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HomeMy WebLinkAbout0014 LUMBERT MILL ROAD - Health 14 Lumbert Mill Rd Centerville A= 168 -098 SMEAD No. H163OR UPC 10259 smead.com • Made in USA crcL,6,, 4C RC ASSESSbR'S MAP N0. /,6 F PARCEL aC� UO CAT ION SEWAGE PERMIT NO. VI L L A G /?r�z,-l �� INST-A' LlE-R-S-�AME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r'� � � �. i � r �` /j /��• J�. ((("' ..o' `✓ r - ` � i .. - � �• � J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct (L-lor Repair an Individual Sewage Disposal System at: L Address or Address Installer Address 04 Septic Tank—Liquid'capacity44W..gallons Length..W.-.6 WidthA�-.0"­ Diameter................ Depth...V::14.1. ZOther Distribution box (A-� Dosing tank W.0.............. Date..... Percolation Test Results Performed by... .41A4.196......... Test Pit No. 1.....2........minutes per inch Depth of Test Pit... Depth to ground water.004C.&jZ0,07VA3W ______________''________________________________________'____'_____________________~___. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions ofTL I'i 1Z 5of the State Code The undersi uac�further agrees not to place the s stem in operation until a Certificate of Com iance has been y the b d of h th. /es . ' Date_./ ApplicationApproved By...... x um" ^ Application Disapproved for the following reasons:.............................................................................................................. ----'----------'------'-'--------'-----------'-------------------'----'-----'—'------' Date |� P�oo�� .........; -_--_....................................................... � -_- s Flns.... . ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6.. j................OF..... 4 =------....----------•---•-------- Appliration for Uiipnsal Vorkii Tonstrnrtinn jJami# Application is hereby made for a Permit to Construct (' or Repair ( ) an Individual Sewage Disposal System at: ........... �„,s:,� �11 :ZiLI�... .�#:. 4.----- -•---------- ................................�`.=T-- ---------•------......---................ Locati n-Address or Lot No. Owner Address W .............�-......r �l -- ; `,e Installer �. Address d Type of Building Size Lot....26,L 2. ....Sq. feet U Dwelling No. of Bedrooms............ Expansion Attic Garbage Grinder a, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------------------•--. •. . -- --•- W Design Flow................a s................_._.gallons per person per day. Total daily flow...............a�?�...............gallons. WSeptic Tank—Liquid capacityl ..gallons Length_ -�. .. Width A_.(Q. ._ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit-No.___--_(...._..._.. Diameter...... Depth below inlet...... _'^;=:__ Total leaching area.... 5.... z Other Distribution box (°-'T Dosing tank Percolation Test Results Performed by... ............ Date...................... Test Pit No. 1---..Z:-------minutes per inch Depth of Test Pit... Depth to ground GL, Test Pit No. 2.._..�.......minutes per inch Depth of Test Pit____ Depth to ground water......................... 9 -----•-•••-•••••••-••••----•................... & �---------------- ---------------- ----------- ------------- --- --•- ---------•------ Description of Soil------....rka.r.....€�°1 .. _. ..... ............ - ................. v ...........7g.... ..................................•..............•......... UW ••-••-•-••-----------------•--------------------•-•-•-•--•••--------•------•----••••-•-•••-•........_...._.....•-••--•---•----•-•---•••................................................................ Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------------------------------------------------------•----------------•-----------•------.......-----•---...------------......--------....•.............------------------•••-•••--•-•.._......-----• Agreement: I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with y the provisions of iITL i; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued'i y the bc�rd of ho'a th. Signed: .:._ __:!...---•• •.•. fs _.tr' ....(.� . if � 7 Date r� Application Approved By......r............ ._. ...^✓�, .�.,,. ....__......� ...c's /Da�e'^�ice' ....-- Application Disapproved for the following reasons------------------------•------------•-----------------------•-------•----------•-------........-•-•-••-••------- ..-•-•-•--••....................••-••••-•........---••••---•-•-•••-•.....-•------•---......••••-••--•-•...--•...••••--•••--•--•••....---•--••-••••--•------••••-••--••--•--•--••-----............--•-•--- ,�. Date Permit No..........4�:.. { !_.. =-- .... Issued....................................................... Date 121 (RM BO.R'TOLOTTI CONSTRUCTION, INC. P 9765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 508-771-9399 508-428-892G FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A CERTIFICATION Property Address: Date of Inspection: - - Inspect 's Name: l� "--� iter's Name and Address', / /r ;�UL � y _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 (lie proper funclion and nmiufenance of on-site sewage dispos stems. The System: Passes Conditionally Passes Needs Further Ev luation I3y the Local Aproving Awliorify Fails Inspector's Signature: ,�-�� _ _Dale: The System Inspector shall submit a py 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 K PASSES: !� 1 have not found i ••; . . ou �d any information w�u�l� mdie.iies that the system violates any of the failure criteria as defined in 310 MR 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 inuninenl. 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): -:t - SUBSURFACE,SEWAGE DISPOSAL,SYSTEM INSPECTION FORM 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"1'he Board of Health): Broken pipe(s)arc 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(lie public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF 1.1EALTII DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL.PROTECT THE PUBLIC HEALTH AND SAFETY AND TILE 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 , rption system and is within 50 Feet of a private The system has a septic tank and soil abso 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 anunonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the systeu►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 deternune what will be necessary to correct the failure. Backup of sewage into facility or system component duc to an overloaded or clogged SAS or cesspool. Discharge or ponding of cfluent 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 G"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year LJO1.due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CF,R'1'IFICATION (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 1 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 coliforin bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large systein 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 11 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 CMIt 5.00 and 6.00. Please consult the local regional off ce of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 4 CHECKLIST Check if the following have been done: t/ Pumping information was requested of the owner,occupant, and Board of Health. _lCNone 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. P'* 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. r/The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. — 7AII system components,excluding the Soil Absorption System, have been located on site. __jZfhe 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, rd th of sludge,depth of scum, e 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- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CIIECKL,IST(continual) 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 CONI)ITIONS RESIDENTLAL• of Current Residents:mber Design Flow: 3�6 gallons Number of Bedrooms; N� u _ �2 — Garbage Grinder. Laundry Connected To Systcm: ,51 Seasonal Use: Water Meter Readings, if avail,�ble: 71'/— Last Date of Occupancy: z22e�— COMMFRCLAIJINDUST IAL: 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 informati Iu/ System Pumped as part of inspection:_/ If yes, volume pumped: gallons Reason for pumping: TYPE F,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 OXIMATE AGE of all omponents,date installed(if nown)and source of information: ewage odors detected when arriving at the site: -4- N.' SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION .FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grader Material of Construction: 11 concrete_ iuelal FRP_Other (explain) __ Dimisions:9,5 'Y(o���Sludge Depth: a Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: " Distance from bottom of scum to bottom of outlet tee or baffle: A/417l Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to utletinvert,structural integrity evidence of leakage,etc.)Zi'1S a,/00D /) GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) _ -- —_ — — Dimensions: Scum Thicluiess: 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 L Depth Below Grade: Material of Construction:—concrete—metal—FRP—Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: _ Comments: (condition of inlet lee,condition of alarm and float switches, etc) DISTRIBUTION BOX: Depth of liquid level above outlet invert: F Comments: (note—if-level and distribution is a 1,evic lice of solid carryover eviden of le age into or out of box,etc. zo ! �U PUMP CHAMBER Pump is 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 (anriinued) SOIL ABSORPTION SYSTEM(SAS): !/ (Locate on site plan, if possible;excavation not required, but may he approximated by non-intrusive methods) If not determined to be present, explain:__ Type: Leaching pits, number: Leaching chambers, number. Lcachiug galleries,number: Leaching trenches, number; length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure lev I of pon i condition of v elation, Daj CJ� etc.) -C — CJ C✓ .._.w -- came at- CESSPOOLS: Number and co ifigeuration: 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 inust be pumped as part of inspection) _ Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) — -—--- PRIVYAof Materianstruction: _ Dimensions: Depth of.Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) —- -- - -G - TOWN�O�F B TABLE /U/ LOCATION .// SEWAGE #ILLAGE D1PZ���� ASSES R'S MAP& LOT n P P' Co ��A -t,NAME&PHONE N y SEPTIC TANK CAPACTTY/(200 06 �/�b�i�' �y- SOY LEACHING FACII.TTY: (type) � � ( / (size) NO.OF BEDROOMS BUILDER O OWNER 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 Facili (If any wetlands exist within 300 feet of le cZii7 faci ' 1 Feet Furnished b � ;� ) i� Cr -a 16`7 , o 30 ► �35� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (ccmtini.ied) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landniarks or benchmarks. 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