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HomeMy WebLinkAbout0106 LUMBERT MILL ROAD - Health 106 LUMBERT MILL RD., CENTERVILLE A= 168 117 I S�// �J�RECYCIFp�,� UPC 12534 No.2-153LOR HASTINGS, MN CERTIFIED SEPTIC SYSTEM REPORT LOCATION 106 LUMBERT MILL RD. CENTERVILLE, MA MAP 168 PARCEL 117 LOT 11 PREPARED FOR SELLER MS. JOAN BRUNNICK 1258 CRAIGVILLE BEACH RD. CENTERVILLE, MA BUYER MS. JOAN E. DILLON 266 BUCKSKIN PATHCQ CENTERVILLE, MA twD °0 JUL 2 4 1995 N wca c �unra�r w PREPARED BY g S HILLIARD HILLER, JR. P.O. BOX 250 CENTERVILLE, MA 02632 508-778-1472 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property /off Owner' s name 1j46. Te>,o9 v t 2�•�.riic.� Date of Inspection 7///A 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 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. V The facility or dwelling was inspected for signs of sewage back-up. 4 ' The site was inspected for signs of breakout. � All system components, �cluding the SAS, have been located on the site. v" 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. r/ The size and location of the SAS 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 SSDS. 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential oq number of bedrooms 3 number of current residents ,A. garbage grinder, yes or no YeS laundry connected to system, yes or no MO seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: y y,S—oa G.9c /�i3 SSoao Gi9L Iclel.2 Goboo GAG afesez-n Y Last date of occupancy GENERAL INFORMATION Pumping records and source of information: 7 1q�5,4/ System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: /T Type of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: �V Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: yy material of construction: v concrete metal FRP other(explain) dimensions: sludge depth a3.,1-- distance from top of sludge to bottom of outlet tee or baffle D scum thickness - distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) TEES /LvV Tffyrt' L1:P91CI-6 CsC29.q_ Ta _14i�r%ZD A./Ya✓�9 x �eco�i/rr�.r�o T�:ri/' /3,� /¢i�i:�.l� /04,�e&y 3 DISTRIBUTION BOX: (locate on site plan). O- 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, recommendation for repairs, etc. ) 0" l3ox L cri.�EC <s�D So�i� Sou,GS G�9/1RYGY/�/C PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 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 and number "O/i leaching chambers and number leaching galleries and 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, recommendations for maintenance or repairs,etc. ) PrT wA.S GoZ. F.P6G Hac�,�y,E� %IV 5>5 AL 7 hero arc v l,� vs� �G 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, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM 'INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: 106 L�ih�iPT h/GG i7a include ties to at least two permanent references landmarks or benchmarks locate al wells within 100 ' PaRG•4 I l' 3 • I DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: /3,4X*',571-5WZ-1y G/S S az,,-.5 7-1,4,C Tv So y� 71171, 4 f3SF/ly�d'/J Tr9,4/ /= Sv/�� /9`J� a�Pr/�✓i.�� �ho4�s 7-i�i' It TO /5 %T h'�/19 T/e+/� /f� 7/7� GSG S ., Ga/t2RcTio.�/ /S '�S', i i1�2 `✓iT /S �.09' t7iz/i/� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) D Backup of sewage into facility? -PO Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? V11 Liquid depth in cesspool <610 below invert or available volume< 1/2 day flow? P Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? IVO within. 100 feet of a surface water supply or tributary to a surface water supply? /10 within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. ' �-_------------- - TOWN OF �i9.Q.G5T�9/,�L,E--- BOARD OF HEALTH -- --------_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS /oG 4«ir1/9.4% Ai14C. Ko F il11 ASSESSORS MAP, BLOCK AND PARCEL # 1G //7 OWNER' s NAME /9;4'5 J2:34i41 PORT D - CERTIFICATION NAME OF INSPECTOR f1/1611f1 O 1114Z L1 COMPANY NAME COMPANY ADDRESS /60 / X o?Sb GL.tm/I!y!G-G� f�i/9 GEC 3.2 Street Town or City State ZIP COMPANY TELEPHONE, ( 617 ) 77�g - �y�� FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa-1 system ai this address and that the information reported is true , accurate , and complete as of the time of -inspection . The inspection was performed and any recommendations 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 one : l/ System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 .303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. - Inspector Signature �,,Q Date � � y ; One copy of this certification must be provided to the OWNER, the BUYER ( where applicable) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc KEY 'NUMBER <5529 > NAME <BRUNNICK, LEO E > B-C 1 B-C 2 B-C 3 B-C 4 STREET 1258 CRAIGVILLE BEACH ROAD CITY CENTERVILLE ST MA ZIP 02632-3506 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO. < 5120> DATE READING CONS STREET <LUMBERT MILL RD NO. 106> 06/30/95 243 33 CITY CEN J Lll ST LOC 12/31/94 210 23 PHONE ( ) - 06/30/94 187 22ys 12/31/93 165 25 ROUTE NUMBER 31 06/30/93 140 3055- SERVICE DATE 07/06/77 12/31/92 110 327— METER DATE 04/10/91 06/30/92 78 286 o CAPACITY 7 12/31/91 50 41 STYLE T10 SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR FRONT RIGHT ADDITIONAL CONS 0 ALTERNATE MIN 0 L.00 A T ION S E W A G E PERMIT NO. 7- V:I.11 A G E VNSTA LLER'S NAME & ADDRESS I'LDER OR OWNER ll�dgFS s All h/ DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 77, G � o TOWN OF BARNSTABLE tt LUCATION 106 T Ai/GL <0 SEWAGE # 77 yo 8'VILLAGE G4/VT�ylLG ASSESSOR'S MAP & LOT LV I INSTALLER'S NAME&PHONE NO. U,frA"/ye /U:;l 5 SEPTIC TANK CAPACITY /GNU �fI L LEACHING FACILITY: (type) /-91T (size) 9::2� 6-46 NO. OF BEDROOMS a BUEL-Dl OR OWNER AVX5. PERMTTDATE: 7/CZ77 COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility o32S 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) I' Feet Furnished by ,5�� � sole, pvR�M � e o, 5 i i C-- O,CA T ION SEWAGE PERMIT NO.. VILLAGE C FIIL,7Fll,,0,41- L--"- INSTA LLER'S NAME & ADDRESS B U1'LDE R OR OWNER DATE PERMIT ISSUED OAT E C 0 M P L I A N C E ISSUED ? - ( - 77. 4' .a.,� ;�� i i , �� a 1,.�� i �Z e .4 �^—J/ — No. m _, ..0. F�s.....1lyT................ +'# THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .�.��1`3.--._.........OF....�t'�Ps2P.�.7. ................................................... r Appliration -for Uiopoiitt1 Ivor ii Tonulrnrtion Vrrniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: L cation•Address or Lot No. 4 A ------------- -----.............................................. Owner ,. _ .t Address -••- ....................►Nam- ---- TL-pc- o � -�---------------•-•----•----- ------------- Cu i� Installer' Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building `Z�► Qt---___- No. of persons............................ Showers — g ---•-- -• --•--- - P � ( ) Cafeteria ( ) Otherfixtures --------------- -------------------------------------------------•----------------------------------------•-------------------------•-------------- W Design Flow.................JCS-------------------gallons per person per day. Total daily flow--------:""Z0Z)--__--______-_-...........gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth...--_-._-.-.--. x Disposal Trench—No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--....___•-__-__-_-- Diameter-------------------- Depth below ' let... _ ___..... _. Total leaching area-------.----------sq. ft z Other Distribution box ( ) Dosing tank ( ) U�'; G - 71,f aPercolation Test Results Performed bY-------------------------------------------------------------------------- Date.........---- --------------------- Test Pit No. 1.....�_---_-minutes per inch Depth of Test Pit.................... Depth to ground water-------..-_--._---.----- fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--. -.-.__-__-.--------. a' -------------------------------------•--•--•-----•------•-----•-----....-----•------•--•-------•------• ............................ -------------- CJ Description of Soil_.- .__L-OAM ... O.IbsQj ,. . . ® ..� .----- �- � x ._sw.D--------�_-_ 1+!.-_�QP�d'�5��e.... -�14..i C�2A 1 L.............................. W x ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed :_ +a.s' �'�--- -------------------------------- y � / Date Application Approved By- - ;7-�- Date Application Disapproved for the following reasons---------- ...................................................................................................... .............................------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I[� Date Permit No.......................................................... Issued---- � ` + ��Z .......... Date PF THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f.C.LOK► ...............OF.... 1 .N .:�..P0:�A.-C................................... Cnrrfifira#r of f omplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b U� i E lz I ►,)o ...........y------------------- ..... ' Installer at -' T �... =--------------------------------------------------------------------------•---------------------- has been installed in accordance with the provisions of :� tide 1I of The State Sanitary CodV as described in the application for Disposal Works Construction Permit No 7-......!tl-(J 0--------------- dated... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.-.JULq..... l-q-j�..---• Inspector..........................•------------------------------- --------•--------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................O F.:....'.J STi 1' ------------------....... / , FEE--- �i����ttl nrk,� C��tT��rttr#i�tt rrmit Permission is herebygranted .TC._iZ_i_---C----- I--lJ?'---- ��l .............. to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal System at No.....` l' T AA ....................... Street � f _ as shown on the application for Disposal Works Construction Pernlit7No-----/ ..�_.....r' ated.... ...K:�-...Y....-....71 DATE----- 1 ---------------------• Board of Health / LV/ -�- ----•----------------- -:----�----1�-�• FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS s .. Flcu......l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... ........... to5..�..�1-��jt�_c .. .... ..... Appliratinn-fur Biipoiitt1 Workii Tomitrnrtinn Vaunt Application is hereby made for a Permit to Construct (J) or Repair ( ) an Individual Sewage Disposal System at: ----I�y1`.LEC _.....-•-t�1i��....-....o........--------------------------- Location.Address or Lot No. Owner Address a ............................E E. 1J0 �'�T K .«S_.. ....I 2tJ......... C Installer Address d Type of Building Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms................. ____----__ ._ -Expansion Attic ( ) Garbage Grinder ( ) ----------- — p, Other—Type of Building _..ROk kt-.--__ No. of persons..._.....(0............... Showers ( ) Cafeteria ( ) A' Other fixtures --------------------•----_-__-_ __ W Desi n Flow..................��O_____.____...__.._ Mons per person per day. Total daily flow._..._...J.�Q).__..................-_..gallons. g g P P P Y y g� Septic Tank—Liquid capacity__..__--__.gallons Length................ Width................ Diameter_----.-..--.-___ Depth...______...--. xDisposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet....... ........._. Total leaching area-------.----------sq. ft. z Other Distribution box ( ) Dosing tank ( ) 6J1 • v e- 7'oc - 7 7, aPercolation Test Result Performed bY----------- --------------------------------------------------------- Date...............................------ Test Pit No. 1----------------minutes per inch Depth of "hest Pit____________________ Depth to ground water...._-_---_----_-.------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water---------------------... lYi ..........-•---•---- --------------------------•----....-•--•-----------------------••......--•-- •--------------------------•---•--•--------------------.. O Description of Soil. - _ -.�7tath �`'�)i"-a' G"at.�------ ,'-t i.._ _ c,filu t= t 1 t' 1 ---- U `,4�U D--.._...._------ ---.'..t'"-"-------- ----------P,l�---------�--_�------- --------------------------------------------------- -- W 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 been issued by the board of health. Signed- ----='`�--'°" '` =''- = x .=' = '== ``c> Date 7 Application Approved BY----- =ram` �'�"�1'-'-ern /...`• y'..Date Application Disapproved for the following reasons------------------------••----------------------•------------------•-----•----- ••............•---••......-- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 Q Date Permit No......................................................... Issued..... Ci--1--]......... Date r- r . 1 ,4 ?" o sox to » ' ' 4 .y, r ►� t 33 70 184 a 8 �-1Z C'o' SE ' ° i TE \ a ,vIc. T T ;;C;'! 7— j .S4Ci9L1":— - - - -- M/N/MU./+J F3u/LOlNG 15E7-Bi90/A< .2E4u/ )eEI-IIE77-5 FiQ 0 I/T f��' O P O S ELF' f.3.E,D F2 co o/vJs � • :5 tP7 7C .5Ys 7",'^/ C on/SST/e U C T-/ 0,V L L CU NF o/2M.,' TO 1W o9 5. . 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