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HomeMy WebLinkAbout0040 NOTTINGHAM DRIVE - Health 40 NOITINGHAM DRIVE Centerville A= 172 -013 S M E A D KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED INITIATIVE CONTENT 10% C.rtlfied Fib erSourcing POST-CONSUMER www.sflprooram.org S"1270 MADE IN USA GET ORGANIZED AT SMEAMOM I 0113 CoMmonwealth of Massachusetts q( Title Official SubsurfaceInsecti®n ®rr� �..� Sewage Disposal System Form-Not for Voluntary Assessments 0 Yo Property Address l Owner 1 (/j 0 / _ / 1=ant Owner's Name !/� 7"� .. information is A C required for every N page. City/Town 0 a(,Zip Code Dte:,:f Ins ection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab ` key to move your 1 Inspector: cursor-do not use the return key. Name of Inspector C � company Name 1A0 / Company Address �jo City/Town Or p� State Zip Code Telephone umbe J / o License Number Bo Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: asses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector' Signature O Date The system inspector shall submit a copy of this inspection report to the Approving of Health or DEP)within 30 days of completing this inspection. If the systemhas a es gnrflow of ity(Board 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate /Y& regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /v® Property Address VVV/ CCCt Owner -rS74e Ice C/ information is Owner's Name required for every e 0 ` �� Ile- page. Clty/Town1 (� B. Certification (cont.) State Zip Code Date of inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System P ses: I have not found an y 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: 13) 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leakingand if a C Compliance indicating that the tank is less than 20 years old is available. Certificate of ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �" a ` 0 �a A,e Property Address 1f C..7 Owner �Sfs�P®►� Owner's Name information is /�� required for every _ en � page. ! X� 01471), ^ ea�L 6 �� Clry/Town State pC. Zip Code Date of I specti �o Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal Sy stem ystem/ Form Not for Voluntary � ry Assessments Ail N f?a Property Address Owner k4L t P sR information is Owner's Name required for everyL , &e— cpage• ity/Town State Zip Cade Date of Inspec ion ------ �o Certification (coot.) 2• System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Fj—,r`— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ �� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ElLiquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonw ealth of Massachusetts Title 5 Official In specti®n Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '4^M G �♦I, �j Property Address Owner ' 9 I r S R information is Owner's Name required for every �- aZ C. page. City/Town � r®s p o`6� State Zip Code Date of Insp ction B. Certification (cont.) Yes No ❑ �equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El 2'- 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. ❑ L Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Ei? Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis nd chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system falls. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4* na Property Address #7 Owner Oviner's Name ke.i#-s4e,, information is ` //� required for every �f4 or, i �s� ®1/3 l r� page. City/I-own —" aR- d 6 ,p Checklist State Zip Code Date of I C. hod 9���4���t pectin Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes ��Were mping information was provided by the owner, occupant, or Board of Health El any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous s 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? l� LJ Was the facility owner(and occupants if different from owner) information on the proper maintenance of subsurfaces wage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 3® t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official In specti®n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ® / o— ✓� �8 Property Address r" Owner Owner's Name information is / required for every (/[ page. Clty/Town State Zip Code Date of Inspection D. System Information 7Description: � /400 A10111 ,� l C �,. iz Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes [ low Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes 0.0, o Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yeses No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts !Title 5 Official Inspection Foy Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM Y Property Address • V of C or— Owner ' information is Owners Name required for every �(`,� � �=page. City/Town State_- Zip Code) Date of Inspe tion D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S em: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'c M �f/I Property-Address , e.1 V7 Owner Owner's Name r information is required for every q page. City/TownStateZip Code Date ofion D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 091016 Were sewage odors detected when arriving at the site? ❑ Yes 10— Building Sewer(locate on site plan): Depth below grade: Q� feet te rialconstrucst iron 40 PVC El other(explain): Distance from private water supply well or suction line: /® feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material o instruction: oncrete ❑ metal ❑fiberglass 9 El polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)) ❑ .Yes ❑ No Dimensions: J O Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W ®Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name B P✓s+��� information is required for every page. City/Town State Zip Code Date of Ins ection — ] � Do System Information (coot.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness !47 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels aass�-related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Officmal Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �c4 M ® �! Property Address e Owner Owner's Name �P°� Q° information is � � required for every ` /�W _4�6 3 a �. �6 ,page. CitylTown State Zi Code P Date of Ins ection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding'Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -No for Voluntary Assessments Property Address �4 �rl Owner Owner's Name information is ��IT required for every page. Ctty/Town D. System Information (cons.) State ZipCode Date of In pectioA Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert �V 'c o 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.): ze"/ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5lns.doc.rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 12 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M - �i/� Property Address Owner Owner's Name �,e► information is ® required for every4 page. City/Town State ZipCode Date of Ins p ction Do System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ eaChing galleries number: leaching trenches number, length: Co if ❑ leaching fields number, dimensions: ❑ overflow cesspool number: — ---. — — ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): P Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System (Form -Not for Voluntary Assessments Property Address Od 7,14 � Owner Owne�Name�� information is �,` ®�3� �• required for every page. City/Town :] State Zip Code Date of I pecti Do System Information (Cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwea9th of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 449 Property Address 7�d'r� Owner Owner's Name information is required for every page. City/Town State ZipCode Date of In pectin D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate ;hand e blic water supply enters the building. Check one of the boxes below: -sketch in the area below ❑ drawing attached separately t I 3 � � i i �oVe, 44 -f4- d 1 a C(- A t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ° ti D Property Address / � Owner kewrsc-4.O� information is Owner's Name / required for every ( �O'60�� C�page. City/Town — 0 �� D. System Information (cont.) State Zip Code Date of Insp ction Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must d;940 any,- -e established the high ground water elevation: ' / /C�vIC, J . T 6-e /C.?k/ D Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection For a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0A Property Address Owner Owner's NamelCZ information is required for every �/` page. City/Town State Zip Code v� Date of nspect on v E. Report Completeness Checklist nspection Summary: A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed Sys Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 110 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: q-0 r� ��✓y t�l' "`�' od 63'� RECEIVED " Owner's Name: Hic Ar 1✓0�l c3c 2 Owner's Address: S4a v f7�r.7 km--7 �+ rvy /e r 7 0.16 3 AUG 2 S 2001 Date of Inspection: q Of /y�/f TOWN OF BAREST. Name of Inspector: lease print) /�'/�r' le / HEALTH DEFT. Company Name: Cl11111 — 7 C/ Mailing Address: U & UX /mot ,17 Telephone Number.;U 3'J 77S-- /74 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 m trainingand experience in the y xpe proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to S tion 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A L�,� �j CERTIFICATION(continued) Property Address: / UTI i h a f7 ,!i^ Owner. Date of Inspection: p Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 4Zhave not found any information which indicates that any of the failure criteria described in 310 CMR 303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: y One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 li obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /� CERTIFICATION(continued) Property Address: 0 /V0#1 A (pia" tQ— G C2d 3a 21 Owner. o Date of Inspection: C, Further Evaluation is Required by the Board of Health: /►/° Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis;performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form 3. Other. { Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: T /I O A 0 -b a rl c--w— rI/j Ile � Owner. G,l 1�c Date of inspection: p D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No/ _ ✓ Backup of sewage into facility or system component'due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool f/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool —,_/Liquid depth in cesspool is less than 6"below invert or available volume is less than%z day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped _ 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. y portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this,form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "Yes"in Section D above the large system has failed The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Lv /v d l T 110 /M Owner. IAIo, ' [ _ Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yeses No —/ —,Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks �— Has the system received normal flows in the previous two week period — Have large volumes of water been introduced to the system recently or as part of this inspection �— Were as built plans of the system obtained and examined?(If they were not available note as N/A) �— Was the facility or dwelling inspected for signs of sewage back up f — 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 Vz _ 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: Yep no Existing information.For example,a plan at the Board of Health Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 0 1 VI G ka o" 1,2/ Owner: of��viG Date of Inspection: 0/ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CIvt 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: // Does residence have a garbage grinder(yes or no):- v - Is laundry on a separate sewage system(yes or no):� [if yes separate inspection required) Laundry system inspected(yes or no):& 4 Seasonal use: (yes or no): I�/ti ' Water meter readings,if available past 2 years usage(gpd)): tid a pp d aD0 ',ILP evo Sump pump(yes or no): AT, Last date of occupancy: / 0 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(rased on 310 CMR 15.203): and 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: 11-7/�e Was system pumped as part of the inspection(yes or no): If yes,volume pumped:--gallons—How was quantity pumped determined? Reason for pumping: TYPROF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if arty) _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: Xlehl 1 S /QP6 WaV Were sewage odors detected when arriving at the site(yes or no):ZVO i Page 7 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: W /o 14!''I �10✓h Q�- Ceo erfl e 4711 426 Owner: Date of Inspection: / O/ BUILDING SEWER(locate on site plan) Depth below grade:�/i O Materials of construction: ✓ cast 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: (locate on site plan) Depth below grade: a2� � Material of construction: fsconcrete_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: C Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: / Scum thickness: 1 5 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or ba$]e: 7 How were dimensions determined v e Ra ti dew Z Comments(on pumping recommendations,inlet and outlet tee or bale condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: L/(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or bale: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or bale condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: 10 /V0#1 V1 40" �o dfo3�- Owner: Vo g Date of Inspection: / v TIGHT or HOLDING TANK: /_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 00111"01 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.): / o lS (eve Iry GeA 11,3 . /l'v Sv /i�S- G-� 7i v,✓. PUMP CHAMBER.N'/ locate on sit e to 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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q0 IW41�,A-101 'dC,3,2 Owner. 1 1 a,_e Date of Inspection: p SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:._ leaching chambers,number: leaching galleries,number: j leaching trenches,number,length: (o leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): i t9" cn.k r?L e o� 4r-eoc4_ �o� �v�� S{�tle Gle�►�� ,/ i arvr CESSPOOLS: 1411 (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 laver: 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:L(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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 N ND fl t✓l 401 Owner. 4✓a2 d�a c e _ Date of Inspection: c 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. 03 -13` •_ d� _G8 41 3 , ^ 1 l r 1 / 0� �h7Kfe- �G{f 3 Q d o� 1 G�ea� OLA4- Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: NoI�M-0 4A D� ✓q�/ Owner. q« Date of Inspection: Vltto/ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 19-?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: _ Town V"1a,�f Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must des ri how you elished the 'gh ground water elevation: / of- �✓; 6. S �► owe �o c. -7 , DATE: _ 6/6/96 raw V/, PROPERTY ADDRESS: .•40 rl-ottinCham Drive Cente.rville ,Mass . AMOM '77- wSt On the above date, 1 Inspected the septic system at the above address. This system consists of the following: ` 1 . 1--1000 gallon septic tank . �� 2. 1 -1 000 gallon leaching pit . _ N z w..; a� &�, 1996 Based bn my lnsrv�ectlon, I certify the following conditions: 1 . This is a title five septic system. 78 Code '2. The septic system is in failure . 3 . System must be upgraded to .a title five septic system. ( 95 Code ) 51GNATUR!-- : G`�( Name: J . P . Macomber Jr.. i Company: J. P_Macomber &— Son_Inc . CentqrvilLe LMass_-02632 ---------- Phone:---SQ8- 77-5a-333a------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY 'IMqr JOSEPN P. MACO�RBER & SON, INC. Tanks-Cestpoola-Leachflelds P Pumped & insUlied Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 V Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection W1.1I4m F.Weld Trudy Cox* Gawnor Y Argeo Paul Cetluccl David B.Struhs LL Gormor Cormi4sbrwr SUBSURFACE SEWAOE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Prop�crty Add.. 40 Nottingham Drive Centerville MAAddress of owner. Date of Imspootion:6/6/96 (If different) Name ofInspoctor. Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal gystem 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: _ Passes . _ Conditional.y Passes I"ds Further Evaluation By this Local Approv nz Authority /�rLLL / / Inspector's Slynat r {l';. �� Date: U —/ 5-� The System Inspoctor 2 submit a copy of this inspoction 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 oMce of the Department of Environmental Protection. The original should be sent to the system owner and copes sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: �l I have not found any information which indicates that the gygtem violates any of the failure criteria'as defined in 310 CMR 15.303. Any failure criteria not evaluatod are indicatod below. B) SYSTEM CONDITIONALLY PASSES: —4)()One or more gygtem components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yee,po, 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 exflltration, or tank failtuw 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 11/03/95) 1 One Winter Stroet 0 Boston, Massachusetts 02106 0 FAX(617) 556-1049 9 Telephone (617)292.5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropertyAddre" 40 Nottingham Drive Centerville ,Mass . Owner. Irving Long Date of Inspection: 6/6/9 6 Bl SYSTEM CONDITIONALLY PASSES (continued) illy Sewage backup or breakout or high static water level observed in the distribution boat 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 QLl� 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: 4/h 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: 4L Cesspool or privy is within 50 feet of a surface water Al . 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 has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is 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 ooliform 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 Is"than 5 ppm. 3) OTHER w 15 (revised 11/03/915) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 Nottingham Drive Centerville ,Mass . Owner. Irving Long Date of Inspection:6/6/9 6 D) SYSTEM FAILS: • e-1 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. 4&41e Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. J,�.,�clt err 5 Liquid depth in oempeoi'is less than 6"below invert or available volume is less than 1/2 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 60 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 large systems in addition to the criteria above:.' oOb The system serves a facility with a design flow of 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 co idit�ions exist: the system is within 400 feet of a surface drinking water supply;: gi y 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) 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 Au•ther information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 Nottingham Drive Centerville,Mass . Owner. Irving Long Date of Inspection: 6/6/9 6 ' Check if t2�=U wing have been done: ping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /V,-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. -Z i he system does not receive non-sanitary or industrial waste flow ,.j1The site was inspected for signs of breakout. All system components,�uding the Soil Absorption System, have been located on the site. _L"The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of battles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. ZThl size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZZfacility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 Ow1er Irv�11n Long Date of InspeoUon. 6/6/9 6 FLOW CONDITIONS RESIDENTIAL- Design flow ns �/'d A Y • Number of bedrooms Number of a=ent residents:oZ Garbage grinder(yes or no): 0 , Laundry connected to system or no): Ye— Seasonal use(yes or no): A Water meter readings,if available: g � �� )$ = / • !� /� Last date of occupancy:,ZZ--i(e'z COMMERCIAL/INDUSTRIAL Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)J& Industrial Waste Holding Tank present: (yes or nold& .. Non-aanitary waste discharged to the Title 5 system: (yes or no)-40 Water meter readings,if available:__ AM Last date of occupancy: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECO San rce of information:�l � , System pumped as part of inspection: (yes or no) 7 If yes,volume pumped: o �r ) // Reason for pump' JEi —'. fj� !,!� I�/dP�rf7` Q T �`Lt e l/Q/•CiZJ'tD6l7`�it.I' d -r E 0 SYSTEM 'MAW )•r1,Cra t �•vv7- m -�� e;� ,,,pjr TYP � �' Sep rption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information:Z�r0;o Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C• - SYSTEM INFORMATION (continued) Property Address: 40 Nottingham Drive Centerville ,Mass . Owner: Irving Long Date of Inspection: 6/6/96 SEPTIC TAN K:161OOO9.9&--AV IWA41 (locate on site plan) 1�r' Depth below grade:._IL Material of construction: Zoncrete _metal _FRP _other(explain) Dimensions: `fj '!� 6' Sludge depth: .. Distance from top of k dge to bottom of outlet tee or baffle:, Scum thickness: Distance from top of scum to top of outlet tee or baffle:_ Distance front bottom of scum to bottom of outlet tee or baffle.,_ Comments: (recommendation for pumping, condition of inlet ano outlet lee or baffle. de h liquid IPvel i ret do to outlet invert str aural integrity, evidence of leakage, etc.)Pump septic tan every �-°� years ;`�n1e�' & outlet �'ees-�are in_= Taos•Se tic tank is s�-izc-�ura�Ty's3�i ;'— " dence o .�.eaka e from �.�?,�pt�i c t�:n No repairs nee e a n time . GREASE TRAP.41eWe (locate on site pian) Depth below grade:, Material of constrn.irtionz/ozoncrete _metal _FRP_other(explain) Dimensions-, Scum thickness: _ Distance from top ui scum to top of outlet tee or baffle: Distance from bottom nr CCOM In nOttMn of outlet tee or baffle:, Comments: (recommendation for pumping, condifi^rl of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, idence of leakage, etci . (revised 8/15/95) 6 PropertyAddreaw 40 Nottingham Drive Centerville,Mass .' '/ ) Owner. Irving Long Date of Inspection:6/6/9 6 TIGHT OR HOLDING TANK (locate on site plan) Depth below grade:M Material of constr u tiion.-Al&ncrete_metal_FRP_other(explain) - Dimensions: Capacity: 4 9 A gallons Design flow: ons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) A rV44 44&WTi DISTRIBUTION BOX:Ajjja- (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if le/vel and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) ,44) PUMP CHAMBER: &,te, (locate on site plan) Pumps in working order:(yes or no)—AZ4 Comments: (n co on of pump chamber, condition of pumps and appurtenances, etc. �fp �tf�lrYl�l�'� (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: 40 Nottingham Drive Centerville ,Mass . Owner. Irving Long Data of Iaspootion: 6/6/9 6 SOIL ABSORPTION SYSTEM (SAS):'LiG (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: Y leaching chambers, number: leaching galleries, numbers leaching trenches, number,length: leaching fields, number, dim Ions:_[j overflow cesspool, number:(/ Comments: (note condition of soil, signs of hydraulic failure,Level of Rondit condition of v nd to fine sand•Hydrau is ai re is p ` Wel�:) Sewa e is over tnje No si ns o on in ; ne a1_�rG+Pm must be up ra ed DY addi—P a leac ing rent 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: j Materials of construction: l Indication of groundwater._ .4)11 inflow(cesspool must be pumped as past of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n a�is�/✓/1l�e?%S PRIVY:�O41t (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments:AWWcondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,-etc.) 1,40 Yl (revised 11/03/95) 8 � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Nottingham Drive Centerville ,Mass . Owner. Irving Long Date of Inspection:6/6/9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: • "Cluda ties to at laast two permanent references landmarks or benchmarks locate all wells within 300' Centerville- Osterville Marstons Mills Water Company 428-6691 �of� c• DEPTH TO GROUNDWATER Depth to giroundwater. 24' feet method of dgtermination or approximation: No water encountered at 121 when system was installed. (revised 11/03/95) 8 Gj1� • ICr� vkV 31 �1� i THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRO�NTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A ,, tbe' General Laws. Issued by The Department of Environmental Protectio . June 8, 1995 Acting Director of the ion of Water Pollution Cc:. : SMISURFAGE, SEWAGF DISIUSAI, SYSTEM INSPFC170 FUHM PAHT 1) CERTIFICATION . t I -_-.: —.­­­_—'­�........ .... , --- -- -------------------- —----- A -TYPE OR PRINT UEARLY- PROPERTY INSPECTED STREET ADDRESS 40 Nottingham Dtive Centerville ,Mass , ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Irving Long TART L) - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State _zl P COMPANY TELEPHONE FAX 508 775 3338 ( 507 790 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of oil- site sewage disposal systems . Check one : System PASSED The inspection which I have conducted has not found any information which indicates that. the system fails to adequately Protect public health or the environment as defined in 310 CHR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . XXXXXXXXyX System FAILED The inspection which, I hove conducted has found that the system fails to protect the public health and the environment in accordance with 'Title 5 , 310 CHR 15 - 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . 6/13/96 Inspector Date Signature One=_QPyof. this cvrtifica'tio'n'-inus"t- be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEAL111. If the inspection FAILED , the owner or".operator shall upgrade the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CHR 15 . 305 . partd .doc TOWN OF BARNSTABLE LOCATION dna J4 s.,5 4 3�P, /'�`1e • VILLAGE eiaii R ASSESSOR'S MAP & LOT SEPTIC,TANK CAPACITY �166n LEACEENG FACILITY:.(type)' (size) zn c% NO.OF BEDROOMS c,_N BUILDER OR OWNER ^ DATE: [�'� DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility A 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 f leaching fac' 'ty) Feet Furnished Ina in Z f2: L � rr G��3 TOWN OF BARNSTABLE LOCATION '-16 k)0TT1 A)6-#A�l b SEWAGE # 'IIILLAGEC) AJ 1 n- Vlt-�-•- ASSESSOR'S MAP & LOT17; 0/-y INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) l ea o6=AL— NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER hvlb LICr BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� 1� 0 v� �- ..� �� 'fit R 5® )))��' O • ��� �! 1 • '�.. _ No. �d Fee 416 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS application for Mi$poal *p.5tem Construction 30ermit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: Location /Address or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. �`�,�_ Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms�� Garbage Grinder( ) Other Type of Building No.of;Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow S gallons per day. Calculated daily flow 33 gallons. Plan Date Number of sheets Revision Date Title L_ p- Description of Soil ut"&V_ a5AA Nature of Repairs or Alterations(Answer when applicable) --,rt&j 5X-VA i)— �a'F (00*,— -r r mke_,i� op., e�sa-v-!�2,. i cooto 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 provisi�Titlee Environmental Code an of to place the system in operation until a Certifi- cate of Compliance has been i p/ Signed Date Application Approved by Application Disapproved for the following reasons g s Q Permit No. G 6 ` a?aa Date Issued !o 6 - �/. �.;. _. .; .;.•`... .. * �;.. .ems .' R —T—..-- � � e.. - ` � _. _ .. .. � c�i No. Fee cje • --,.tt THF+CONWEALTH OF MASSACHUSETTS ,,, ! i PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS �'" ZfppCication for Migpogal *pgtem Construction Permit Application is.hereby made for a Permit to Construct( )or Repair(-w<an On-site Sewage Disposal System at: y Location Address or Lot No. Owner's Name,Address and Tel.No. .. 7 G "OTT 1'I. �.Cl4\��Uti i�.�•�.., Installer's Name,Address,and Tel.No. �/'„�_ Designer's Name,Address and Tel.No. i Type of Building: Dwelling No. of Bedrooms Garbage Grinder( ) f Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures r Design Flow gallons per day. Calculated daily flow 3:3 0 gallons. Plan Date Number of sheets Revision Date Title L_r) Description of Soil rn,_.e,Q_. S Nature of Repairs or Alterations(Answer when applicable) i�r7�..Ll�'�.. �`C' r r arc_h, ©�'✓_. 2�'r'S7`t f� l�c�y SE-�fT��c�`C A,.-� tom, J 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, of to place the system in operation until a Certifi- cate of Compliance has been issue ), is B. ard.af-He Ith. r Signed Date /0- �-�.4 Application Approved by Application Disapproved for the following reasons q l Permit No. Date Issued f!-- ———— ---_--- ———_--------- -- a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Certificate of Compliance THIS IS TO CE FY that bh -si a Sewage Disposal System installed( )or repaired/replaced(1/f on -q by ,/ is c ��.- �) e,-4 5 for S"(ZVill L ooua_ as " r c.-'r e-,. has been co structed in accordant/ with the provisions of Title 5 an the for Disposal System Construction Permit No. 9 7�dated �!f, Use of this system is conditioned on compliance with the provisions set fort low: !' No. v , Fee /y THE`COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS ligpogar *pgtem Construction 3permit Permission is hereby granted to c�' oc ' t i ✓r to construct( )repair( L,,)--Xn—On-site Sewage System located at �n l 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 within two years of the date below: Date: Approved liy r r CERTIFICATION OF SKETCH AND APPLICATION FOR DESIGNED DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at or k�e- 6VtiT,- meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • Theie are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the teaching thcility • . There.is no increase In flow and/or change in use proposed • There are no variances requested or needed. SIGD: UAT9: • =1 G�'o LICENSED SEP71C SYSTEM[INSTALLER IN i ICE TOWN OF 13ARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed Installer posesses a certifled plot plan, this plan should be submitted]. G �1 (¢YO 0�r T✓�a,�Lj »' TOWN OF BARNSTABLE LOCATION SEWAGE # d' , 'VILLAGE ("P/1�P1��/ l��C //ASSESSOR'S MAP & LOT �-v O1,5 INSTALLER'S NAME&PHONE NO. IC,5 SEPTIC TANK CAPACITY & 6.71 LEACHING FACILITY: (type) l TeenC (size X / NO.OF BEDROOMS 2 BUILDER OR OWNER �2 r/n C&7!9 PERMIT DATE:9"''2'10-f—24�'COMPLIANCE DATE: t< ' 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 lea f lity) Feet Furnished by ��4 ( �� c t ClN-7 6 6 333& L3� �- _3 3�' Q3 • ` Ilk No.....4 f 4-••--• Fn$... ..................... THE COMMONWEALTH OF MASSACHUSETTS ®®AR®. OF HEALTH . ....... ..............'OF ... . - 1 _ Appliration for Tonotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal y.. �l�. ...... .... . ... U / .3 ... ... ..... .. ..............11.1.:Lf. ? tion. d.5. .. ...... ...A..or.Lot No............ ..,............ AA .� .. ..Y::. ............. ," Y..4..� .. ss a ....................... Installer;.' Address . r UType of Building ;:;° Size Lot.__f�.................Sq. feet Dwelling—No. of Bedrooms.`..�..... Expansion Attic ( ) Garbage Grinder ( ) Other"-Type of Building 1�I�3:.. ............. No. of persons.........._.(__.-.--........ Showers ( ) — Cafeteria ( ) Otherfixtu es ................. ••-•••......-•-•-••-••-•......•• •. W Design Flow................... ......................gallons per person per day. Total daily flow........... ....................gallons. WSeptic Tank—Liquid capacity--_gallons Length................ Width................ Diameter................ Depth................ Trench—No..................... Width,.. ....... Total Le gth......_...__....__.. Total leaching area....................sq. ft. x Seepage Pit No..................... Diameter.�X... epth belowet.................... Total leaching area.,.a..�":`.sq. ft. Z Other Distribution box ( ) D ing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-_---_______-__--_..__- fZ, Test Pit No. 2................minutes per inch Depth of Test Pit---_................ Depth to ground water________-__----_..-____- ---- ODescription of Soil . •----- � -------•-•-------------------------------------------------------•-•-...-•---•••••-- ----_....----••--••--••--- x -- U .......................................... ..................................................... ........................................ .........................................-...................... W U Natur'e of Repairs or Alterations—Answer when applicable................................................................................................ -•-•--•-•---------------------------••......•--••••--• ----•-•-••••-•--•--•----•--••------•.......---•••......-- •----------•---•-•-••--•--••-•-•---•-----••--•---------•••••-•----•--•-•-•-•----.----•- Agreement: The undersigned agrees to install the aforedes ibed Individual ewage Disposal System in accordance with the provisions of Article XI of the State Sanitary C —The nder gn further agrees not to place the system in operation until a Certificate of Compliance has bee sued by and alth. Sig _. .. ..: ••-- •-•....'- •----•---••-•--• ••-•----•••-•--•.......... ............................. .. Application Approved B . __ Date PP PP y------- ........ •----- •----•--•-- ../ ...7 ' Date Application Disapproved for the following reasons-------------------------------------------------------------------------------------•--•-••••......-•---•-•It. -----•---•---------------••--••--•••••---•••-----••---------•-••---•--•......---•••... .................................... j L Date 7 Permit No..... -�..... - Issued:. l . ....... Date j, No......................... Fimit...o.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .r� ;t ..,�!,. o .�vOratiou for Bisposal ,arks Tonstrurtion trait Application is hereby made for a Permit to Construct ( ) or Repair ( ' ) an Individual Sewage Disposal System at .+' r t ¢ rr9 � Location A / - r `— !t I y dress or Lot� � r- No. ................:. �Y 'a.- +/'rn - ..... y? . . .. ti r i i.. t .:......... ........................ �.._ Owner .......... ............... Address ! f/ a ................ ^.... .... � �:.... ° :. ...................... '. :... ....... :.:. x ............ M 3 ... t. .. vr.. ti G•.B .ass: ( / Installer Address UType of Building Size Lot....: ......Sq. feet a Dwelling—No. of Bedrooms.......... `...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building No. of persons____________ ______________ Showers ( ) — Cafeteria ( ) Otherfixtures '•------•---------•..............•---•--••••-••--••---••--:............-••..._.................................................... W Degign Flow.....................:.............:.........gallons per person per day. Total daily flow........... '`.. %'_.__...._..__-----_-_gallons. WSeptic Tank—Liquid capacity/' ...gallons Length................ Width................ Diameter................ Depth.............__. x Disposal Trench—No..................... Width.................. Total Length.................... Total leaching area..............._....sq. ft. Seepage Pit No-----------------_-- Diameter.::____:..,_ `'-Depth below inlet.................... Total leaching area.- ...'.sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................................. ....................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_.___-__----_-_-.----. raq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil_ . -'` �r -.,.ter 2 - V .......--•-------•-••-•-----•---•---•-•------•••-•••._...--••---•---•--••••-••-•-•----••---•----••-•-•-•••--•--•••-----•--•-••--•------•--••••--•------------••-•---•------•-•-•-•....••----••------•-- W V Nature of Repairs or Alterations—Answer when applicable.........................___.............____....._...............,__....._..................... ....-•---•-------------------------------------------------••------•----------------•--..............---•---------------------------•---------.....---•--------------------------------------------••••. Agreement: The undersigned agrees to install the aforedes ribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary C The under gned further agrees not to place the system in '11operation until a Certificate of Compliance has bee�ssued by,,�he b and of'Yplth. Sign 4 ........................... ................................ �'" �/ y� Yid fl, Application Approved By----- ..................� -`.... �' 2/ '/ 1 ` ---- Date Application Disapproved for the following reasons:..........................................................................=..................................... ---••------------•••......-•-••------•---•-••-----••-••-•--- ••-••--•-Date PermitNo.................................•..........------........ Issued.---- ` ate THE COMMONWEALTH OF MASSACHUSETTS -, _ BOARD ,OF HEALTH :........:.............OF... r........................ ................................................... Trrtifirate of Tomphaorr THIS IS J'OO �ERTIF Y+ T a� t" ndiv dp Sewage Disposal System constructed �) or Repaired ( ) by f t" InStanPpt . _ jrp at......................- . . 'r._?Mf g-ri x =�``.+�..;.it1:..4 — n!i�f.rt . ............'__._T' -' •- .._....__.__....._......... has been installed in accordance with(tii e provisions of Article XI of The State Sanitary Code a desc•ibed in the application for Disposal Works Construction Permit No----------6-_.l__ ................ .V, 7_ ........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 13E CONSTRUED AS A. ARANTEE THAT THE SYSTEM WILL UNCTION SATISFACTORY. DATE......... . ......y 'Z ......---............---..........__. Inspector....... :-= r'r' '�..r�.. .j..... THE COMMONWEALTH OF MASSACHUSETTS BOARD,,b.F HEALTH �{ ,. . �,"YS,,. y /�.t f ........... f No......................... Fi;&...................... �i���a��l� ork� C�oosfr��r#ioo �fprntit Permission is hereby granted..... s r:. ": c.. . ....... ................. ! / r f to Construct ( ,) or Repay.( r� a ndividullewage Disposal S st�i71� r at No. = f i�ws 4 rv "r v .., r Street as shown on the application for Disposal Works Constructi rmi : ....:.......... Dateat'_ _1.... ' ....................... P�- . .. � Board of lth - DATE----•----------- ----- ------ -�...---......---.............................FORM 1255 HOBBS & WARREN, INC.. PUBLISHER$ '