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HomeMy WebLinkAbout0115 NOBADEER ROAD - Health 115 Nobadeer Road Centerville P A = 251 22 G- 9-SOU 1 n 1521/3 ORA 10% P2 C01M0NWEALTH OF MA SSACHTi.=SETTS -'r � EXECuTrvE OFFICE OF �: �- E T- � I DEPARTMEI� OF EI�`47R0?v1�IENTAL 't�-OTEC I.i ON o sl aa9 i OV TITLE 5 OFFICIAL INSPECTION FORAM-NOT FOR VOLUNTARY"ASSESS:k ENTS SUBSURFACE SEN SAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /y D�.,�epY 1Rd Owner's Name: ,J'D/A111 h S11a I Owner's Address: / v Date of Inspection: Name of Inspector,gip print) Iease Company Name Z ;1k//t 0— %Ec—a Mailing Address: O 0� -ems q✓7 /f'�/f b�� Telephone Number:/,Sod — Cf CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the imfor=?on re-cored below is true, accurate and complete as of the time of the inspection.The inspection was performed based on ,- rtainina and experience in the proper,function and maintenance of on site sewage disposal syste— i am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The S-ystem: !✓ Pses Conditionally Passes Needs Further Evaluation by the Local ApprovL=Aut�ori-,v Fails Inspector's Signature: Date: —oZ3—o� The system inspector shall submit a copy of this inspection report to the Approzzng Author: (Board of H earth or DEP)within 30 days of completing this inspection.If the system is a shared system or has a desk ffl ow of'!0.?OO gpd or greater;the inspector and the system owner shall submit the report to the approp rate regional ©c,of=he DEP.The original should be sent to the system o"ner and copies sent to the buyer.if appircabl`, and- e authority.' _ Notes and Comments ****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 diflereur conditions of use. Title 5 Inspection Form 6/15/2000 Pate l Page 2 of 11 OFFICLA-L INSPECTION FORM—NOT FOR VOLL-'-'N-TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: I 0 Lr.de 1- Owner: h' 0.0 4 /� Date of Inspection: :3 3— �/ Inspection Summary: Check A.B.C.D or E/ALWAYS complete all of Section D A. S em Passes: I have not found any information which indicates that any of the failure criteria described in 310 C1IR 15303 or in 310 CvIR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.�{S-,,stem Conditionally Passes: /y One or more system components as described in the"Conditional Pass"section need to be replaced o_ repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health. v=11 pass. Answer ves,no or not determined(Y,\T,N, D)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 exfilttation 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 Cor_!nliance indicating that the tank is less than 20 years old is available. \71J explain: Observation of sewage backup or breakout or high static water level m the distribution box due to broken er obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(:•-ith 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(s1. T_e s_:sr_--• _' pass inspection if(,xdth approval of the.Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORIM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORAI PART A CERTIFICATION(continued) Property Address: //J� /v O&'C)G&� _ 4d Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: AConditions exist which require further evaluation by the Board of Health in order to determine if the s-sterrr is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 C1IR 154.303(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 Svstem(SAS)and the SAS is-within 100 f et 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 I of a public water su-,-Dl. The system has a septic tank and SAS and the SAS is within 50 feet of a private water suonly--ell. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more_`_oun 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 colifot-n bacteria and volatile organic compounds indicates that the well is free from pollution:tom that faciliL� and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprn.provided that no o ter failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLL T_ARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: // / ,04`1 C,49�— Owner: �/V1 5 G Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes'or"no"to each of the following for all inspections: Yes -, _ V sewage of seage 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 ogged SAS or cesspoolpl ` Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ iquid depth in cesspool is less than 6"below invert or available volume is less than /z day flo v Required pumping mole than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number —5�f times pumped V _ ny 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 /fvater supply. �y portior.of a cesspool or privy is within a Zone 1 of a public well. _ y portion of a cesspool or privy is within 50 feet of a private water supply w ell_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a pri-vate Rater supply well with no acceptable water quality analysis. [This system passes if the well eater analysis. performed at a DEP certified laboratory,for conform 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,prodded that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/N o) The system fails.I have determined that one or more of the above failure crteria exist as described in 310 CNIR 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 flog'of 10,000 gpd to 15.000 gpd. YXso ust indicate either"yes"or"no"to each of the following: wing criteria apply to large systems in addition to the criteria above) he system is within 400 feet of a surface drinkiing water supply he system is within 200 feet of a tributary to a surface drinking water supply he system is located in a nitrogen sensitive area(Interim Wellhead Protection.fir=a— 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 am--ere d "yes"in Section D above the large system has failed.The owner or operator of any large system en_idered a significant threat under Section E or failed under Section D shall upgrade the system i-accordance., th=1(, 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLLN-TA_RY ASSESS-TENTS SUBSURFACE SEW-AGE DISPOSAL SVSTEI7INSPECTIO\ FOR1I PART B / CHECKLIST Property Address: /f/0�hG�-lw- — Owner: k-► ✓)S a Date of Inspection: oZ3—fl� Check if the following have been done.You must indicate"yes" y ., or"no"as to each of the fo1owinns: Yes \To _ Pumping information was provided by the owner,occupant;or Board of Health. / V Were any of the system components pumped out in the previous two weeks ✓ Ha the system received normal flows in the previous two week period? _ Have large volumes of water been introduced to the system recently t p or as part o rL plus inspection tror_ Were as built plans of the system obtained and examined?(If they were not available note as\_3) 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 condi�:on of the bafflesor 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 ix-:th informaron on the nmop_er maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been deterrn-ned based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field an if( y of the failure criteria related to Part C is at issue arinroxur"�a:_.ion o'_ ,si;tance is unacceptable) f310 CMTR 15.302(3)(b)] Titlo� Tncnartinn T=nrrr. �il:!7!1llrt C Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLLT'T_a RY ASSESS-TENTS SUBSURFACE SENYAGE DISP -OSAL SYSTEM I'�TSPECTI©\ FOR-Al PART C / SYSTEM INFORMATION Property Address: Owner: K /✓? S� Date of Inspection: — o2,7 FLOW CONDMONS RESIDENTIAL `Number of bedrooms(design): 3 Number of bedrooms(actual): �l�^+ DESIGN flow based on 310 CiV1,);Z 15.203(for example: 110 gpd x 1 of bedrooms): 5y o�! Number of current residents: Q ,(� Does residence have a garbage grinder(yes or no): /f/V ' p� Is laundry on a separate sewage system(yes or no):,/tV 'if yes separate inspection required! Laundry system inspected(yes or no):/W Seasonal use: (yes or no): X'0 Water meter readin_s, if available(last 2 years usage(gpd)): Sump pump(yes orn Last date of occupancy: CO-MMiERCIAL/INDUS TRIAL Type of establisl-=ent: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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: /V Was system pumped as part of th mspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T VP F SYSTEM Septic tank.. distribution box; soil absorption system _Single cesspool _Overflow cesspool _Priory Shared system(yes or no) (if yes, attach previous inspection records;if any) _Innovative,Alternative technology.Attach a copy of the current operation and maintenanc: obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components 1-te i�s�ed(if rg and source of info,oration: Were sewage odors detected when arriving at the site(yes or no):/(/ Q J Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLLTNTIARY ASSESS:U TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INI7SPECTI-O_ti FORM PART C SYSTEM INFORMATION(continued) Property Address: LS 0l��CJ4 AU / �. Ceh el-VIlle, Owner: A G v✓ Date of Inspection: 0/9 BLTLDING SEWER(locate on site plan) Depth below grade: 96 Materials of construction: ast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(Io`� sate on site plan) i/ Depth below grade: l / vlaterial of construction: concrete _metal_fibers,ass_polyethylene --other(explain) y If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a cep of certificate) Dimensions: Sludge depth: Distance from top o sludge to bottom of outlet tee or baffle: o�� Scum thickness: 2leSf —/ // / ri Distance from top of scum to top of outlet tee or baffle: (i Distance from bottom of scum to bottom�Yf outlet tee o baffle: a How were dimensions determined: late- a Z'(" Comments (on pumping recommendations;inlet and out et tee or baffle condition, structural integri-ty.. lirn i lez e1_s as r ated to outlet invert; evidence of I kJ$Qe, etc.)/ ^7� illy" ✓"► �n 00� flia- y a7 �tI �l�',t ! GtH �/ ci ti b 110�1 r GREASE TRAP:' (locate on site plan) Depth below grade:_ ?Material of construction:_concrete_metal fiberglass_polyethylene othe_ (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 lute^i • lcuid?e,eh as related to outlet invert, evidence of leakage,etc.): Page 8 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNT_ARY ASSESSMEE TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPFCTION FORA! PART C r SYSTEM INFORMATION(continued) Property Address: vt e Owner: kyl v►S A 6i v✓ Date of Inspection: 0 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/dav 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) Depth of liquid level above outlet invert: P?Orwr 4 L— Comments(note if box is level and distribution to outlets equal,any e-vidence of solids car .vover. anv e6dence of leakase i�n/t�/�Or o/ut of box.. etc_): I- ye, /✓ v J�/iC f. �l� Q ��G h/s . PL'�1P CHAMBER: !lam (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 appurtenance:; etc.): 1 Page 9 of 11 • OFFICIAL INSPECTION FORA—NOT FOR VOLUNTARY ASSESSZIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM n:,SpFCTTO` FOR1I PART C SYSTEM INFORMATION(continued) Property Address: /l/D�� t4 ✓v1 e, Owner: 5-4 o tv Date of Inspection: —oZ.3—0 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type L (o leaching pits,number: leaching chambers..number: leaching galleries,number: (�✓ ^� �J y leaching trenches,number,length: pC leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Tv pe/name of technology: Comments (note condition of soil;signs of hydraulic failure;level ofponding,damp soil. condition of vegetation, etc.): �� , / CESSPOOLS: /v (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 laver: 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-,,egetation. etc.l: PRIVY:Z(Iocate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic faibure,level of ponding, condiror o-z:-2_e-a-'o e-c..: T;tl. G T.,c.+cn4;n L _ cn^dnnnn 0 Page 10 of 11 R OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENT INSPECTIO` FORM P_A-RT C SYSTEM INFORMATION(continued) Property Address: iYOhP��� Ad Owner: 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. 14 /�.U- 30 /12 -`t0 as T;tlo G T evcrtinn fin.r !!1 e/�nnn 1n I • Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR V OLUNTA-RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTTON FORM PART C SYSTEM INFORMATION(continued) Property Address:�� /Uo6,�1 , v v, e, ;;�4- 0l,2 Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar _ Shallow wells Estimated depth to ground water /C� feet (r0 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 re-�e-.ed: 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: You must describe how you established the high ground water elevation: C, 'f 4, ��/f �Q�w�(iN /S p o v1 D f i , 9 p�✓ i.. 2 W , _J • .f �o e T1LJ EL - 59 59 ��s�e�, /s i�r��/lei �o ��-► �, T,t!c `Z5 i , .CEL Z2� _ajrtlED DEC 2 1 2004 I O'fJIV c' qt-; '1STABLE DATE 1i22io4 'I WEPT. PROPERTY ADDRESS 115 No gadeea Rd.� A ' Cent eav:i.e.ee, Na.- 026 32 On the above date, the4eptic system at the address above was Inspected. This;system con$ists of the,following:. " 1. 1- 10.D0 'gaLeon 3p-,QUc tank. 2.- 1-d.i�La igut.ion fox 3. 1- 1000 gaiioa,. Xeach.in'g., 12 it. Based on inspection, I certify the following conditions: 4. 7h.i,3 .i,6 a t.itPe `dive 3ept.ic zy.3tem (78code)., 5. 7he 3e/2tis aystem L3 .in "paopea woak.ing oadea at th pae,3ent time., 6. 7he ieach.ing 12.it waz day at time o,e .in3/2ect.ion.- 1 SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber& Son Inc . Address: P. O. Box 66' ={ �3 �W Centerville. Mass 02632 Phone: 508-775.3338 or 508-775-6412 ` a 7 P .^ won J!OSEPM P. MACOMBER & SONO: INPW Tanks-Cessp00404chfields Pumped..&•4nstalled T6wn Sewer-Conneotlons P.O. Box 66 Centerville, MA.02f 32-0066 775.3336 775-6412 v. i COMMONWEALTH OF mASSACHUSETTS EXECUTIVE OFFICE OF ENVIRcrNMSNTAL AFFAIRS DEPARTMENT OF IN,VIRIDAMTAL?ROTUTION y TITLE 5 OFFICIAL INSPECTION FORM—'NQT.D SFOO L SYSEM FORM SUBSURFACE SEWAGE PART•A CERTIFICATION Property Address: 115 N o g arl g e e Owner's Name: V ,5, Owner's Address: A a m e, Date of Inspection: 11 /2,�, 0 4 Name of Inspector: (please print) Company Name: ,,Z % •( acom9al -Sion Lac. Mailing'Address: • en. eay.c e, 7 a.6.a. 02632 Telephone Number: 5 0.8 7 7 :3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system:at this address and that the.iitformationceported 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 for Section.15:340.of-Title 5(31.6 CMR I5:800). The system: XZ X Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving.Authority F ils L{ � Inspector's Signatare.. • Date:• The system inspector shall submit a copy of this inspection report-to the-Approving,Authority-Moard of Health or DEP)within 30 days of completing this inspection.If the system:is.a.shated system or has a design flow of 10,000 gpd or greater, the inspector and the system owner.shalf submit the report to the appropriate regionatoffiee of the DEP.The original should be sent to•the system ovmet and copies sent to the buyer,if a�pp[icab[e,and the approving. authority. Notes and Comments ****This•report only describes conditions at the time of inspectla 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT.FOR'VOL'[ NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARYA CERTIFICATION(continued) Property Address:115 N o g a r/o o a Rd rP-.,_.t o_,.v.iZP, Na Owner: I/ Date of Inspection: I I/2 2/0 4 Inspection Sunrma,ry: 'ChfA AB C;D or.E/ALWAY'5bcomplete-all of SectionsD A. System Passes: no 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: no' One or more system components.as described in the"Conditional Pass".lsection 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. no The-septic tank is metal,and.over20 years old*or the septic-tank.(whether metal.or not).isstructurally unsound;exhibits substantial infiltration or exfiltration.or tanl 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: n o 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. obstriict'on is removed distriblatibn box is leveled'or.replaced ND explain: —no 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 pipes)are replaced obstruction is removed ND explain: ' '2� Page 3 of 11 O�ICL4 L Sr�tECZ'ION FOIaNi w N©T SYSTEM ;NSAUNTAA- y T'I N PRMNTS SUS51tTRFE Sys' '�i�GrL5RrOS?�►L PART A . . CER.T-MCA'HON(toritimed) Property Address:Ili_AaL n d n v Iz ?d _ ' Owner•. Date of Inspection: C. Further Evaluation•is.Required by the Board of Health: no Conditions.exist which reyuirefurther..evaluation•by.theBoard:ofHeaith;in•orderito;detertriineifthesystem is failing to protect public,health,•safety or thb environment. ( )(b) 1. System will bass nnless+Board otelth detetmineskfta a�eordace with 310.CMlt 15:3031 that the system is-not fugetionibg ita.a manoer-whicb.vOl•protect p0lic health,safety.an¢•thee.environment: n o Cesspool or privy is.within,50 feet of a.surface water 20 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),datermines that the system is functioning in a mariner that protects theptiblic Health,safety and environment: n o The system has a septic tank and soil absoTption'system•{SA•S).:and the SAS is within 100 feetof a surface.water supply or.-tributary to asurface water-supply, n o The system-has a.sepiic tank and SAS and the,,SAS is--w•ithin.a Zone 1 of.a••public wateresupply. no The system has a septic tank and•$AS and the SAS is withink50 fett of a•private water.supply well. LLa The system has aseptic tapk and SAS and the7SAS is less than 100 feet.biat 50 feet ormiore fionl a private water supply well**.Method used to determine distance- **This system passes if the well water analysis,perfonn6 well is free froEP m-pollution laboratory, abo at r,m that for ifo ty and bacteria and volatile organic compounds indicates that is p rovided that no-othor the presence of ammonia nitrogen and nitrate nitrogen is equal to or.less than 5 ppm,p failure'.critefia are triggered.'A copy of the analysis must be,attached to-Ibis form. 3. Other; Page 4 of 11 omcmL•INSFEETI<ON FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSIE;IRFACE.SEWAGE DISPdS*L-, SYSTEM INSPECTION YORM PART A CERTMCATIQN, (continued) Property Address:,1 1 5 Al n 0.ri d o o rs /?d Owner: 12 n r Date of Inspec ion: D. System Failure Criteria applicable to all systems:. You must indicate."yes"or"no"to.eacb.of the:fol]owiug,for al_1 inspections: . Yes No _ . BackuIp.ofsewiito.tdto-fiLttjty-;or'systeTcomponent•duelo-overloaded-.orclogged'SAS..or.cesspool x •.Discharge:or­ponding of effluent to the.surface bfthe:,gt:.ound or..surface:waters due to,anoverloaded 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 x L,iquid depth in cesspool is less than.6"below invert or.availablvvolume is less than''A 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,cessp©ol or privy is below high ground water elevation. x Ariy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface T water supply. x Anyportion.:ofa'cesspool,or.privyiswithin,a:Zone:l.,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 5Q 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 pollutloq:from:that.facility and:thg 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 analysisariust be attached*.to this forte.] . h o .(Yes/No)The system fails.I have determined that one ormore.of:the:above failure�criteria exist as described in 310 CMR 15.303,therefore the.systern.-fails..The-system owner.should contact the Board of He.alth•to determine what will be-necessary to correct the failure. E. Large Systems: To be considered a large system'the:systtem must.serve.a.:faeility,with.a.design flowof 18j000 gpd-to 15sQ00. 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)' 1 .. yes no ' x the-system is within 400 feet of a surface drinking-water supply x the system is within 206 feet of a tributary to a surface drinking water supply x. the:system is located in a nitrogen sensitive area(interim Wellhead Protection Area IWPA)or a mapped 77 — Zone II of a public water supply well If you have-answored"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. Page 5 of!! OFFICIAL.INSPECTION-FORM—NOT FOR V-0LUNTARY ASSESSMENTS $Lb3SURFACE'SEWAGE DISPOSAL.""SYS'TEM INSPECTION DORM PART CIECIMIST Property Address: 115 No gadeea Rd, o_nfP_n»J �P� Na. Owner: /i n i n i p R n u n r•/ Date of Inspection: n!� /!�Z 4 0 Check if the following have been done.You must indicate"yes"'or"no"as4o each..of the following: Yes No x — Pumping information was provided by the 6wner,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-pan of 4-inspection? x Y Were as built plans of the system,obtained and exardined? (If they were not available:bote is 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;,Dpened,and the interior..of the tank inspected for the condition TT the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and:depthof 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 deternvined 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 approxiniatiomof distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFI?CIAL U'4SPTCTIUN.'IFI}RM'-NOT FOR'Y.M.U-NTARY ASfiESSMENT;S SUBSURFACE SEWAGE DISPOSAL;SYSTUM INSPECTION FORM PAStT.0 SYSTEM:INFOR-MATION Property Address: 1 1'5 /V o 9adeea /2d.• Cent eay.i.�.�e, (7a. Owner: V,iAgirzia. Bouad Date of Inspection: 1 9/,J 40 4. FLOW CONDITIONS RESIDENTL4J, Number of bedrootxts(design)::,:3 r ,dumber of.bedrooms..(jptUaI)- 3 DESIGN flow based on•310 CNIR 15.205':(i'or exaiiiple •110 gpd ii#-of bedrooms):/"/0 x 3-3 3 0 g p d Number of current residents:•., 1 - Does:,residence.have a garbage grinder(yes or no):n_n is laundry on a separate sewage.system-(yes or:no) o .Cif yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):r,.n Water meter readings, if available(last 2 years usage(gpd)):94)0-rL �.��p7�(o= 11�'9 M%pJ Sump pum (yes or no): n_n ,00�.� q 1 �,e a i 5(n,20 g Pei Last date o occupancy: 2/L e,6 e n t COMMERCIALM- USTRIAL Type of estate t: .n a . Design flaw. �, on•310 CMR 15.203):• na avd' Basis.ofd.mo-.. ow(seats/persons/sgft,etc.);, as Grease trap•'present(yes or no)-' Industrial waste holding tank present.(yes or no): n a Non-sanitary waste discharged to the Title 5 system•(yes or no): Water.meter readings, if available: n n Last date of occupancy/use: . n.rt OTHER(describe):. GENERAL INF9 ATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity,pumped determined? Reason for.p..umping: 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 ahy) _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: Zg R q Were sewage odors detected when arriving at.the site(yes or no):n o 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: 1 9 5 A/n 0. Owner:_V r n g.i.n i a Date of Inspection: AiA 4Y �. BUILDING SEWER(locate on site plan) Depth below grade: 16" Materials of construction:_cast iron xx 40 PVC_other(explain): Distance from private water suj ply well or suction Be- 10'. Comments(on condition of joints,venting,evidence of leakage,etc.): 2oint6 a�Rea2 tight. No ev.idenee o� ie, akage Sy-3tem vented thizough the house ventz.. — SEPTIC TANK:gzAlocate on site plan) Depth below grade: 7% ' Material.of construction: concrete metal_fiberglass--Polyethylene _ )other(expla _ If tank is metal list age:n o Is age confirmed by a Certificate of.Compliance certificate) (yes or no):_(attach a copy of Dimensions: 5 ' 8'h.igh/4' 10'w.ide/8' 6'.gong Sludge depth: n Distance from top of sludge to bottom of outlet tee or baffle: 3' Scum thickness: f � n Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined; m Q a z u 2 e d ' Comments(on pumping recommendations,uilet and outlet tee or baffle condition,structural inte as related to outlet invert,evidence of leakage,etc.): grity,liquid levels 12 ga2.s .s.tzuctu2a 22 pound. No nd out Pet tees ate in .�aee. GREASE TRAP:'L o(locate on site plan) - - Depth below grade:h a , Material of construction: concrete metal fiberglass_polyethylene_other (explain): n a Dimensions: n a Scum thickness: Distance from top of scum to top of outlet tee or baffle: n_a Distance from bottom of scum to bottom of outlet tee or baffle: n a Date of last pumping: n a —Comments(on pumping recommendations,inlet and outlet tee or baffle irate condition,structural as related to outlet invert,evidence of leakage,etc.): integrity,liquid levels aye tea not 2esent. Ti+lo C TnonPrfinn TFnrm r./i i/,)Ml1 7 Page 8 of I I OFFICIAL IN-8-PEC)<'ION FORM—NOT FOR VOLUNTARY ASSESSMENTS S"'WUF ArCE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C• SYSTEM INFORMATION(continues}) Property Address: 115 lV n f nrl o Q4 ?.l,, 1 a Q an m Owner,• �, 7,7 cji n i n 13 6-a a a�.' Date of Tz�spection: 9/„�2,i6L, a TIGHT or PIO•IrDING TANK:n o (tank must be pumped at time of inspention)(locate on site plan) Depth below grade: na Material of construction: concrete metpil_f€berglass.____polyethylene other(explain)- Dimensions: iari Capacity: nn gallons Design Flow: rzqgallons/day Alarm present (yes or no): Alarm level: . nu Alarm to working-order(yes or no):n�, Ditty of last pumping: n n Comments(condition of alarm and float-switches,etc,): DISTRIBUTION BOX: _�,ez(if present must be ope'ned)(locate on site plan) Depth of liquid level above outlet invert: n 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.): 1z12X hrz4 onv fni ?rjP o_ A J ga A_(ZP .P�.,.. P'-;kagv r_nlo oa out 01 &nX A/n A wnA n4 . nfiaA rnnny�n>>on_ PUMP CHAMBER: no (locate on sife.plan) Pumps in working order(yes or.no):na Alarms in woNng order(yes or no):no,,,,,,' Comments(note condition of pump.chamber,condition of pumps and appurtenances,ett:,): 1)tipl,o rhnmfoa naf DarAo_ni -- Page lU of 1-1 CIAL•INSPF�3''IQN VO VI O'I"�'pI �VOI�INS EG•TION FORN� TS a SRWAGF mISR0SAL SYSIMP SISA PART " 3y.S'•FEM MDRK4 TION(pentrnued)' 15 NoiadPDR /?n a Property, Address:•9 . C P_n" JJ pro 117�r yzlc4,n,[¢ Lnu Ld OWneT. 9 9 /�.7��(y4A �• Date of Inspection: SKETCH OF.5E�'YAG��DISPOSA.L SYSTEM ties to at least two per n W.refersnue landmarks or Provides sketch of the sewage disposal system including ublicwater supply enters.the building. bencbmarks•Locate all wells within 100 feet.Locate where p o � • �' ' ��i� • is 10 Page 11 of 11 Sp SPECTION FORM—NOT FOR VOL�S�C,�oI N FORM TS OFFICIAL� SEWAGE DISPOSAL SYSTEM SUBSURFACEPART C SYSTEM INFORMATT'ON(continued) • Property Address: a � K �nP�c�r�ee2 l2cl.• Owner: Z 4 Date of Inspect►on: 1 SITE EXAM Slope Surface water Check cellar. N Shallow wells .x, d water ,feet Estimated depth to groun. e indicate(check)all methods used to determine the high ground water elevation: Pleas plan viewed: n o Obtained from system design plactts on record-If checked,date of design Observed site(abutting property/observation hole within ISO feet of.SAS) o Checked with local-Board of Health-explain: =ex lain: &a/Laz. a��e. ma. uh n,o Checked�with loll excavators,installers-(attach documenmtio� . Accessed USGS datab P You must describe how you established the high ground water elevation: • used•,Gahert & Miller model 12 ed •USGS observation w us 1 _ - . used- Technical bu etil wa er a eva ions. Leaching Pit =t High Crroundwater Adjustment 1.8 ft per Vn4Pt7.Meth0 Groundwater; Feet Bclow.Bottom;of Pit erafore the vertical separation distance between the bottom ' 1• of the leaching pit and the adjusted groundwater table is � feet. • tt ....,....*m•.,..,r..",..t...�*,+*..,,.....��,+ [v)A}i0 OF }IEA.LTII _..� ^^^^•' 'TOWN OF Barnst •y' SU119i1RFACF 9FKA(;F ()}91'U$A�L SY9�'FM IN9}'FCTION FURM - PART D•- GEII'f}F1CATIU ' — mmin T.n%.• TT�7'ISM'�IIT�TR"r"T RTTR�' 1•Ir'{ITIP.VIP1'-T P'I �r RIN L`•.. i V 4 1 P1tOPERTY TNSP617'ED STREET ADDRESS 115 No&ucLe�2 i2d. ASSESSORS MAP , DtOCK AN D PARCEL # ` � n tj L n ' NAME V,.IL9.ia q /3euad OWNER- s ,FPM.••' PART D - GCRTXFXCATI0H NAME OF INSPECTOR �12o eti l uo C1a-i Joseph P. Macomber COMPANY NAME Inc Box 60 CenterVille- Mass 0263.2 sc�c. zrP ._. COMPANY ADDRESS _- 5trefQ� rows or c crQ FAX ( 508 ) 790-1.57$ COMPANY TELEP14ONE ( 508 ) 775-33.38 CfR'PIP1CATION. STATEMENT of that Z .. hay.e persona lly insprteddishtr.ue., aoouratej andystem r 1 e sewage -di cer Y .this adcJr.ess and that the information repo of the time o1? ,inspection, The inspection was crmed and omplete as upgrade*, maintenance , 'reC0101B'2i(�ations 1'e ardlll$ i-o nin and experience in the proper functipn and maintennnce of o with my' train Eosa1 sYstems , . site sewage disP Check one : ' xxx system: PASSED any The inspection which I have conduils to adequately protectopublicn which indicates that th-e system fa i 1ealtli. or the enviror)ment as defineedd i.n the �ILURE3CIZITERIAf section c critexta not evaluAted are as stat , this form . J. System FAZL>✓ll* • The inspection wll'icli I have concG ticted. h.as found that the system fails otect the j)kib.lic henith and the. enkirnat��tonnPARToC��n ce with Titl FAILURE ['r and as specifically 5 , 310 CMR i5 . 3Q3 � CftITERIA of this insPectio fo„x. ,r z ate Inspector Signature • F' yne copy of this c�c.l�f ioation must be provided to the t1WN-ER, the �IIUYER =( where a}�Plicabl�') and the p0!>RD QP ri$A1+7ir•„ mrAtor. eha] l �Pgrado the eyeter r .It the inspection FAILED , �h!e. ow-nor or op. uired within one year o (' the date of th16inspectiorl, unless allowed or reQpurtd otherwise as provided in 3.10 , r _ pp TOWN OF BARNSTABLE LOCATION ��5� �0 %7� SEWAGE# _VILLAGE(�(,Z!�;,P-L, —ASSES SOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. A/6 SEPTIC TANK CAPACITY r LEACHING FACILITY:(type) ( c. NO. OF BEDROOMS OWNER PERMIT DATE: 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 t C • �101. .f!d� Commonwealth of Massachusetts Executive Office of Environmental Affairs �w Department of `® Environmental Protection ��9 William F:Weld Governor +' Trud r y Coxe ' Secretary,EOEA �. David B.Struhs Commissioner J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �� 1 PART A CERTIFICATION Property Address: I I� N010'&N Deev—(?(� `� Address of Owner: f�r1 Y .Z-�� ��.i ►�/`/ Date of Inspection: (If different) Name of Inspector.1410s- Company Name, Address and 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.,The system: y Passes X Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Sir atuse r Date: The System Inspector shall submit a copy of this inspe ton report to the Approving Authority within thirty (30) days of completing this inspection. .If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and.the system owner,shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original 'should be sent w mc• system owner ano copies sent to the buyer, if applicable and the appro�ing au:horitj.. INSPECTION SUMMARY: Check A, B,C,' or D: A) SYSTEM PASSES: . have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,i ,. passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/951 . One Winter Street • Boston,Massachusetts 02108 • FAX(617)W6=1049 • Telephone(617)292.5500 `j,Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:. 15. Nob(-n d e.e r. rd Owner: 7 0.h l J ((X0 Date of,inspection: 3--al ._ CI G B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due.to a broken, settled or uneven distribution,box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled'or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The,system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) 'SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. -- 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE" ENVIRONMENT: " _ the system ha,- a septic lank anu soli absorptiun system and is wilhiu iOG feet iu a suliaCc '�ha�ci SupNi)'Gr trlbUtarj i0 a surface water supply. _ The system hay a septic tank and soil absorption,systern-and is within a Zone I of a public water supply well _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well (•� _ The:system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that thelwell is'? .f," . free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• DI SYSTEM FAILS: I-have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303 The basis for this determination is identified below. The Board of Health should be contacted to determine:what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 6/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A � CERTIFICATION (continued) Property Address: ] 1 5 N o b a n ckQ.C.Y— K Gt r L.t rl f e—Y V i l i c Owner: Z.CX I. CL}/L Date of Inspection: ` _q(O D)SYSTEM FAILS(continued): 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or.privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private.water supply well. b 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 large systems in addition to the criteria above: The design;flow of 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 treatmenuprogram requirements of 314 CMR 5.00 and 6.00. Please consult the local regional,office of the Department for further information. trevised B/15/95) 3 • 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:. H o b a n c�L er V.i C Owner: Z-CL r) i I Cc Yl Date of Inspection: Check if the following have been done: ✓Pumping information was requested of the owner, occupant, and Board of Health. 2/(Done of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 1<5 built plans have been obtained and examined. Note if they are not available with N/A. /fhe facility or dwelling was inspected for signs of sewage back-up, The system does not receive non-sanitary or industrial waste flow ,z1he site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _the septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. :f The size and location of the.Soil Absorption System on the site has been determined based on existing information:'or ap o..ximated by non-intrusive methods. she facility o.;;c ;and occupants, if differs^t from owner! were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 8115/95J, 4 . f t' - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: I I'J N 0 bars be cr Rct. L e o tc r V I l IC Owner: . Z(Lh, 1J 1&n Dateof Inspection: FLOW CONDITIONS RESIDENTIAL: Design•flow: a lions Number of,bedrooms:_*a Number of,current 'residents: C� Garbage`grinder(yes or no):�{ Laundry connected.to_syste (yes or no):_11-z Seasonal use (yes or no): Water meter readings, if available: AA, Last date of occupancy: { J COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ w' Industrial.Waste_Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last'date-of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /\/oNe, To N-) System pumped as pan of inspection: (yes or no)_ If.yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM eptic tank/distributiori box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,.attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed iif known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 6/1S/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:' J i 5 N o b an cUt r PCB.. . aI' &r V f e Owner: 'Za h i I a� Date of Inspection: 31 a,Iq(o SEPTIC TANK:Z (locate on site plan) " it Depth below grade: 1� Material of construction: zrconcrete _metal _FRP—Other(explain) Dimensions: Sludge depth: L 3'r Distance from top of{ludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: C I ! /it Distance from bottom of scum to bottom of outlet tee or baffle: 4 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffl s, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) V'�✓�� L��✓� G L-cA'N GREASE TRAP:�I (locate on.site plan) Depth below grade: Material of construction: _concrete _metal _FRP_other(explain) s Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom ro crinn in hottom of ou!le! tee or bailie- 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.) y (revised 8J:5/95) 6 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.-FORM PART C SYSTEM INFORMATION (continued) Property Address:: . 115 N ob an cla r Pct. &n_t c r.vj 11 e Owner. 'Z_an f I(L.r) Date of Inspection:. TIGHT OR HOLDING TANKI�� (locate on site plan) Depthbelow grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm.level: Comments: (condition of inlet tee, condition of alarm and float switches,.etc.) ) DISTRIBUTION BOX:_V (locate on.site plan) 'Depth of liquid level above outlet invert: Comments: mote ii level anu distribute h eyuai, e��uence of surd: ca;r)o�er, evidence of leakage into or out of box, etc.) VZ �—/ G1bo� PUMP CHAMBER: (locate on site plan) Pumps in working order,(yes or no) Comments: (note condition.of.pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 1' Celn� 'ery( ^1t l Property Address: lit t V� 3 aVA O—uf (` Owner: ���� , an Date of I pectic .I l 3��IIq�e 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: 1 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, level of ponding, condition of vegetation,etc.) CESSPOOLS: (locate-on site plan) Number,and configuration: Depth-top of liquid to inlet.invert: Depth of solids layer: . Depth of Scum:layer: Dimensions of cesspool: Materials of construction: indication of groundwatc--: �,. .. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) :j:n. PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids. . Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) # " (revised 6/15/9,5) 8 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1.I 5 W bo,(LoL e.r Vol. U n t-( Y v I 1 I-e, Owner: Date of Inspection:. 2 l + n SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all.wells within 100' i DEPTH TO GROUNDWATER /1/0 Depth to groundwater: f o1' feet method of determinat ion_or approximation: S-�-C V,% 1C, oue(Z— 146—e— t-� V� (revised 6/1S./9S), 9 No.13d........_. Fs$..`�4.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a<t- i2 oF............1 r ff./ ................................ Appliratiun for Dhipaii al Workii Cfuntitrnrtiun Famit Application is hereby made for a Permit to Construct (✓f or Repair. ( ) an Individual Sewage Disposal System at: ...............L .....1.5......Pao, cr...._ ...... ................................ G G, Location-Ad.................. T...7.` _....� u/�-ess -c O .. o ... ,/�. • ........... Address ................... :........ ......... 141Q.............................................. Installer ! Address UType of Building Size Lot--- -2.2.7__......Sq. feet .-, Dwelling—No. of Bedrooms................'I........................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type e of Building No. of persons............................ Showers G4 yP g ---------------------------- P ( ) — Cafeteria ( ) Q'' Other fixtures ............................... .. ----------------------- •--------------------- w Design Flow...................::r .................gallons per person per dgy. Total daily flow..............3Ji5 ...................gallons. WSeptic Tank—Liquid capacity/�B�.gallons Length............... Width._............._ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........./.......... Diameter.._. Depth below inlet..LS-o_..... Total leaching area,3./?.,--1F1_.sq. ft. Z Other Distribution box (✓) Dosin&tank ( ) 3 '—' Percolation Test Results Performed by. i uGG���� ,(� ��Date.....r�lr ............. ,4 Test Pit No. .1...4.L_._minutes per inch Depth of Test Pit------/t....... Depth to ground water.._/A/,P?4=._.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 1 ---•.............................. .................................. •-------------------_-------._....----------...---•----•-••---------...'.../....---- O Description of Soil-•-----------•-.-_...�.'..¢.....77OR..Z.45.4 s ,� B ( � -.....�ll� .s ...------•-----•-----. x ----------------•----------- -- �.r 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 LITLZ 5 of the State Sanit11a"ry Code— e undersigned further agrees not to place the system in operation until a Certificate of Compliance hie f d by the board of health. ......... ........................................................................... ................................ Date Application Approved By..................... .......... Date Application Disapproved for the following reasons:-----------••.......................•--......----------•---•--------------•-----•------------•----.............. --------•-•---•-----•----••-------•---------•----------------------------•-------.........------.........._......_....---•------------------------------------------------------------ ----------...._.. Date PermitNo......................................................... Issued-....................................................... Date w No......................... Fina.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ----------------------------•----•--.................._....---- r Application for Dispaaal Vorkg Tontitrnrtion rrntit Application is hereby made for a Permit to Construct ( ') or Repair ( ) an Individual Sewage Disposal System at: ...............�.`...:........� /�� �,� _f.�:: ..ltc! ............................................................. ` ................. L cation-Address j or Lot No. 1 Owner �/ Address ................................... ....... .........--•---------••....--•--/ Installer Address QType of Building Size Lot. : .: .-Z ....... feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 04 .... No. of persons............................ Showers —Other—Type of Building ........................ p ( ) Cafeteria ( ) Otherfixtures ------------------------------•----------------------.-•-•-•••-•--•••••••-•••••-•-•-•----•••._...-•-•••............-••-•-••--...................---•- W Design Flow................__-`..-5.............___gallons per person per )ff. Total daily flow_._........_.z�_34f"'................._..gallons. W Septic Tank—Liquid capacity��l'"--gallons Length._..% = _ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......... Diameter.._ Depth below inlet.:'i::.!2..._... Total leaching area.�F.'f.�?.sq. ft. Z Other Distribution box (✓ ) Dosing tank ( ) '-' Percolation Test Results Performed bye% u _� '. :........ J�ti'`'%..l-'�`% � Date__.. ?`` :j.� _________________ aTest Pit No. I_. _':_--._--minutes per inch Depth of Test Pit.....jZ_...._.._ Depth to ground (%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R4 ...................................................•---•--------------:/......_...------------------.......... , - / -- O Description of Soil... .....................................•---•••-•------I---------------------------- ......--------------------•-• ----••-�=- . r U ..............•---••-•-•--------...........---------....- ---...=:-------d.ate" W -•-•-•-•••-•••......_...••-••----••-••••--•-•••••••••••-••••-••--•-•-••••••••---•••••••--•••.........................•--•-••••••-•-•-•--•--•••--••-•••-•-•••----•••-•--•••••......-••••.....-•---••-•-- V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ............................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 54ned.................................................................................7 4.....•...........•-•-;;- Date ApplicationApproved By...............•••--••-•••-•-•-•-••--•._..........-••••-•--••-•--•-.................-••-•-•-•--••. ........................................ r Date Application Disapproved for the following reasons------------------------------------•--------------------------------------------------•••- -•---•...-••--•-- ........--•---•............................................•------•------------------------------•-•----------•-•-.._....--••-------••-•---•••-•-•--•-•-------•••••----•---•••••----•••••••••------•-•-- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OR HEALTH .........OF.... .... :.:.. .... ... ................................. %rrtifirate of Tontpliatta THIS IS TO CER Y, That th nd idual Sewage Disposal System constructed ( ) or Repaired ( ) by....... ......................... ----------------------------------------------•-•----•----•-•--..--- Installer has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code de cribed in the application for Disposal Works Construction Permit No-------lyl-n: ' .......... dated..-.._.__t'' , --- ------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL U TION SATISFACTORY. . DATE...--...A.. Inspector ' THE dOMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ' jj� .................. ..............OF...... " . ��7 ' .............................. No. �P... FEE....:!.: � Disposal rk� �o #ruction rrnti# _._ Permission Is hereby granted............... ----- - ----•----.......----..._....-------------._.......------......._........._...... to Constru ( ) or Rea ( an Individual Se e Dis os System , Street as shown on the application for Disposal Forks Construction Permit, o ________________ Dated_.____..._ .'6 .: ........... r .......... ._ _ ,r t'` ... ......................... a of He -- DATE...........................................................7..................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS y ds--- THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA < r u , � s ` S . SITE PLAN T YPICAL PROFIL E SCALE — / 3a' NOT TO SCALE IB"STD. LT WGT C.I. MH COVER - __ -- ---7 G9, 2- / -G4. 75 4"C.I. PIPE T 4"BIT. FIBER PIPE TIGHT JOINTS FLOW LINE OUTLET LEVEL _ r TO FIRST JOINT DWELLING F-e-, /O" ---� - —/4 — Go.43 C.I. TEE C.I. TEE CGo•30 � STANDARD PRECAST 4 CONCRETE IO40GAL LON SEPTIC TANK I 01STRIBUTION BOX B TO BE INS TAL L ED ON LEVEL , STABLE BASE. SEPTIC TANK TO BE INSTALLED ON LEVEL , STABLE BASE 2 //B' TO //2" WASHED PEA 5 TON F L EACH/NG P/T ALL AROUND FREE OF IRONS, FINES BASE TO SE LEVEL AND DUST IN PLACE U BRICK Q MORTAR COURES 3/4" TO I-//2" WASHED CRUSHED AS REQUIRED TO BRING STONE ALL AROUND FREE OF �pT 4- hn LOT /G COVER TO GRACE. 24"C.I. MH COVER �, IRONS, FINES AND DUST /N PLACEw ------- --------- --- - _- _—.. 2D, L 2 7 AND FRAME N ryV -- N. STD P,2,ECg1T C'.CtC _. - LE�7CN R,l�E.O �„ � - - - - --- -- �. y. 19,osw _ ,'" ,ate ` P. -— — L E-ACHING Pl T E,fC SEC T/ON— INLET B FLOW L lNE I i PIPE I. CONCRETE TO BE 4000 PSI 28 DAYS 2. REINFORCED WITH 6" x 6" NO. 6 GA. W.W.M. 3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREATER ? DEPTH REQUIREMENTS. OPENING WITH 4 //B" 4. NUMBER OF PITS REQUIRED j i OUTER DIAMETER Q NOTE: EXCAVATE TO ELEVATION OR LOWER AS /-3/4" INSIDE DIAMETER N I 3 REQUIRED TO REMOVE AtL_LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED 144ATERIAL WITH CLEAN GRAVEL TO DESIGNED GRADE Bje rVL 4'-0 I MIN. EFFECTIVE DIAMETER (NOT TO EXCEED 3 TIMES FFFECT/VE DEPTH) i �•��Q'.e,, --� --�-�. WATER TABLE cp I �`` a� SOIL ANO F EhC. DATA GENERAL NOTES -- PERC. RATE t2 MIN. /IN . NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. 't SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD ?EST BY: /3�2UG.E /�/�'1.�D •C�i2 ��. -- PRECAST REINFORCED CONCRETE UNITS. -�09. WITNESSED BY. ��' �1 (,���+ ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE 'e= 33 ,,\ ` - �1�Q. -- _ % TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE , TEST PIT GR. EL. G�.O DATE '__ 83 MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF TEST PIT NO. P/975 TEST PIT NO. 2 SANITARY SEWAGE EFFECTIVE I JULY 1977. 0 - 0 - --- ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE Top �u3�oiG BOARD OF HEALTH. 4- GD•qze4G IY)150 AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE �, S9Nd• C©Jd1 ,E6 BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATEC OTHERWISE. DESIGN DA TA BEDROOMS--3 DISPOSAL- V"'V4Z EST. TOTAL DAILY EFF 3.31n GALS. L EGEND — SEPTIC TANK - GAL SIDEWALL AREA GAL./SO. FT BOTTOM AREA _____�.� GAL./SQ. FT ✓'✓AGE DISPOSAL SYSTEM, 0 x � 00 EXISTING GRADE LEACHING REQUIRED 5��-SQ FT ZONE c?_\ FINISHED GRADE ACTUAL LEACHING AREA _ .,fit'-��Z SQ.FT. FOR , DOMESTIC WATER SOURCE: 7"p4---)AJ w4 rEP_ 0 00 INVERT ELEVATION `� `� r �d ---- --. ------ -- PROPERTY LINE !L 4F �sf/ —�O�1IF�R_✓/� f� 'hlTR .t.�, �5_-- PLAN REFERENCE:_ ---- --- - MEAN HIGH WATER WILLIAM M SCALE: AS INDICATED DATE ! BENCH MARK DATUM' US4rS � � h? f9L3L D,g�tr�»� MARSH _(`� w:+ e � to W�R�ncK Mo, isn i . k WM. WA WICK 9 A SSOCIATE S , M. s' BOX 80/ — NORTH FAL INOUTH cl `.° �r1 0 5.4CHUSE T rs 02556