HomeMy WebLinkAbout0334 NOTTINGHAM DRIVE - Health 334 NOTTINGHAM DR., CENTERVILLE
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HASTINGS.MN
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.- it does not;give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 'I st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: 5 t� 1 j - Fill in please:
APPLICANT'S YOUR NAME/S: I A tc hct�6 1"C�k'� (M
r
BUSINESS YOUR HOME ADDRESS: 33L1 No H i V^�Mawr .Dr►
�t3-233_Ib3� Cenl-cc-�t�l� )AA e-
u TELEPHONE # Home Telephone Number Lot - Z3 3- 1630
it
NAME OF CORPORATION: 6009e.h ,n av�et
NAME OF NEW BUSINESS _ JD (7% o.unc a- TYPE OF BUSINESS FncncA
18 THIS A HOME OCCUPATION? YES MA ADDRESS OF BUSINESS lOo t r 2-0 ko
I [Assessing)�/ " �
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMM SIO R'S OFF E
This individual e inf r d o a er i r it ents �pertain to this type of business.
ut oriz d Si natur..e*
COMMENTS:
2. BOARD OF HEALTH
This individual ha en informed
�d o permit requirements that pertain to this type of business.f
ALXhorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed-of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
COMMONWEALTH OF MASSACHUSETTS
f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
m 9 d
DEPARTMENT OF ENVIRONMENTAL PROTECTION
4
�'9b 5V 0
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PANT A
// CERTIFICATION
Property Address: 23 //T /V O `�� 17r,wj Q/./Ye,
C-eo4gi-vl-lle, 0a6-?d,
Owner's Name: 2 1,11 G.i 11,
Owner's Address: 3341 IVO i% /jo,-" 1-9,i p
Ge-,-1e vi' 002442,
Date of Inspection:
Name of Inspector: (please print)
Company Name: L/O —
Mailing Address: o A719.x /o! $l
E G�,wt /YJ)�ylOa6�,t
Telephone Number(.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Sec ' n 15.340 of Title 5(310 CMR 15.000). The system:
l� e
Pass s
} Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
' Fails
t
9
;Ins�ctor's nature: Date: 111119 O
c�fThe system ins for shall submit a copy of this inspection report to the Approving Authority(Board of Health or
:DEPb�ithin 30g ays of completing this inspection.If the system is a shared system or has a design flow of 10,000
Z-gpd rd�reater,the inspector and the system owner shall submit the report to the appropriate regional office of the
EP. e origina l should be sent tothe system owner and copies sent to the buyer, if applicable,and the approving
uthoity. 1 �O h C/, L-ebe/
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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: -?-�'5'
Owner: t, �l
Date of Inspection: I!O 0
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst asses:
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. Sy em Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain: /
T;rlo c r. o r;,,F,,— 2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
?L� CERTIFICATION(continued)
Property Address: ale-_
Owner:
Date of Inspection: I 910
C. Further Evaluation is Required-by the Board of Health:
Conditions exist which require fiuther 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:
3
Page 4 of 11
OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: i
Date of Inspection: o
49�-
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
LZ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
gged SAS or cesspool
S 'c liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
esspool
uid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
tunes pumped
�fiy portion of the SAS,cesspool or privy is below high ground water.elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
,/any portion of a cesspool or privy is within a Zone 1 of a public well.
/ty 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. barge 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 n
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—TWA)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.
T41. G T,.-.,f:nn r'.,,-,,, Aii 4
Page 5of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CHECKLIST
Property Address: �J / �
Owner: W /
Date of Inspection: // /o D
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes o
ZWere
umping information was provided by the owner,occupant,or Board of Health
any of the system components pumped out in the previous two weeks?
v — Has the system received normal flows in the previous two week period?
V Have large volumes of water been introduced to the system recently or as part of this inspection
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
_ Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_✓_ Was the facility owner(and occupants if different from owner)provided with information on the proper.
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
'P;tte C T—.........,F...-.,, 4n c/7AAA 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
7 SYSTEM INFORMATION
Property Address: �J 0 N'4l 'v"7 a—
// �I N
Owner: W
Date of Inspection: /o
OW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 3 ?�O
DESIGN flow based on 310 CMR 5.203(for example: 110 gpd x#of bedrooms):J
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):.4/0[if yes separate inspection required]
Laundry system inspected(yes or no):,
Seasonal use: (yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: ��.�—
COMMERCIAL/INDUSTRIAL
Type of establishment:
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 nn
Source of information: 00 `/
Was system pumped as part of the inspection(yes or no):."
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
T OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
—_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if kno )ap d source f info on: 7/
19-IF
Were sewage odors detected when arriving at the site(yes or no):
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
��--
Owner: W�l fi
Date of Inspection: 1 /c 0
BUILDING SEWER(locate on site plan)
Depth below grade: /A�Mt
/
Materials of construction:_ n L40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: lo'� cate on site plan)
—( P )
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) �X
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 07
Scum thickness: -3 1
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottoJ�gf outlet tee or baffle: Y
How were dimensions determined: die/e �ag his_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as rela*to outlet invert
,nevidence of leakage,etc.):
f -1 t.1 / eC d n//���`•h/ G�•9G `f eB� /�)
GREASE TRAP:&,(locate on site plan)
Depth below grade:—
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of olatlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels.
as related to outlet invert,evidence of leakage,etc.):
T41.. T„ +;, F,.,T 411 cionnn 7
Page 8 of 11
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ✓lam/�4 z2,
eo , 11e14
Owner: i
Date of Inspection: / o
TIGHT or HOLDING TANK:&(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
•
DISTRIBUTION BOX. (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: V201 A 1 eq 6_-
Comments.(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or outdbox,e tc.): Z-eve A xt4 soh
^O
PUMP CHAMBER: /li (locate on site.plan) .
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM fM IN/FORMATION(continued)
Property Address: 3�T %0//�'� 6�4✓`7 �I''
Owner
�V►���� � � oO2�302
Date of Inspection: 0
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
7leacg
,f'y`'pits,number:L
leaching chambers number:
leaching galleries,number: J ��
leaching trenches,number,length:.
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): U00 7L �('� S�G 4 1—rr-e—
d
CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
•r;*to c r„.„o,.+;,.,,r•,.,-,,, An vMnnn 9
Page 10'of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: avh
// � �
Owner: W h I
Date of Inspection: // /O
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
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Page 1'l of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART C
(, SYSTEM INFORMATION(continued)
Property Address: �37 /en
Co-
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells i�4 O
Estimated depth to ground water C2 G feet 60
,/` ur
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:
O erved site(abutting property/observation hole within 15 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must escribe h w you established the high ground water elevation:
o c oh 1 s 6-�
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Tt4l5 V LAW Pe, LJaT 1F5&SC-t) v" A" �S�E�wILtL c? �trC.LSS.
Town of Barnstable
�pF 1HE Tp�
Regulatory Services
BAR NSUBLE,
Thomas F. Geiler,Director
' A•�� Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
i
j3 _-O
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld I
Governor
Trudy Coxe 0 Sseretery,EOEA
ii
David B.Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
3 3 � fi0�h AAA? ar PART A
_ G�����✓, � CERTIFICATION
Property Address: Address of Owner:
1.2 1'yau�rr�- � iZc7
Date of Inspection: 3 (If different) �) e IM S �ar C7 /r'1
Name of Inspector: W.E. Robinson Sr. e,7 �a y
Company Name, Address and Telephone Number: W.E. Robinson Septic Service
P.O. Box 1089
CERTIFICATION STATEMENT Centerville MA--77�77
1 certify that I have personally inspected the sewage dispos�l sps7Ur t 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 sew a disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: /IV �,-�. '- Date: 3
The System Inspector shall submit a copy of this inspection 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 to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A) S,YSTE PASSES:
V 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) TEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicat yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain wiry 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 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-SSW
i,Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 3 'L/ /1® K/ 9-/n Ar (�y-ew f1
Owner: 1Igy-Ma,��
Date of Inspection: ,\
61 SYSTE 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
C1 FURTH R EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
ublic 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:
rSYSTEM
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) WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
6 HE 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 supple or Uibutary to a
surface water supply.
L The sy tem has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
N The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
D1 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 dogged 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 /95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ,3 3 y h a it)P7'J h4m ���27-e,'v
� a�'
/
Owner: �f�y— h' 'P, /
Date of Inspection: ��
D] SYSTE AILS (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 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 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E]LARG SYSTEM FAILS:
he following criteria apply to large systems in addition to the criteria above:
he 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 II of a
public water supply well)
The owne or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requireme is of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
i
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3 3 17e Alen f Am
Owner: /✓q 4-tW,4'Te e__
Date of Inspection: /
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
`None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
JAs 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.
1/fi/he system does not receive non-sanitary or industrial waste flow
✓fhe site was inspected for signs of breakout.
_I,All system components, excluding the Soil Absorption System, have been located on the site.
_L/he 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.
7/The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
l/The facility ov ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
7 SYSTEM INFORMATION
Property Address: 3 J /�/ 17D�iy im i2l, �L/�/ ✓ �/i /c—
Owner: /�-;'P
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 33 0 Kallons
Number of bedrooms: 3
Number of current residents: 0
Garbage grinder(yes or no):_.A=-'
Laundry connected to system (yes or no):�
Seasonal use (yes or no):_&e' 3 ��
Water meter readings, if available:
Last date of occupancy:
CO ERCIAUINDUSTRIAL:
Type o stablishment:
Design fl w: gallons/day
Grease tra present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanita waste discharged to the Title 5 system: (yes or no)_
Water met readings, if available:
Last date f occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPIN RECORDS and source of information:
A,16 n-&
System pumped as part of inspection: (yes or no)Lo
If yes, volume pumped. t~allons
Reason for pumping:
TYP SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
her(explain)
APPROXI TE AGE of all components, date installed (if known) and source of information: �l/2
Sewage o s detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
z
Property Address: J 3 /V /7D A11-'?y1i'-71" mil'
Owner: / y,e e-
Date of Inspection-� In,,
2 SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: ✓concrete _metal FRP other(explain) j
Dimensions: a''
Sludge depth: 4
Distance from top of sludge to bottom of outlet tee or baffle: :3
Scum thickness: J 1 4
Distance from top of scum to top of outlet tee or baffle: 17 '
Distance from bottom of scum to bottom of outlet tee or baffle: i
Comments:
(recommendation for pumping, condition of inlet agd outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) l' a C. n So 5 E= c'n o� /1/)z
GREASE RAP:_
(locate on site plan)
Depth bel w grade:
Material ol construction: _concrete _metal _FRP—other(explain)
Dimensior s:
Scum this mess
Distance om top of scum to top of outlet tee or baffle:
DlStanCe rom bottom of 5rum t- hottom of outiet tee or baffie:
Commen s:
(recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leafage, etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 -3 L/ /'� i q�3O//Y� A2/'
Owner: ,Q� �— /Y�A��e—
Date of Inspection.!
TIGHT OR HOLDING TANK:_
(locat on site plan)
Depth be w grade:
Material o construction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: allons
Design flow- gallons/day
Alarm level:
Comments
(conditio of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: 6
Comments:
(note if level and distribution is equal, evidence of solids carr)•ovcr, evidence of leakage into or out of box, etc.)
PUMP CH MBER:_
(locate on s e plan)
Pumps in w rking order:(yes or no)
Comments•
(note con ition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 3 /-/ h d#//f 1-2l9-0-7 0,�Z- 2/77,'?-rc)i
Owner. /��� �� �� /✓���
Date of Inspectio .
3 -/l-9�
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 ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) F< �sK S
:-h. IC i�� I P Z,tJ w)�;2 'g C�o¢ICJ
CES OLS: _
(locate o site plan)
Number a d configuration:
Depth-top of liquid to inlet invert:
Depth of lids layer:
Depth of um layer:
Dimensio s of cesspool:
Materials f construction:
Indicatio of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comme ts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate n site plan)
Materials f construction: Dimensions:
Depth of s lids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33"/�/ 12d/i ih1V h q1n or
Owner: /�4-7'
Date of Inspection: cJ
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
G�L
f
� q
L�
w \ J
DEPTH TO GROUNDWATER
Depth to groundwater: )�`�' feet — J `�� y�
method of determination or approximation: !J�� 5 1 �a / ✓ S •6
(revised 8/15/95) 9
z`.
"No...1 9A:_6.6 � '� ._ •" -- � Fps. .....................
THE COMMONWEALTH OF MASSACHUSETTS'
BOAR® F H A H
�..U.W..v`.... OF............. ....... ----- -----.......-----..................
ApptirFatfivu for MipaaFal Vorks Tonstrurttua% Vamit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
...............................................................
/ cat' n-Address
or I of No.`t u r'u
\\ ff G✓ W:}
.............6._......._w ........._... .........••'................................... ....................._.......•--------•--•--...__............•----_..............................
a /w er Address
............................................................
Installer
Address �
UType of Building Size Lot...._...�SJ... .....Sq. feet
.-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (/L-p
Other—Type of Building ._.... No. of persons............................ Showers —
a YP g ---------------------- P ( ) Cafeteria ( )
Other fix ..............................
w Design Flow................15s—.......................... allons per person per day. Total daily flow....... . ......................gallons.
WSeptic Tank—Liquid capacity/ allons Length................ Width................ Diameter................ Depth................
xDisposal Trench—���No..................... Width,,,:.................. Total Length._......p..._ Total leaching area......._��jj............sq. ft.
Seepage Pit No...... ------------- Diameter--_--1�i-_____-_-_- Depth below inlet......1Q__._.. Total leaching area.P-.�sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY........................................................................... Date.........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
LZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-----_---:..--------
...........A. .................................•---•--------......•-----.._..--•--_-----
O Description of Soil-------- .......... y •.`• ....__ .......
t., -------------------------------------d..,-- Z------- .
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 proy pions of H7PTL E 5 of the State Sanitary Code The rsigned ther agrees not to place the syst in
operation :until a Certificate of Compliance has bee is d by o rd o alth.
e -•------- ---- ....................... --------------- ..-�•-.•.
D/Al/Application Approved.,By.:-- ---- --- - •--- ---•--- ..............
----•-_---- �
Application Disapproved"for the following reasons:.---- a e..............
--••----.....-•-----------•-------•-•----------------------------•--.....-------•----........-----•-----
Date
PermitNo......................................................... Issued_.......................................................
Date
No. Finc .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF H ALTH
. ' !
ApplirFa#ilan for Uispoii al Works Tomitratrtiun Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
_ ....1 ....... ... .
.........................................
M) ` ��_
-i n•Address or Lot No.
... ------------------------------- ------------ ------------------•- ---- ..........__
(� / 1��� Address..
.......... •.......... -
a Installer Address
UType of Building Size Lot___ _ _ __ ....Sq. feet
Dwelling-No. of Bedrooms_____ _________ _______________________Expansion Attic ( ) Garbage Grinder (A-0
pa, Other—Type,off Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other
W
fix Design Flow_____________ alons per person per day. Total daily flow........3,3, ___ _.__gallons.
9 Septic Tank—Liquid capacity/ _ __ allons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_____________________ Width __.._.__.__._.___ Total Length_.________... Total leaching area....................sq. ft.
Seepage Pit No______ _____________ Diameter----- -------_... Depth below inlet...... ....... Total leaching area_ _fUsq. ft.
Z Other Distribution box,(.,,_) Dosing tank ( ) ,, J,"
'~ Percolation Test Results Performed by........................................................................... Date=___....._._.._.._____..._____________..
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.____-___--_-______._.-
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------•,...........
____.
a ---••••. ..�.
O j ,� '
Description of Soil " k __---------•-- " 4 f
x - -- ----I . ..........................................
W •--•----•-•-•----------------------•-------------....--••-•--------•----•--._.._..:--•-•---------•------•----•-•------.-.-•----...:---._....--•---•---------•---.......................................
UNature of Repairs or Alterations—Answer when applicable_______________:_
Agreement: ;
The undersigned ,agrees to install they aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITILS 5 of the State Sanitary Code The d rsigned rtl:er agrees not to place the st in
operation until a Certificate of Compliance has bee is d by oard o iealth. /�--;s
ate
Application Approved By... - ••_.. . *. .... ....-• ......... ........
D to
Application Disapproved for the following reasons------------------ ________-_______________---__________.__.________.._..__. __.._...............____
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD,& HEA T
C�rrtifiratr,of TrrntpliFanrr -
THIS IS TO CERTIFel
at the Indivi 1 Se, a e isposal System constructed (. Repaired
by �' ...____----- �,
er
at - f -- .�-r------ '._.. - -----------
has been installed in accordance with the provisions of TI 1 L: r of The State Sanitary. Code as described in the
application for Disposal Works Construction Permit Ro. "_.___8__ _ ____________ dated---------':....................................
t
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................--•-••••.........� �......:........::..•-_. Inspector---'----------1`/f �j(-•-------------_____-__________-•--••----___-_-_
HE COMMONWEALTH OF MASSACHUSETTS
BOARD ,, F HEA T
t
Nu ..'"../..�� �/...
talttl inn ' n anti#
Permission is ranted_____________ -"
........1� _ .
Yg
to Construct ( ep r ) an Individual Sew e Dispos
at No............... .... t''. 7"71!'.:..... ._._...x �-- . ---------------------------------------------------------------
.O
� r� Street
as shown on the application for Disposal Works Constructio erm No.___ -------
Doted..........................................
�� Board f $ ...........
-•--------------•---•-----
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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L O C AST ION SEWAGE PERMIT NO.
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INSTYA LLER'S NA'Mi� i ADDRESS
I UILDE R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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