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HomeMy WebLinkAbout0008 NATKA DRIVE - Health '8 NATKA DRIVE, CENTERVILLE A= 1 9129 . I w m UPC 12534 ' NO.2 53LOR HASTINGS,MN TOWN OF BARNSTABLE ".► "L=OC;A`t'ION <SlAA)'e) SEWAGE # VILLAGE QoWtRnnx,PLe, ASSESSOR'S MAP & LOT 96 _g)9 IIVSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) A X 6' (size) NO.OF BEDROOMS BUELDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 0 D 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 facili ) Feet Furnished by a Ll 3 'Lt;C 3 S'-�+'� a �. 35J��J 3 0 COMMONWEALTH OF MASSACHUSETTS ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION David B.Mason,R.S,Certified Title V Inspector,508-833-2177 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Owners Address:31 West 52 Street,NY,NY 10019 Date of Inspection: December 18,2008 Name of Inspector:(please print)David B.Mason Company Name:—N.A. Mailing Address: 4 Glacier Path East Sandwich,MA 02537 Telephone Number: 508-833-2177 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inf6rmation;rgported4 below is true,accurate and complete as of the time of the inspection. The inspection was performeOased onmy 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 CMR 15.000). The system: " _X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ` Fails co c� Inspector's Signatur JL Date: Z 0rn ��`'3 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: System as inspected is operational. Increase in occupancy or use may result in failure. Tank needs maintenance pumping. The information as identified represents only the condition of the system on December 18,2008 at Noon. ****This report only describes conditions at the time of inspection and under the condition's 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. LAI Oboe Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection: December 18,2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ 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: 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 (THIS IS REQUIRED TO BE COMPLETED) 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: OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 2 r Page 3 of 11 PART A CERTIFICATION(continued) Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection: December 18,2008 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: I _ 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. i The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 9 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. �R i 3. Other: OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 PART A CERTIFICATION(continued) i i Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection: December 18,2008 i i D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ 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 _X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool e _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface 1 water supply. M X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X 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 W are triggered.A copy of the analysis must be attached to this form.] , NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as I 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. j 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• s' 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) e P 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 4 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 y 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection: December 18,2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X _ Pumping information was provided by the owner,occupant,or Board of Health _X Were any of the system components pumped out in the previous two weeks? _ _X Has the system received normal flows in the previous two week period? _X Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X _ Was the facility or dwelling inspected for signs of sewage back up? _X _ Was the site inspected for signs of break out? _X _ Were all system components,excluding the SAS,located on site. _X_ _ 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? _X_ _ 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 _X _ Existing information.For example,a plan at the Board of Health. _X_ 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(3)(b)] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 PART C SYSTEM INFORMATION Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection: December 18,2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3(per assessors records)Number of bedrooms(actual): 3 septic design DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):(330 gpd capacity) Number of current residents: Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): 2006;26,000 2007;54,000 Sump pump(yes or no):No Last date of occupancy:Approx. 6 months COMM ERCIALANDUSTRIAL 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: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: System pumped moments after inspection due to the need for maintenance pumping. TYPE OF SYSTEM _X_ 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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1996 Were sewage odors detected when arriving at the site(yes or no):no OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 6 Page 7 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection:December 18,2008 BUILDING SEWER(locate on site plan) Depth below grade:Approximate;30 Inches Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage. SEPTIC TANK:N.A.(locate on site plan) Depth below grade: 22 inches Material of construction:X_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: Typical 1000 gallon tank Sludge depth: II" Distance from top of sludge to bottom of outlet tee or baffle: 14" Scum thickness: 10 inches Distance from top of scum to top of outlet tee or baffle: 15" Distance from bottom of scum to bottom of outlet tee or baffle: 12.5" How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) PVC inlet tee in good condition,PVC outlet tee in good condition,Effluent level with outlet pipe. In need of Maintenance Pumping. No evident structural issues. GREASE TRAP: N.A. 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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 7 i ,Page 8 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection: December 18,2008 TIGHT or HOLDING TANK:—N.A.—(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:_X_(if present must be opened)(locate on site plan) Depth of liquid level even with outlet invert: liquid level even with outlet pipe 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.):Dbox is level. Flow levelers in place on one outlet pipe. Effluent level with outlet pipes. Dbox is approx. 34 inches below grade. 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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 e . PART C SYSTEM INFORMATION(continued) Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection: December 18,2008 SOIL ABSORPTION SYSTEM(SAS):_X_(locate on site plan,excavation not required) If SAS not located explain why: Type _X leaching pits,number 2 pits, _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, etch Observed with camera. 2nd leach pit is empty and clean,no signs of hydraulic failure or ponding,nor excessive vegetation growth.Appprox. 12 inches of effluent in pit#1. Signs of staining in both pits. 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:_N.A._(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.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection: December 18,2008 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. FRONT A B W Al 36' 1 B 1 35'-4" A2 40'-9" B2 44' A3 42' 133 54' A4 56'-1" 2❑ ❑ 134 35'-5>' O a o OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Natka Drive,Centerville,MA Owner's: Deutsche Bank Trust Co. Date of Inspection: December 18,2008 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water_20_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography. Groundwater Contour Map. Title 5 Inspection Form 6/15/2000 11 COMMONNVEALTH OF MASSACH USE'I"I'S = EXECUTIVE OFFICI� OF E NN7 I lZONME,NTAL AA,iu , DEPARTMENT OF ENVIRONMIsN'I'AL PItO1'ECTION •Q=� f"F'BAR -rot �1 APR _s PM y•y P 69 LC-C ���. TITLE 5 _. OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ,tR Owner's Name. L Owner's Address: r Date of Inspection: Name of Inspector: (please print) I '1 tcA\a Al-0'L,�,�,�Y�1 t Company Name: Mailing Address: 1 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 CMR 15.000). The system: . Passes Conditionally Passes Needs Further L•valuation by the Local Approving Authority Fails Inspector's Signature: 6 AN lv� Date: t Lk t~ 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 Conuncnts ****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 I Page 2 of 1 I , r OFFL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS'll"NJ INSPECTION FORM PART A CI?RTIFICATION (con(inual) Property Address: 4 - y� D-a , Owner: ---�-- Date of Ins icction: C Inspection Summary: Check A,I3,C,D or E/'ALWAYS complete all of Section I) A.' System Passes: / V .I have not found any information which indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated arc indicated below. Comments: B. System Conditionnlly 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, Nvill pass. Answer yes, no or not determined (Y,N,ND) in the for the followint;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 I Icalth. *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 pipes)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of I Icalth): 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 pipc(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 '`rage 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOIL VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: I I�ti�J� r1 Owner: Date of Insl ction: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by die 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 licalth determines in accordance ,vith 310 CMR 15.303(l)(b) that the system is not functioning in a manner which will protect public heal(h,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 Ilealth (and Public Water-Supplier, if an),) determines that the system is functioning in a manner that protects the public Ilealth,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 front a private water supply well**. Method used to determine distance **This system asses if the well water Y a cr analysis, performed at �p ) , ( � DEP certified laboratory, for colrfonn _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 lire analysis must be attached to this form. 3. Other: 3 Pagc 4 of I 1 a OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PAIZT A CERTIFICATION (continued) Property Address: Owner: Date of In cclion: r D. System Failure Criteria applicable to all systctns: 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 duc 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 12 V Liquid depth in cesspool is less than G"below invert or available volutne is less than 'h day Plow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped V 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. rr� Any portion of a cesspool or privy is within a Zone I of a public well. fAny portion of a cesspool or privy is within 50 feet of a private Y 1vate water supply well. —+� An 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 systern passes if the well water analysis, performed at a DLP certified laboratory, for coliforrn 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 pprn, provided that no other failure criteria are triggered. A copy of the analysis trust be attached to this form.] (Yes o The system fails. I have determined that one or more of the above failure criteria exit as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of I Iealth to determine what will be necessary to correct tl,e 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 systern in accordance with 310 CMR 15.304. The systern owner should contact the appropriate regional office of the Department. w Page 5 of 1 i OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 13 CHECKLIST Property Address: Owner: Date of in ection: C Check if the following have been done. You must indicate"yes"or"no"as to each of the followin • Yes No Pumping information was provided by the owner,occupant, or hoard of Health y Were any of the system components pumped out in the previous two weeks ? V _ 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 ?- V 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: Ye no _ Existing information. For example, a plan at the Board of health. V _ 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(3)(b)] 5 s I';igc 0 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION I'roperty Address: g n n Owner: Date of In cetion: FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: I I 0 gpd x It of bcdr(mms): : Number of current residents: I Does residence have a garbage grinder(yes ore?: Is laundry on a separate sewage system (yes or [if yes separate inspection required) Laundry system inspected (yes or no):— Seasonal use: (yes or to Water meter readings, If available(last 2 years usage(gpd)): Sump purnp (yes or nc : Last date of occupancy: 0 c1- t�O tr COMMERCIAL/INDUSTRIAL Type ofestablishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(scats/persons/sgft,ctc.): Grease trap present(yes or no):— -- Industrial waste holding tank present (yes or no):_ Non-sanitary waste discharged to the Title 5 systern (yes or no): Water meter readings, if available: — Last date of occupancy/usc: OTHER(describe): GENERAL INFORMATION I'unlping Records e — Source of information: d&Ain,—_� f �,�� 1 r�G�q Q- Was system pumped as part of the ins)cction (yes 0 rt�: D o --mom 0�� 3 O If yes, volume pumped: gallons - How was quantity pumped determined? Reason for pumping; TYJ'E OF SYSTEM V 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 systern owner) Tight tank Attach a copy of the DEP approval _ Other(describe): A proximate age of all cornponents, date installed if known)and source of it for ration: Were sewage o or det tcti wlrcn arrivin at the c tc � 2 6 l� g (yes or no :_ - • 6 I y 'rage 7 of 1 1 OFFICIAL INSPECTION FOIZM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continual) Property Address: $ n� �Z.ra� AD(N,, Owner: Date of In pection: � q10 t' BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance fr6nt private water supply well or suction line: _ Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: Zoocate on site plan) Depth below grade:�_ Material of construction: Vconcrete_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) ��p Dimensions: FOOD 0rlA1z� Sludge depth- 6' V ,1 Distance from top of sludge to bottom of outlet tee or baffle: Scumthickness:�— �t Distance from top of scum to top of outlet tee or baffle: g �� Distance from bottom of scum to bottpip of outlet tee or bafnc: How were dimensions determined: ZraALIA), Comments(on pumping recommendations,1 inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of.leakage, e c.): b GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass _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 recommenda(ions, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORNIATION(continued) Property Address: Owner: Date of In )ectiou: ( 5 TIGHT or BOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete rectal fiberglass`_polycthylcnc othcr(cxplain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order(yes or no): Date of last purnping: C'Utnmonta (condition of ninrm and front nwitei,oa, etc,): DISTRIBUTION BOX: V (if present must be opened)(locatc on site plan) . Depth of liquid level above outlet invert: ) Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leaks a into or out of box, etc.): 2t t- k &ft9 �_(jocatc .�C.O c�'f�f9PU11 I' CIIA LR. 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.): 8 y Page 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (comintic(l) Property Address: ( �(I Owner: Date of 1 pection: r SOIL ABSORPTION SYSTEM (SAS): -k/ (locate on site plan,excavation not required) If SAS not located explain why:. TypS t/ leaching pits, number: — (� ,2 Grp QSt�.J� `�� G Q -trnrv� leaching chambers,number: leaching galleries, number: 14 —,10 tu. .)rvU d J leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool, number: in.novativc/alternative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, clamp soil, condition of vegetation, etc.): (AAA,' -ts-- 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: Corments(note condition of soil,signs of hydraulic failure, level ofponding, condition of vegetation, etc.): 9 Pagc 10 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURTACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Ins ection: I, SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including tics to at least t-o l,ermanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 1 36� Do ,,r..0- u LA 3 � a L4u' 3 S� c,, y 7J CJ' v� RM�iI 10 t"1age 1 1 of 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Ins ection: 6 S SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 10 feet + Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _ Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: Capp- ('p `-fal"__ 111K c Yj Y You must describe how you established the high ground(�wa�tteer-elevation: (� -�' 11 STABLE LOCATION O.41 e G A L e i,< SEWAGE # -'VILLAGE,. ASSESSOR'S MAP &LOVV.9 11eg INSTALLER'S NAME&PHONE NO. RAgdLJ J� " SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �J1'04i6',4 (size) 0 NC.OF BEDROOMS FOR OWNER � v PERMITDATE: f e? "2��—'—COMPLIANCE DATE: '7— Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of l0 eaclu'ng facility) Feet Furnished by �,f�� . r r � �_ O� r� � � �i � �� � � � J � � / �' ` � '� o i � 0 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE 4ec-��, �� ASSESS S MAP & LOT _ AME&PHONE NO. 44 SEPTIC TANK CAPACITY /000 �`` �/ D/ o/ LEACHING FACILITY: (type) 7L C ,- (size) AQCQ NO.OF BEDROOMS BUILDER R OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o leac g ility) Feet Furnished by age � �� C �cnrl G / F e3 �� No. `+ Fee $ 401.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zip Yication for Mi5po5ar *pgtem Con5tructiou 30ermit Applicari�onh rel yhfy rfafle fbi a I°'e> ds��cinstruct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 222 Donegal Circle Centerville, Benjamin Lim Mass. 02632. 4 Blueberry Hill Road Andover,Mass. 01810 Installer's Name,Address,and Tel.No.77 5—3 3 3 8 Designer's Name,Address and Tel.No. 7 7 5—3 3 3 8 J.P.Macomber Jr. J.P.Macomber Jr. Box 66 Centerville,Mass . 02632 Box 66 CEntyerville„Mass.02632 Type of Building: DwellingXXX No.of Bedrooms 3 Garbage Grinder( ) Other Type of Building RES No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily flow1 1 nx 3,='�0 gallons. Plan Date 11 /4/8 5 Number of sheets Revision Date Title Description of Soil 1 1 Loam & Sub Soil! next 10 t C1 es mad l»m sand Nature of Repairs or Alterations(Answer when applicable) Adding an additional leaching ng nit to an existing tank box and nit. 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 and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board 9f He th. 0,07 Signed 6 Date 7/1 /9 6 Application Approved by Application Disapproved for the following reasons Permit No.Z1e— \J 6F IF Date Issued - --————————————————————————————————---———— No. Q Fee I L01.00 ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC-HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS .,,,�Priration fvojr� jBiquai 6pelem Comaruction Permit Applicat" fo 'srre /✓rrfafle VaP'ei� g' &nstruct( )or Repair( )an On-site Sewage Disposal System at: AfficAoX Location Address or Lot No. fi Owner's Name,Address and Tel.No. 222 Donegal Circle Centerville, Benjamin Lim Masa. 02632. 4 Blueberry Hill Road Andover,Mass . 01810 Installer's Name,Address,and Tel.No.77 5=-33 3 8 Designer's Name,Address and Tel.No. 77 5—3 3 3 8 J.P.Macomber Jr. J:,P.Macomber Jr. Box 66 Genterville,Mass . 02632 Box 66 CEntyerville„Mass.02632 Type of Building: DwellingXXXNo. of Bedrooms 3 Garbage Grinder Other Type of Building RES No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 30 gallons per day. Calculated daily flow1 1 Ox3=3 30 gallons. Plan Date 11 /4/8 5 Number of sheets Revision Date Title Description of Soil 11 Loam & Sub Soil: next 1 O t 01-pam madi um sand _ Nature of Repairs Alterations(Answer when applicable) Adding an additional leaching pit to an exist g tank box,-and pit. i 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 and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Board Hey}th. 7/1 96 Signed- s r Date Application Approved by Application Disapproved for the following reasons IQ ell,Permit No. Z h de- �Gf Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(XX)on by _T.P_ (inn- v3+ I- for Benjamin z.. Lim as 222 Donnanl f' m has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. , XA7 dated 4� Use of this system is conditioned on compliance with the provisions set forth below: hi r ��...�. No. --—p ��------- —----——---- ---`,---Fee 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE.. MASSACHUSETTS Miopoar *potem Conotruction Vermit Permission is hereby granted to . J.P.Macomber Jr. to construct( )repair]ZX)�an On-site Sewage System located at 222 Donegal Circle Centerville,Mass , 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. All construction must be completed with' two years of the date below. Date: Approved lI r t i 1 OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) d I, J.P.Macomber Jr. hereby certify that the appli1cation for disposal works construction permit signed by me dated 7/1 /96 ! , concerning the property located at 222 Donegal Circle ,Genter_yi I I P Ma, meets all of the following criteria: i l 1� tl • There are no wetlands within 300 feet of the proposed septic system `j,i ;ia private wells within 150 feet of cite proposed septic system • The observed groundwater table is A feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED DATE: 7/1 /96 LICEN SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted], //l' W E.::., 9/. ;�i��-t•'.:,�1 L !�/%— U� /,tea �.4L. �?' � i SELL 7. 7 dam/ 4ssc.vv/ED ( 77 • Z �I ( i EST/4, f/773 /!%��� //��/A � �%/��/'i Lam..✓/ .t.��// /�\y//�.� / �L`/i�.� y/�+' // Z.o — �'r35o�L /000 l�/5T. /.�/✓, 4L. /nA ice!y7.3 Lc4c1,F '_ �Ox I7. I X�TiL Cl / /A/c/ /2 8 Z 3 . .. Existing 1000 Gallon tank p Existing D-Box New 1000 gallon Leaching pit. Existing 1000 Gallon Leach ing Pit. 222 Donegal Circle Centerville,Mass 4 ;f ASSESSORS MAP ., PARC7.NO: . 8 BORTOLOTTI CONSTRUCTION,INC. .40 •�y� 765 WAKEBY ROAD, MARSTONS MILLS, MA 112648 u6 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO q PART A CERTIFICATION Property Address: - / Date of Inspection:& aS-9 o Inspector's Name: / t�P�s Owner's Name nd Address: -. ' 122� d�ei/C) _CERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based.on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes Needs Further Ev ation B the Local Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty,(30)days of completing this inspection. If lie 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, 11LISPECTION IMMARY„3 A)SYSTEM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing Sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): SUBSURFACE SEWAGE DISPOSAL SVSTF,M 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 The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh: 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and is within 10 0 Feet to a surface and soil system a absorption sy p water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a.Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day flow. Required pumping more than 4.times in the last year NDJ due to clogged or obstructed pipe(s), Number of times pumped - 2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone 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 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: V_Pumping information was requested of the owner,occupant, and Board of Health. '--None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓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. system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. 1/All system components,excluding the Soil Absorption System, have been located on site. __j,-The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, d th of sludge,depth of scum. he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION / FLOW CONDITIONS RESIDENTIAL:v Design Flow: allons Number of Bedrooms: Number of Current Residents:__ Garbage Grinder: Laundry Connected To System: S' Seasonal Use: Water Meter Readings, if �ailable: Last Date of Occupancy COM_MERCLALZINDUSTRIAL:4/0 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: GENERA NFORMATION PUMPING RECORDS and source of informal�' �n: /?�l �7 System Pumped as part of inspection: / 6j— If yes,volun umped: gallons Reasqn for pumping: TYPI50F SYSTEM: Septic Tank/Distribution Box/Soil Absorption.Systein Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): APP OXIMATE AGE of all cot nents,,date installe (if known)and source of information: OT - 'S , ` ✓ ewage odors dete ed when arriving at the si e: C.) -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM .INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: i/ Depth below grade: Material of Construction: concrete metal FRP Other (explain) — Ditnisions: Sludge Depth: 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: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid - - level in relation t outlet invert, structural integrity,evidence of leaky e,etc. a� 12e, .. GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) TIGHT.OR HOLDING TANK: Depth Below Grade: Material of Construction: concrete_melal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc:) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER; Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- t 1 _ r i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 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, number: Leaching chambers, number:. leaching galleries,number: Leaching trenches,number, length: Leaching fields,number,dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure)evel of polvding,condilti'o 1 of vegetation,. Kn',.4— Vn2/, it a7f ZdI ✓� f` - -- CESSPOOLS: ----- — _ i Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:^�'�1J Materials of construction: Dimensions: Depth of Solids: - Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. U/ 0 a DEPTH TO GROUNDWATER Depth to groundwater: Fe od of Determination or Approximation: A2,1 el -7 - 6p fy►�/CG g Pu_, l Z9 No.... �l 04 q -" Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........................................OF.......................................................................................... Appliratiou for lliipniitt1 Workii Tonotrurtiun Prrutit Application is hereb made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal at: MATK4 &� S97 � 6Aj1cwu r Z/ -• -•--.....••••-•--• .0 6 6---•• -------•---- -----------•-----....--•-•-•- P,.. Location-Address ��or Lot No. - -------------------------------------•------- ..... ' Q__._ ! .......rs/A-`k---S2...---...---...----.. Owner �c Addres a . erQ� Nip -- Pv Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms______ __________________________________Expansion Attic ( Garbage Grinder ( ) Other—Type of Building W� _Sl9.�Y No. of persons_____ ___________________ Showers (/ ) — Cafeteria ( ) a' Other fixtures .....-1.!e• 47..-- ------------------ ----•---- W Design Flow.._....�_S..............................gallons per person per day. Total daily flow----3.3_C1............................gallons. - .W Septic Tank—Liquid"capacity.1,000..gallons Length 4' Width....6......... Diameter________________ Depth__`1_`_S" x Disposal Trench—No_____________________ Width.................... Total Length....._.............. Total leaching area....................sq. ft. Seepage Pit No./_. ".. Diameter....8_. ......... Depth below inlet...._........... Total leaching area___ 0-0...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by...__A.K t^_f1_W.E=-VZ.-_............................... / Date_----�/•-zS`�-�----------- ,`.a Test Pit No. 1. ` _minutes per inch Depth of Test Pit._.Z Z_..______. Depth to ground water_�LlDws'_ �✓ � c��r� Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ P O Description of Soil 2..._L© "_`__...... ................... .....------.'( off:... "f...........? L ._... U -------------------•--------------- W ----••-------------------•----•-----------•--------------•----------•---•-------••-••-•-••--•------•-----•-•---------------------••-•------•---•--•-•-••---•--•--•---•-•------•-•-••----._............_. UNature 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 TITLE 5 of the State Sanitary Code— Th w3oersigned further agrees not to place the system in operation until a Certificate of Compliance has been is t board of health. Signed..... •• •-••• •...................................•--•-•...:-•-•-- - f (ale 5Application Approved By-•--••••••• ••••. •••-•- --••••• ..._.._ •••• •-• ••--•••. •--•••••--_--- ------..(1_.__�z iir f No......................... Fits.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... ...................OF............... ....................... Appliration fur Disposal Works Tonstrurtion Frranit Application is hereby made for a Permit to Construct ( ✓j or Repair ( ) an Individual Sewage Disposal System at: ..L �5- . -•--- Lc�r�� -,- bpi �...gyp_ -• -• ---_..................................... .-- Location-Address or Lot No. .....� �.�a e .L....1`.'� ! '•--._....-•--------•------•.................. ...... d Qi L �=j �e / ........- Owner Address tifff--•---------------------••---•--------------- _... ©CI.O Installer Address ...... Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms_...._3.................................Expansion Attic Garbage Grinder ( ) a Wood ' y a Other—Type of Building ________..��Slc,�!_" No. of persons.....,.3................... Showers ( ) — Cafeteria ( ) dOther fixtures ......0�'-�~--------------------•------------------.....----•--------------•--------- ------. W Design Flow..-..SAS.............................gallons per person per day. Total daily flow....3-2,.............................gallons. WSeptic Tank—Liquid capacity./L0.0_gallons Length...L .Y. Width...... Diameter................ Depth...,?-" x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........�.____._.._ Diameter___.,e_.____._._: Depth below Inlet___.1............. Total leaching area__.�_OO...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by 4 ✓!..Q.W--.IL�:___:___________________________ Date....:Z.. ..._....... Test Pit No. 1.�_minutes per inch Depth of Test Pit...��......... 'Depth to ground water.A/a!er.fik!r,6,, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water------------------------ ---- ---------------------------------- .......................... D Description of Soil = �G` V�' S_n!_�_........ G�e��=''' �° = ... ................... x 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 TITLE 5 of the State Sanitaryai5pAiq un rsigned further agrees not to place the system in operation until a Certificate of Compliance has be board of health. Signed ... �� 2 8 ..._ D tApplication Approved By--••....... ............l,J....-• Z ...... ate Application Disapproved for the Mowing reasons----------------•-------------•--------------------------------------------------------......................... ..------•--•---------------•---------•-----------------------------------.......------......--------...--•-------------.....------•-•-••---••---------••-••------•-----•-=--•••-----••-•-••---••-------- Date PermitNo............................................,--=-•--_.... Issued:....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q ........................ Tnfifirat e of TuntpliFanrr THIS IS TONER FY�That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---------------------- - " (= .....j............................................................................................................................................. Installer has been installed in accordance with the provisions of TIT f The State Sanitary Code as escrib d in the application,for Disposal Works Construction Permit No---------- _._ ' (_ � dated----------- �.- __ THE ISSUANCE_ OF THIS CERTIFICATE SHALL N®7"BE CONSTRUE® AS� GUARANTEE THAT THE SYSTEM WILL FUNVT N SATISFACTORY �� _...----- :� yr �� - DATE=-......:... -••/ ...§ Inspector......( /7. f. THE COMMONWEALTH-QF MASSACHUSETTS a BOARD OF HEALTH b �Q ...................:......................OF...........----................................................................._.... No...- FEE-----5.............. Dispo nn,�trntion erntit Permission i ereby granted.....__ eaForks 1�. ..._...._..'__.........1'VI_.A/A/j_ to Construct Permission Repair ( ) an Individual ewage Dispersal item at No...---•-•0-�-•-&-46....... ----Sale_..-----•.C Street as lh,sown on the application for Disposal Works Construction Permit No� �. Q. Dated..... ........................................... --- ------ ��..� /4$p '------•_ rDATE-_- d of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS waT7F2 ' �I �• 9 / /,k/ C ice//.�/- c2 LE 9�• 32, � N EL ry- dam/ s .3c,_17 4-/-77 3.. 7Zsg5 �y 3 1/0 Z.o — SOIL /ooa — �i5� /�/✓, G aL. /�% 17. � T 3/y`To// 073 L A OL-)A. F �.k •r...'r� F L L0C•-A�TIO., . : � SEWAGE t , e9 5- 'V I k L A C E ve le I N S T A LLER'S NA ME,,: _& ADDRESS i B U I L D E R OR OWNER M4A�JA., y DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r ` ;mow __�:.,� - ' • - \ i C ►�/3 5 � Cam ' �� Fp