffle:� �
Comments:
(recommendation for pumping, condition of inlet and outlet s or baffles, depth of liquid level 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_FRP--other(explain)
Dimensions:
scum♦hkkum•
Distance from top of scum to top of outlet tee or baffle:
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,etc.) 1�,
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: I S e'ux
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 distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER �V
(locate on site plan)
Pumps in working order-(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ( � �h`� 15-ulek
Owner. '
Date of Inspection:
SOIL ABSORPTION SYSTEM
(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 per, number:
leaching chambers,
number-._
g genes, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)_
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:__
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
PRIVY:_
(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 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of'Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
inchide ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater:&P-(-'y feet
matbod of determination or approximation: i �_� „2 p, fJ �/i
-�
(revised 11/03/95) 9
i
c:A I o N �a� 3s s E w A C E
A tIER'S NAME i ADDRESS
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LRAATION SEWAGE PERMIT NO.
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INSTA LLER'S NAME i ADDRESS
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I UILDE R OR OWNER
DATE PERMIT ISSUED
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DATE COMPLIANCE ISSUED
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NJ�.......... Fimim....................it........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
Q. ................OF.. ................................
Appliration for Dhipoiial Workii Corm rurtion 1hrutit
Application is hereby made for a Permit to Construct (t/ 'or Repair ( ) an Individual Sewage Disposal
System at:
r IS e6vaC° oc
.Lg... ........__------------------ .. .................................... _....-•--••-•-•C-- rZ►�••-•--e•. ...............................................
L cation-Address or Lot o.
----------------------------------------------- --! ! '---- YiJ_t. o� -----------•-------
„ G e ,_ Co
,"`�Q _Owner /p_ ��VV I k Address
Installer Address
Type of Building. Size Lot_g .00..._..Sq. feet
�v Dwelling —No. of Bedrooms-__----_ Expansion Attic ( ) Garbage Grinder (IUo
_l -••-•------•----------- —
A4 Other—Type of Building _'___________________________ No. of persons............................ Showers ( ) Cafeteria ( )
a4 Other fixtures ____________________ ___
d ---------------------------------------------------------------------------------------------•-----•-
W Design Flow_��r_.___._.��_��o_________________ gallons per person per day. Total daily flow-----___.___.-'�__.3.4.__...............
WSeptic Tank f-Liquid capacity/,, ...gallons Length................ Width---------------- Diameter_ _ Depth................
x Disposal Trench—No. .............:...... Width. ....... Total Length...... _.... Total leaching area....................sq. ft.
3 Seepage Pit No---------/......... Diameter---------- ._. Depth below inlet_-..._ _... Total leaching area._sP_:0..1.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Resu i Performed by.. C.t_ tom_ ._.___. . __a :;R 3..... Date.._.+/I(at...............
Test Pit No. 1 ___minutes per inch Depth of Test Pit.................... Depth to ground water.....................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------------- ----------- ----------.
O Description of Soil..........Q- ^2/---•-----•- Vi m•--------•---- .'�-6�a/ ----------------------•---------------------------------•-------------
i !��_U
x -•--•--•---•-------- -------•----•--....----------------------•----------•--•----------•-•--•••••--------•---------------....---------------•••----•--------•-•-----•---------•-------•---•-----•-••----
V 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 lI .."
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee sued by t e board of health.
Sig d
Date
Application Approved By. .................................
Date
Application Disapproved for the following reasons:................................................................................................................
...........................................--•----•------------•---•----....-•------••...-•-••-••-------
Date
PermitNo......................................................... Issued_.......................................................
Date
P
CPO; .2
FRB ........
THE COMMONWEALTH OF MASSACHUSETTS
BOA RJJ OF HEALTH
................0 F_11�.. ..-Tow ...OGI(0���
. ................................
AVVfiration for DhiVoq"ai Works Tomitrurtion ramit
Applicationi is hereby made for a Permit to Construct (�or Repair an Individual Sewage Disposal
Sy
eOyJ (24 Mcl-e.-
4........... ..................................... ............ .. .............................................
t4on-Address V t T o.
......... . .
A wner .............. Address YVL . .. ..................
o;*.....*...............".....I&C 4- (2604 4k a
......................................>..
$4 ---------------------*---------------- -------"------- .......I........... .....................................................
M Installer Address
UType of Building, Size Lot_.A.3,40(3......Sq. feet
5� Garbage Grinder (W
Dwelling No. of Bedrooms--------I-------------------------------Expansion Attic
Other—Type of Building ............................ No. of persons______.___________.__._.____ Showers Cafeteria
Other fixtures .............................................................
Design Flow 3, 0 3. . ... . .... gallons per person per day. Total daily flow____________ ...................gallons.
Ix Septic Tank T1,_iq,'u',id,....capacity'' "' �&.A
W ....gallons Length_______.__..__:_ Width____...._._..___ Diameter________________ Depth____.____._.__--
Disposal Trench—No. .................... Width..... --- Total Length_____________ ---- Total leaching area....................sq. f t.
Seepage Pit X'o.--------/--------- Diameter............� below inlet...... ..... Total leaching area.-.,2.0..Zsq. ft.
Z Other Distribution box Dosina tank
Percolation Test Resu4j, Performed by.j:�!O.M_r.. 44 !A(;a.M.T iP4..... Date-.-. --------------
Test Pit No. minutes per inch Depth of Test it.................... Depth to ground water------------------------
r3:4 Test Pit No. 2................minutes per inch Depth of Test Pit___.__..___.__._____ Depth to ground water___._..____._._..__.-__.
P4 ..............................................................................................
0 Description of Soil------.... 17 ........................................................................
......................................... ........
U -6.0.0e 54�.....t5wl-44d.,�......vin?_P�e_l------ ......................................
.............................................................................................................................................................................................
U Nature of Repairs or Alterations--Answer when applicable------------ --------------------------------- .................................................
........................................................................................................................................................................................................
Agreement: I I
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TAITLE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beer&sued by tle board of health.
Sigd . . .............. .............................................. ---------
Date
�4..
Application Approved By..... ................ ...............................
7
Date
Application Disapproved for the following reasons:.......................... .....................................................................................
-------------------
Date
Permit No------......... Issued.......................................................
................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................OF...... ...........................
(Intifirate of Toutpliattrr
THIS,IS'TO C TIFY That th Individual Sewage Disposal System constructed (V or Repaired
by........ ................................ ........................................................................................................................
C, Ins)fller
LO r Gat.__................................................I . ...... . ........................ .............................................
7 ----------
has been installed inaccordahce with the provisions of T 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.---- ------ ---------- dated-.-f ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION/SAT!,SFACTORY.
DATE.............................. ........................
'THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..OF..... RA-1............................
..........
No... ................... FEE........................
Diavoga Ir Vl IV P tr poltyr it
"I L
CPermission is hereby granted...i; I ... -_ n..11 ................ ....................................
to Construct (y/) or Re�'p.airh ) n I ividula Sewage Di ;a'.2 Ispo d Systejq
atNo....1)�......".P ........P'". ...............................
Street
as shown on the applicati6h for Disposal Works ConstructiRny,�P�Imit o...... ...........
Date.d...._....,.................................................
Board of aKth
DATE.......................... .................................................
FORM 1255 HOBBS,a EN, INC.. PUBLISHERS
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DATE: �' a% O REVISED
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LICENSE # 006653 DRAWING NUMBER
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EQ., E.Q.
9'-5"
�LOOI; PLAN r-PON'r ELEVATION
P-o
L — — — — — — — — — -f
f
NEW ADDITION
183LONGVIEW DRIVE
�, Drawing Name: Proposed Plans for:
C. PALTS I O & SON• CENTERVILLE, MA. 02632 Office Addition Arthur & Barbara MacBride
BUILDING & R E M O D L E I N G 508-771-1410 C Long Pond Circle
Centerville, Ma Al
LICENSE # 006653