HomeMy WebLinkAbout0311 MAIN STREET (CENT.) - Health (2) 311 Main Street
Centerville
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oulford. NO. 152 1/3 ORA
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COMMONWEALTH OF MASSACHUSETTS FILE COPY
W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ,
4 = DEPARTMENT OF ENVIRONMENTAL PROTECTION
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PARCEL 1 �-
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FO
PART A RECEIVED
CERTIFICATION
Property Address:S 1 FEB 13 2004
TOW NOF BARNS7ABLE
Owner's Name: r, ,o��t+ 1c r� n s ` HEALTH DEPT.
Owner's Address: 6ArMCc
Date of Inspection: L-5—04 Cf
Name of Inspector: (please print) Brad J White
Company Name:Windriver Enviromental Q
Mailing Address: 107 N.Main Street
Carver,MA 02330
Telephone Number: (508)-866-2576
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant too Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: -A P` Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 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
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority:
Notes and Comments
�yST�I� PA�SLS
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
g
Page 2 of 11
- s
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 211 NVAI k1 6T2kmT
Owner:Z i c�N.3vS
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
6�isr-nn Ppr45SF-s
B. 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or,exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 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
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:<�1 yy-*,, ,11y < 12t L
QFNTv ee_�)I L-t - .l via
Owner:�Er,:;,�s
Date of Inspection:Z-5-6ij
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 public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in.a manner which will protect public health,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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
T;tIA C rnc„anrinn V-All CPMOA 3
•Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
-Property Address:�'31[ jhA1 N -6►¢t 'T
ENiui OnA
Owner:�C_,n)�S
Date of Inspection: 2-S
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
x� 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''/Z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
,1 Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of 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.
f Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_,Z 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Tit]. S T--f;n 17.,—All r,110 lh 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:, MAW-) S►�.c-cam
Owner:"D,, �
Date of Inspection: 2- S-ol-f
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ _ Was the facility or dwelling inspected for signs of sewage back up'?
Was the site inspected for signs of break out'?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CNM 15.302(3)(b)]
411 1;1')01)1) 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:2l l "l N
Owner:,.'\fir•,.,S
Date of Inspection: 2-5-
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): _
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):s
Number of current residents: '—
Does residence have a garbage grinder(yes or no): �4 c
Is laundry on a separate sewage system(yes or no):N h [if yes separate inspection required]
Laundry system inspected(yes or no),
Seasonal use: (yes or no):tAL
Water meter readings,if available(last 2 years usage(gpd)): +.j N
Sump pump(yes or no): N c)
Last date of occupancy: o r)ctj
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:Qj As,„c g- Nir-OE z Pt):r.P'2 a
Was system pumped as part of the inspection(yes or no): -,
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
ND Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):U0
r;*iA G Tnc,.ortinn F,.,,,4/1 Ci')nno 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:311 ry\A!N 5ry,
C-h NMf?-Z� LC.-TWA
Owner: cr,,,s _
Date of Inspection.:. -S -6-1
BUILDING SEWER(locate on site plan)
Depth below grade: +
Materials of construction:_cast iron Z40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakag , etc.):
SEPTIC TANK:,locate on site plan)
Depth below grade: IG !_
Material of construction: ,/concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: X
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: a2,,
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 1'2,
Distance from bottom of scum to bottom of outlet tee or baffle: a i ,
How were dimensions determined: M w n,SU e
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert, evidence of leakage, etc.):
1 er S IN (n 0,n o "-rr-►[�,.,
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 bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
T41.G rn .,t;nn Pi 411 f/100n 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:",II MA%v S 12,;�%
N*r-(2A)1LLT
Owner: 1)E:0.N,C—
Date of Inspection:2--,;-6 u
TIGHT or HOLDING TANK: (tank must be pumped 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: _gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) 33� CLr;
Depth of liquid level above outlet invert: -&
Comments(note if box is level and distribution to outlets equal,any evidence of solids canyover,any evidence of
leakage into or out of box, etc.):
1)- Rc) C r— n�_
n�0 EL ir:J>*tylr_- C 1J 0.2 0
PUMP CHAMBER: (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.):
T41. c r .,f;-- ., ,,411 snnnn 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:311 IMAm,�
vyA_
Owner:Dizt,ti11S
Date of Inspection: 2-n-D-t
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type --
leaching pits,number:_
leaching chambers,number:
✓leaching galleries,number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
�l�'�i!_ 'I —zpQ"i ba[D �i1r-NS dy H-4Z QAUt iG A lLU'�
—(—�TAZlc��.�
CESSPOOLS: (cesspool must be pumped as part of inspection)(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(yes or no):
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.):
T41A t A/1 fM(1M 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION(continued)
Property Address: 31 I Ny-11 7 r-
L' u ty Z 2 t.t o vv�rx
Owner:,r,,t 5
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building.
A 0u 2
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A2 � zi,. ►� a3 20.2'
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T41. <r„--f-;--T7 r,,,411;i')01)0 10
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
311 Main St.
M
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the �/ U
computer, use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
feb P.O.Box 763
Company Address
Centerville Ma. 02632
rerwn City/Town State Zip Code
(508)477-8877 S14454
Telephone Number License Number
B. Certification
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 the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CM 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Np4s Further Evaluation by the Local Approving Authority
6/17/2011
Ins is 'g ure Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 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 DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�L
1
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Di sal System•Pag of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. CitylTown State Zip Code Date of Inspection
B. Certification'(cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D.
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
1
Y
B System Conditionally Passes:
Y Y
❑ 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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
;M 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 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 ❑ Y ❑ N FIND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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 public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
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
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
;M 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of 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. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form: Not for Voluntary Assessments
M 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. CityfFown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the'proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual):- 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
GSM 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2009:91,000
g ( y g (gp ))' 2010:99,000
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes .❑ No
P. Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
311 Main St.
G7M
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
GSM 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
r
❑ cast iron ® 40 PVC ❑ other(explain):
lu 10'+
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gallon
Sludge depth:
5"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle 10'
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
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 bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
wM 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
r
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
y
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached?. ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
ti. W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is level.box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
• I
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is Centerville Ma. 02632 6/17/2011
required for
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4 Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil No signs of hydraulic failure.lnfiltrators were dry at time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Y
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Map Page 1 of 2
Town of Barnstable Geographic Information System
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http://66.203.95.23 6/arcims/appgeoapp/map.aspx?propertyID=208114&mapparback=208 l... 6/20/2011
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
GSM 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is required for Centerville Ma. 02632 6/17/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 16'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built
3 ❑ Checked with local excavators, installers - (attach documentation)
r
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate #2 annual ranges of
groundwater elevations.
Y
r
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 311 Main St.
Property Address
Robert Hazelton
Owner Owner's Name
information is Centerville Ma. 02632 6/17/2011
required for
every page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A,B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION b� // Mom. j"' SEWAGE # 72., S
VILLAGE �'���, ASSESSOR'S MAP& LOT Q —1 i`f-
INSTALLER'S NAME&PHONE NO. R.eX
SEPTIC TANK CAPACITY /.Ci'd,0 S �P
LEACHING FACILr Y: (type) Li t (size)
NO.OF BEDROOMS .21
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
,�,Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
1
� �
F
�. . .q �
•d�,�J����GJ..
i
r
� i1� �l
va �-a
�3 � �3
3 s�
No. Fee '
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for loi-4po.5ar *pgtem Congtructiou Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
(
Assessor's Map/Parcel ,0 _/1Installer's Name,Name,Address,and Tel.No. Designer's Name,Address and Tel.No.U
20 U�+9
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow _3310 gallons per day: Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ,1S00 iN vkk) v Type of S.A.S. 01 i T LTJa tPf
Description of Soil
Nature of Repairs or A tera ions(Answer when applicable) S-_
c�v\2 a C�. 0 G i r v` GTv� a S w i t 0, Yt W-e—
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code a d not to place the system in operation until a Certifi-
cate of Compliance has been ' oar
Sig ed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. r—Z/0 Date Issued / —3p—
TOWN OF BARNSTABLE
LOCATION �3 I/ Mtuk �r SEWAGE #
VILLAGE �' �r„i,n1/� ASSESSOR'S MAP&LOT-2Q2 11,_Y_
INSTALLER'S NAME&PHONE NO. VWttJ e R97
SEPTIC TANK CAPACITY 1. rev 5
LEACHING FACELITY: (type) U t (size) y'Aw, t `1.
NO.OF BEDROOMS
BUILDER OR OWNER !&ZL--,
PERMTTDATE: II 23_Ciu COMPLIANCE DATE: la - ! -If
i
Separation Distance Between the:
I
Maximum Adjusted Groundwater Table to the 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
j Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i
�7 G cr
•"`Y.e. ..,r.,,-.Y,.. y. .., r ,� r. _ :-.�_ .A"7 . ....,,•s^l,�p.,,�w:+'` ... .. _ ..,.,p.�..ri .. r.`.'�•�1v-.....-..._ .. n- - ... , .=c.-.y.. ,
g 7 6-7 3 S--U
No. Fee t
THE COMMONWEAL"rWOF MASSACHUSETTS Entered in c Mputer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
RpplicAtion for Migomt *p$tem Conttruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) X Complete System ❑Individual Components
Location Address or Lot No.3 N U "J� C � Owner's Name,
Address
p�and
�Tel.No.
Assessor's Map/Parcel "" ''E
Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No.
&ot5
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
'..., Other-Fixtures _
Design Flow 3-r�. gallons per day. Calculated daily flow 3�C( gallons.
r. .i.a.i !'' .
Plan Date `` f Number of sheets Revision Date
Title t
Size of Septic Tank �SO(�' 1 a , U v Type of S.A.S. t 1 T T G,45
Description of Soil 1 `'`ASL 5 `V
Nature of Repairs or Al era 'ons(Answer when applicable) , —57 A"1
c�v�2 a C� r - t,Tvn 0�2s
Date last inspected: E
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of-the Environmental Code a d not to place the system in operation until a Ceitifi- I'I
cate of Compliance has been*w&by-t ar Signed ,, r - Date /l-a 3_
Application Approved by 4-- Date
Application Disapproved,for the following reasons
j j
Permit No. �'7G Date Issued /�� 9
---------------------------------='-- Y�
THE COMMONWEALTH OF MASSACHUSETTS
r
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Di§poossal System Constructed( )Repaired ( )Upgraded(V )
Abandoned( )by —CV}
at I k Ow L) 5�6e-L-T C,421LTLq(VI WE' has been constructed in-accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 51'— 7G 3 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date 4 -- l �?� Inspector � ?
C7 "
No. / �"�{�.� ---------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mioogai *pgte�ngtruc ion Permit
Permission is hereby granted to Construct( Repair( Upgrade( Abandon( )
System located at ki ST
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction pust Pe completed within three years of the date of this PC Fmit.
Date: Approved by
I M/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only:
'CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
. ENGINEERED PLANS)
i
a _
J�y , hereby certify that the application for disposal works
construction.per mit signed by me dated I �3 U , concerning the
property located at vt`� meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
4
There is no increase in now and/or change in use proposed
'flare are no variances requested or needed.
;P.. , . • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
i proposed leaching facility will uM be located less than fourteen (14) feet above the maximum adjusted
groundwater table elevation.
i
I Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.1.S..map) ,
B)Observed Groundwater Table Elevation(according to Health Division well map
4t ��-
SIGNED
DATE: 1' P'H
+ LICENSED SEPTI SYSTEM INSTALLE THE TOWN OF BARNSTABLE NUMBER
R N
.A
(Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder.an
j ,
2.yr
O
I `� I
11-23-1998 11:40PM CENT OST FIREDEPT 5067902385 P.02
MCIKe aYNuvauVtr w jocai rtre ueparmtertt
;re Department retains original application and issues duplicate as Permit.
�QtiyYY!/I9'UQ7`lf,UE'CZ�if�'Lazaa&GiQ�i f ,I . ... . ..
4A,
APPLICATION and PERMIT I Fee: 1Q.00
for storage tank remcval and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 1-48. Section 38A, 527 CMR 9.00, application is hereby rime by:
I
i
ank Owner Name(pie se print) John McCarthy X
Address 311 Main Street, Centerville, MA 02632
srs.r �yy stare Lp
• 71.E
Advanced Environmental
Company Name Co.Orinavidual Advanced F.ny ironmQntal
P.O. Box 472, 9."Iennis, MA P'x"r
Address Address
Ar
Signature ' applying ' - rmit Signature(if applying er:ermit)
IFCI Cerurie: Other Z: IFCI Certified = L=?R Other
• . j .
Tank Location 311 Main Street, Centerville, MA 02632
Sleet Address -- rh
Tank Capacity(galicns Substance Last Store- _ Unknown
Tank Dimensions(dia;reter x length) ,
Remarks:
Advanced Environmental MV5083856100
IF irm transporting waste State Lic.# -
Hazardous waste mJ� E.P.A. #
Approved tank dispesai•.,fa:°d J.G. Grant Tank yard# 03501
Type
Yp of inert gas yard address Readville, M?,
City or Town Centerville FDID# 01920 Pa
rmit#
Date of issue November 23, 998 Date of expiration December 7, 1998
Dig safe approval nurrdrr. 984706342f Dig Safe Tc11 Tel. Number-800-322-4844
Signature/Title of OfSc`r ranting permit
After removal(s)send Fs =?-290R signed by Local Fire Dept.to UST Regulatory Compliatxm—Unit. One Ashburton Place,
Room 1310.Boston, MA M—08-1618.
CO
TOTAL P.02
LOCATION SEWAGE PERMIT NO.
3 fi � ��► s�
YOLLAGE _.�� , ,
INSTA LLER'S AME ADDRESS
a
6UILDEIII OR OWNER
DATE PERMIT ISSUED q_�6_& !
DATE COMPLIANCE ISSUED l0-
II�
T�
�-- 43.
off` i
r
�r- 4 � x �
.. ..
No.p...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..................0F...... ... �' J. --------------.---------------..-
Appliratiou for DispasFal Works Tomitrur#inn Frrutit
Application is hereb. made for a Permit to Construct ( ) or Repair l� ) an Individual Sewage Disposal
System at• ,��/
.--• . »........ . - ----- -----------------------------
ocat' Ad - AMA
.... tit _ .- ----------•........................
v..»J.._.. .. r -.
Add
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons......................._---- Showers ( ) — Cafeteria ( )
a' Other fixtures ..........................
W Design Flow............................................gallons per-person per day. Total daily flow............................................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 inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date--------------------------------------
a Test Pit No. 1................minutes per inch Depth of Test Pit.............:...... Depth to ground°water........................ .
04 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -•••-------•-----------•------•----------------------•--••-•---•----•••....---------•••--•-----•---...........................................................
0 Description of Soil........................................................................................................................................................................
x
U ----------------
-----------------------
•-------------
.---------
•---------
•--------------------------------------------------------------------
--------------....
-------------------------------•------------------------------------------------...---------------•--------------------------------. --•---�c.
U Nature of Repairs or Alterations—A swer whe ap �
b _._.___10..q --- ' _ __------------------------- . � I U - ----- 04_t&....---e -- .G �� ...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI 5 of the State Sanitary Code— The undersigned further agrees not to place the ystem in
operation until a Certificate of Compliance has bee i sued by the board of alt
C1et�
Signed l - .... -- . ....... ..
Da�
Application Approved By._ _ _�_!.., � L!
Date
Application Disapproved for the following reasons--------------------------------...............................................................=................
...-------•---•..............•----•------••-----....------------..•--••••-•----------•---•--•------•...•-•--•-•--------•--••----••-----------•-------------------•••-------------••--•----•-----------.
Date
PermitNo......................................................... Issued_.......................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
No.!..� ..`t f,/ Fps.. '.--- ........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR®_ OF HEALTH
.. .......................•------......................
Appliration for Uiipogal Workfi Tonitrurfion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: � �
�1 J /. 1 r ..
Location-Address or Lot No.
-. .........)..-•.. ............•----•----••---•-..... .. =.... ......................................
. . T' I 0/ner f .� Addresrs�`
i r �,. _ J! c. u...f�..............'.....�
---- . ..---.....-----.............---------
-- ._...
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ..................................
---------------------------------------------------
-........
•-•------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................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 inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-_______•__--_____.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -•--•-••--••------••••••-••--•••---------------•-----------•---.....----•-------•---••-•••.........•.........................................................
0 Description of Soil...........................................•--•-----...........----••-------•----------------•---------•-------•-----....---.....------------------------------------•--
x
U --•.............•••-••----••-•-•--------------------•----------------------•-------••----.....--•--••------•------•-•-......-••-•--•-••------.......•--•-------•-•-----•----------......-----••--------
W ---•---•--•--•--••------•---•••••-----•••---•---•-•---••-••---••---•---•••••----•••-•---------•--•------••......----•--------••---•--- -----------=-------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.--____�- -°_d-..,1`' ?.:...........`.." ''..�° ...I...``� �� 'W
-- -------- --. .... -- •. ------ -�.
--------------••••...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TT LE.
p 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: ��
SignedGli"✓�iL� /c ' L :l(._.. G�
......................•-•-•------ ---•.....----------•--•--• ........................../ _....
Application Approved By____.___.=..................................... �'�f� - G `�j �
Date
Application Disapproved for the following reasons-------------------------------------------------------•--------------------------------------------------•••---
----------------------------•-----...-------------------------------------•--•----......................................................................................=..............................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............................I..........OF......................................I...................11.........................
Trrtifiratr of Toutplianu
THIS IS T.0 CERTIFX.)That thSIndividual Sewage Disposal System constructed ( ) or RepairedInstaller
(� )
U /
---------------------•-----------•--•-•-••-- ------------------------------••------•••---------•--...--•--••-•.......------•-------------•-••••--•--------•••
has been installed in accordance with the provisions of 'rITL r j�of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No r . - ................ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................................... ................ Inspector.......................... �Z.A�j
THE COMMONWEALTH OF MASSACHUSETTS
_.� BOARD /O}_F HEALTH
..........................................OF....._....:........ ........................._....-•---...................._........
0....I/................ FEE.....::................
Disposal Worke Tom iott 1phrmff
Permission is hereby granted..... ` fJ 7 �' ( � ° )...._...._•--------•---------- - ---------------- ------------ ... ---------
to Construct (_) or Repair ( �) an Individual Sewage Disposal System, ,
at No..••........•---•=- ; fLr.
_��... . ........--•---......�-_.._....._ ...............................................................................
/f t' Cf
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
.. .
Board ofhealth
DATE - ..- // �
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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