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Home My WebLink About1000 OLD STAGE ROAD - Health E= 208 D STAGE ROAD, CENTERVILLE 012 I //!/- /� Cal to nl&d. UPC 12543 IUA co �, HASTINGS,GIN TOWN OF BARNSTABLE LOCATION 1600 Q/ �G SEWAGE # VILLAGE Pal lei'cl,A ASSESSO MAPI&`LOOT io r AME&PHONE NO. SEPTIC TANK CAPACITY ,A 00 .QA LEACHING FACILITY: (type) _f�� J (size) NO.OF BEDROOMS BUILDER 0 O PERMITDA : COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f 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 f i 'of leaching fac ) �//i¢ Feet Furnished by, n�I�CcC'.+ �G�. Z7VC. it � f� �a a� �`�� ASSESSOR'S MAP NO. PARCEL f _ 116, L.9 C•AIT ION SA W A G E PE RMIT NO. V I L L A G E lisp', 000 $1 d INSTA LLER'S NAME i ADDRESS K . \A '�i U I L D E R OR OWNER P.. DATE PERMIT IS.SDED �z� �� DATE COMPLIANCE ISSUED �� r �• � a , `2 b' L' NwoL_'a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 000 �'f�tiw:.. ...........OF.��`�.' -'?. r..... ----------------------------------------- Appliration for Dhip vial Works Tmitrurtinn autif Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal System at: ..l 4 e... Q ..............r.i .✓...fs� ocation Address .--or Lot No. - 19?2 .5 .�r��.�c�crs�9.......•..--•------- "' �' .................................................... % ---• - • ••-...... •-- ? 7....... Owner Address Cll� �fv!Si rUf�`�G�^- �57�'wrG�G .__.........`�....-----•. - ---•-•-•................................. ...............•- ---------- - Installer Address Type of Building Size Lot_CZ...!Y-2---Sq. feet Dwelling—No. of Bedrooms..__.......................................Expansion Attic (ACJ Garbage Grinder ......_..... No. of persons............................ Showers — Cafeteria Other—Type of Building :��_ p � ( ) ( ) Q' Other fixtures ............................... .. W Design Flow.............. .._&'..._gallons per person per day. Total daily flow____.._............i .v......_......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 (-1 Dosing tank S ------------- h to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_.................... Q+' ----------------—---------------••----•-------.......--------•----•------------•••-----•--••---••.......................................................... 0 Description of Soil.........0.----• ...............LU,�in y...S_v � -----------........_...... .................... V ................•------...---...--------� ��----------��.L�-------Ss't��•�-� -------•------•-•--•-----•-•----•-••----•-...... ... .... -......`'�-•---- -----------------------------------------------------•-•------•-•----------......--•-•-------.... U Nature,of Repairs or Alterations—Answer when applicable.........................................................:..:.................................. -- -------- -----------Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL%, 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in oper tion untiLa Certificate of Compliance ha been issued by the board of health. T Signed r S y ---•--•- ---------- �u c c--•--••-•--•----• ..;.... ..............- Application Approved By............ �'� a Date Date Application Disapproved for the following reasons:-----•------•---------•-------•--------•----••-------........................................................ ...................................................-..............................................-_-.....---------------------------------------••-------------•---------------...------...----••..----- Date Permit No.................. — ...7...... Issued_....................................................... Date ��77- { <=:V 0� No.. ._-.L—.. `� Fps -............. ..:. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................•..............---•-- Appliratiun for Disposal Works Tonotrnrtion "prrutit Application is hereby made for a Permit to Construct (`-") or Repair ( ) an Individual Sewage Disposal System at: _........................ ......_. ................................. ..._.......•-•------••...-----._....----••• .....-•--••--•_.... _ Location-Address or Lot No. / Owner Address Installer Address UType of Building Size Lot.... 7....Sq. feet ►-� Dwelling—No. of Bedrooms.....'`.? ....................Expansion Attic Garbage Grinder aOther—Type of Building e��............ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures . = W Design Flow..•........... ........... ..gallons per person per day. Total daily flow...................-^'-� '.............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.............--..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by...`7% . � �G^� Date........................................�' S Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f;rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 -------------------------------•-------.... ----------------- ----------------------------- ---------------- .---------------------------------------- D Description of Soil.......... . e r S v/3� .................... x�• r� . ...... ....*--------------------------------------------- ...... .... ... ............................•---•---.....c:......-.V �:.... r��. ............� � ..... ...... --------------------------------------- ---•.--- •- --------------------------- --- ----- i . M. -------------•--------...----------•--- ----------•------------------------------•----------...-•••--•--•••--•••------•••-•-- V Nature of Repairs or Alterations—Answer when applicable.....................................•......................_.................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAITI.i 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation unti Certificate of Compliance has been issued by the board of health. Signed--` t ...........sue. `? A licat>on A roved B PP PP Y ........................................ Date Application Disapproved for the following reasons:. ---•------------•...............•-•-----...................-...---•--....--•---....-----------...-----•----••••---------...----------•••----••--••------•-••••--•-----•••-•--•--••-•-•••-•---•-•-•-•••--- . L — Date Permit No... - . 1----- Issued---------------------------- -------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................OF.... f.2 S/2 - C� ..................................................... Trrtif iratr of Toutplianu THIS IS Tq CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) b J/ Installer. at---------1l'•r-.... --------------f:)e Sid e-- '`' '= ��C ' has been installAd in accordance with the provisions of TITLF,-5 of The State Sanitary Code. as described in the application for Disposal Works Construction Permit No..........4= ' _..`.----7 dated............ .....�. .. .. `'C-... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S TISFACTORY. DATE.............•-.._• Inspector_... - .--... THE COMMONWEALTH OF 'MASSACHUSETTS BOARD OF HEALTH _ 7Gl7�r" OF L� ................................................................................ . Disposal Works Tonstrttrtion Prrutit il 5; /'?. Permission Is hereby granted / �� ......�G=- --------------•---•-----�=--------..................•.............................. to Construct (�_or Repair ( ) an Individual Sewage Disposal S item at No............ Gl � wif- Street as shown on the application for Disposal Works Construction Permit Dated.... . .......................... . . i...... DATE-------------••••..11I.C.e ........................................... Board of Healtha' FORM 1255 ,A. M. SULKIN, INC., BOSTON DaAtLY 'FLavl 1io x 3 s'33o G.P.V. �-�, .PT1C. TA le_ = 330 x IS'o f°o .�4 5 G.P• D. 7St LoT .�. 1 USE 1000 GAL TAKS1L 51OGWAU . ArZEA z IS'o s, F 1�5'o s.F 2 .S"; . . 37.57 Gm P. O �,•S go-Trc-m A9—eA So �s�F —_ o s.F. x 1 0 Sc� -G:P. o p t o So•'L 1 �QI /St To TA u OESIGQ s 42.�m G..P. 0. 7-T/AL DAILY FLOW = 33o G. P. D.` _V n PMCot,A iaN 1 P-AT t,rlN! � 1 o(t`IJESS �o� y oe PETER t09% # �' :��'•+ RICAARD� ;t � SULLIVAN v Dg' ` SSA } � o 2933 T IniT1 41 P¢oP K T 41 r- h 1yT ;✓{O ... /OIA ..��'� Doti _ 9/tb 8S r / I ./ so � t (aq_ 'L--12 f"I DAMES �v�- --- S7,f �. ?-a•"�s�o• sZ� ,... E"L' -So,'o FG x So;Z't FG' Z 49 /oon ( f1' Disr 5E /D OO :+•,. o 80X /NV Cegc:N �• 49 4606 P, sE,PrrG 4g T .e 7AN.t $, �.' W�i s H/C-uD ;• i 4� Z ' "AG'E.2T/F/EO 'j�G OT pL.4�/ t� LOG.GT/ay Fib ---w .�'�---G'•. / t"�{ -_ . .. eErV TZ:7LV PROM 1 LE , ..C IQA,dl.4rsi .�E,2Fs�c� r CE.er,CY Tf/�4T THE.,moo �. :,SHoW�/ 31 Z $ S- �_yE.�Eov'.GOMfP�Ys W/l�/7i�E.S�1��•,c,/is��c ,B.exr�,e ' � Ti-14 ,2EGisr�.ecl..Ga�vo.St�,2Y�yo,P,S I TDW.s!of eYrcGc' �l.�s.� . G95 o us z 5=...8:�. � � T•f/!t P�.t /s �YoT-13ASEo o/v.�.v rs%sT.tz- d�EiYT.Sv,2�/EYQit/O T//E aGFS.� 14>0957 05 Commonwealth of Massachusetts Executhre Office of Environmental Affairs � � x Department of Environmental Protection o� ciEO T � wlnle�Frnor Trudy Coxe 199, David mrnie hs sk"w� � c0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A S t CERTIFICATION Property Address:XD00 Gyc�� C;Roo,i 6/'9/6'U/I�eAddress of Owner: Date of Inspection: //-9S (If different) (2e1-jv(P�,11� Name of Inspector:TO,&j ;r7' Company Name, Address and Telephone Number? ,./ /Q,/zy' ap ve CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: �3( 7 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 sew to the buyer, if applicable and the approving authoriq' INSPECTION SUMMARY: Check A, B, C, or D: A] S�YSTTEE PASSES: I have not found an information which Y htch indicates that the system violates any of the failure criteria as defined to 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. lrevieed 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(817)sse-1049 • Telephone(617)202-UN Z Printed an Recyekd Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ProperlyAddress: 1000 Ole)S)4?9e/ �PO(2 di Owner: EIC,090, �L ei'ljS f4e Q d Date of Inspecliom /G B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soli absorption system and is within 100 feet to a surface water supply ui tributary to a surface water supply. _ The svmen, 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 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 6/15/95) 2 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1600 Owner: 621eal7UI- Date of Inspection: /O 95- Dj SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or,more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a,tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 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 further information. i (revised 9/i5/9s) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /060 old Owner: e/E'QhQr 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. t""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. The system does not receive non-sanitary or industrial waste flow i-The site was inspected for signs of breakout. t'i All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. vThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b�, non-intrusive methods. 6---The facility ov:rcr land occupants, if differen! from ovvneO were provided with information on the proper maintenance of Sub. Surface Disposal System. frevie*d 8/15/9S) 4 y.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:I&W Qk Sr 3'e�o'2d, Coo/1-U'Ae Owner: eiAwl)of' QO/ Date of Inspection:&) FLOW CONDITIONS RESIDENTIAL- Design flow: •!-IVgallons Number of bedrooms: "Z. Number of current residents:-- Garbage grinder(yes or no):1l/0 Laundry connected to system)yes or no):-)�S Seasonal use (yes or no): O Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL: 1,4 Type of establishment: Design flow:__gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of inform ati n: / System pumped as pan of inspection: (yes or no).21ZO If yes, volume pumped: gallons Reason for pumping: TYPE OfWSTEM 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Ao7te ( Sewage odors detected when arriving at the site: (yes or no) fsevieed 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1000 01d S."a 1P AU QC)' C-0 Owner:'e/B2/10l' Date of Inspection: /0 SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: ✓concrete _metal _FRP —other(explain) Dimensions: 32 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3y /r Scum thickness: 7N Z � Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liqui level in relation to outlet invert, structural integrity evidence of leakage, etc.) f' Q OCr 62 G ,, In Q V, Vw- a" S � 11 foel— GREASE TRAP: /T (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of «ism in hotinm of outlet tee or baffle: ' Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Iravis�d B/15/95) 6 - J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /00() G�d Sy'��6(f. ¢�j OQC), Owner elLoglr e- A"Ov�-,S)zeF') Date.of Inspection: QS— TIGHT OR HOLDING TANK:!Y 4 (locate on site plan) Depth below grade: Material of construction: ,_concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design f1ow:-----_�_gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:,, (locate on site plan) - G Depth of liquid level above outlet invert: �.c'0/'�in� leue/ Comments: to if level and &stribu!ior, is a ua!, evidence of solids carryover, evidence leakage into or out of box etc.) �y`O J � PUMP CHAMBER:4a (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Itrevised 1/15/95) 7 inflow (cesspool,.must fie bumped as part of inspection) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM d) } INFORMATION (continue Property Address: /Ow old S�Jr. e�Gczd, 6,12 Owner. 08Q17C)I' ilr S 164-6j Date of Inspection: /p //serf- 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:' v leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (qote condition of soil, signs of hydrauli failure, level of ponding, condition of ve tation,etc.) Cif C CESSPOOLS: ,�— (locate on site p an) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:�/ (locate on si plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) frevised 8/15/95) B 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION (continued) Property Address: /Wo a13 ,-�9G: yf/Oac), oev -01�11& Owner: �i7Or Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' T F p� o DEPTH TO GROUNDWATER Depth to gmundwater.—LZ_feet method ofdeterminaQon or approximation: /�I;Tel /'� v (sevseea B/15/9s) 9 E= 208 D STAGE ROAD, CENTERVILLE 012 I //!/- /� Cal to nl&d. UPC 12543 IUA co �, HASTINGS,GIN TOWN OF BARNSTABLE LOCATION 1600 Q/ �G SEWAGE # VILLAGE Pal lei'cl,A ASSESSO MAPI&`LOOT io r AME&PHONE NO. SEPTIC TANK CAPACITY ,A 00 .QA LEACHING FACILITY: (type) _f�� J (size) NO.OF BEDROOMS BUILDER 0 O PERMITDA : COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f 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 f i 'of leaching fac ) �//i¢ Feet Furnished by, n�I�CcC'.+ �G�. Z7VC. it � f� �a a� �`�� ASSESSOR'S MAP NO. PARCEL f _ 116, L.9 C•AIT ION SA W A G E PE RMIT NO. V I L L A G E lisp', 000 $1 d INSTA LLER'S NAME i ADDRESS K . \A '�i U I L D E R OR OWNER P.. DATE PERMIT IS.SDED �z� �� DATE COMPLIANCE ISSUED �� r �• � a , `2 b' L' NwoL_'a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 000 �'f�tiw:.. ...........OF.��`�.' -'?. r..... ----------------------------------------- Appliration for Dhip vial Works Tmitrurtinn autif Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal System at: ..l 4 e... Q ..............r.i .✓...fs� ocation Address .--or Lot No. - 19?2 .5 .�r��.�c�crs�9.......•..--•------- "' �' .................................................... % ---• - • ••-...... •-- ? 7....... Owner Address Cll� �fv!Si rUf�`�G�^- �57�'wrG�G .__.........`�....-----•. - ---•-•-•................................. ...............•- ---------- - Installer Address Type of Building Size Lot_CZ...!Y-2---Sq. feet Dwelling—No. of Bedrooms..__.......................................Expansion Attic (ACJ Garbage Grinder ......_..... No. of persons............................ Showers — Cafeteria Other—Type of Building :��_ p � ( ) ( ) Q' Other fixtures ............................... .. W Design Flow.............. .._&'..._gallons per person per day. Total daily flow____.._............i .v......_......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 (-1 Dosing tank S ------------- h to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_.................... Q+' ----------------—---------------••----•-------.......--------•----•------------•••-----•--••---••.......................................................... 0 Description of Soil.........0.----• ...............LU,�in y...S_v � -----------........_...... .................... V ................•------...---...--------� ��----------��.L�-------Ss't��•�-� -------•------•-•--•-----•-•----•-••----•-...... ... .... -......`'�-•---- -----------------------------------------------------•-•------•-•----------......--•-•-------.... U Nature,of Repairs or Alterations—Answer when applicable.........................................................:..:.................................. -- -------- -----------Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL%, 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in oper tion untiLa Certificate of Compliance ha been issued by the board of health. T Signed r S y ---•--•- ---------- �u c c--•--••-•--•----• ..;.... ..............- Application Approved By............ �'� a Date Date Application Disapproved for the following reasons:-----•------•---------•-------•--------•----••-------........................................................ ...................................................-..............................................-_-.....---------------------------------------••-------------•---------------...------...----••..----- Date Permit No.................. — ...7...... Issued_....................................................... Date ��77- { <=:V 0� No.. ._-.L—.. `� Fps -............. ..:. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................•..............---•-- Appliratiun for Disposal Works Tonotrnrtion "prrutit Application is hereby made for a Permit to Construct (`-") or Repair ( ) an Individual Sewage Disposal System at: _........................ ......_. ................................. ..._.......•-•------••...-----._....----••• .....-•--••--•_.... _ Location-Address or Lot No. / Owner Address Installer Address UType of Building Size Lot.... 7....Sq. feet ►-� Dwelling—No. of Bedrooms.....'`.? ....................Expansion Attic Garbage Grinder aOther—Type of Building e��............ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures . = W Design Flow..•........... ........... ..gallons per person per day. Total daily flow...................-^'-� '.............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.............--..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by...`7% . � �G^� Date........................................�' S Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f;rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 -------------------------------•-------.... ----------------- ----------------------------- ---------------- .---------------------------------------- D Description of Soil.......... . e r S v/3� .................... x�• r� . ...... ....*--------------------------------------------- ...... .... ... ............................•---•---.....c:......-.V �:.... r��. ............� � ..... ...... --------------------------------------- ---•.--- •- --------------------------- --- ----- i . M. -------------•--------...----------•--- ----------•------------------------------•----------...-•••--•--•••--•••------•••-•-- V Nature of Repairs or Alterations—Answer when applicable.....................................•......................_.................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAITI.i 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation unti Certificate of Compliance has been issued by the board of health. Signed--` t ...........sue. `? A licat>on A roved B PP PP Y ........................................ Date Application Disapproved for the following reasons:. ---•------------•...............•-•-----...................-...---•--....--•---....-----------...-----•----••••---------...----------•••----••--••------•-••••--•-----•••-•--•--••-•-•••-•---•-•-•-•••--- . L — Date Permit No... - . 1----- Issued---------------------------- -------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................OF.... f.2 S/2 - C� ..................................................... Trrtif iratr of Toutplianu THIS IS Tq CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) b J/ Installer. at---------1l'•r-.... --------------f:)e Sid e-- '`' '= ��C ' has been installAd in accordance with the provisions of TITLF,-5 of The State Sanitary Code. as described in the application for Disposal Works Construction Permit No..........4= ' _..`.----7 dated............ .....�. .. .. `'C-... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S TISFACTORY. DATE.............•-.._• Inspector_... - .--... THE COMMONWEALTH OF 'MASSACHUSETTS BOARD OF HEALTH _ 7Gl7�r" OF L� ................................................................................ . Disposal Works Tonstrttrtion Prrutit il 5; /'?. Permission Is hereby granted / �� ......�G=- --------------•---•-----�=--------..................•.............................. to Construct (�_or Repair ( ) an Individual Sewage Disposal S item at No............ Gl � wif- Street as shown on the application for Disposal Works Construction Permit Dated.... . .......................... . . i...... DATE-------------••••..11I.C.e ........................................... Board of Healtha' FORM 1255 ,A. M. SULKIN, INC., BOSTON DaAtLY 'FLavl 1io x 3 s'33o G.P.V. �-�, .PT1C. TA le_ = 330 x IS'o f°o .�4 5 G.P• D. 7St LoT .�. 1 USE 1000 GAL TAKS1L 51OGWAU . ArZEA z IS'o s, F 1�5'o s.F 2 .S"; . . 37.57 Gm P. O �,•S go-Trc-m A9—eA So �s�F —_ o s.F. x 1 0 Sc� -G:P. o p t o So•'L 1 �QI /St To TA u OESIGQ s 42.�m G..P. 0. 7-T/AL DAILY FLOW = 33o G. P. D.` _V n PMCot,A iaN 1 P-AT t,rlN! � 1 o(t`IJESS �o� y oe PETER t09% # �' :��'•+ RICAARD� ;t � SULLIVAN v Dg' ` SSA } � o 2933 T IniT1 41 P¢oP K T 41 r- h 1yT ;✓{O ... /OIA ..��'� Doti _ 9/tb 8S r / I ./ so � t (aq_ 'L--12 f"I DAMES �v�- --- S7,f �. ?-a•"�s�o• sZ� ,... E"L' -So,'o FG x So;Z't FG' Z 49 /oon ( f1' Disr 5E /D OO :+•,. o 80X /NV Cegc:N �• 49 4606 P, sE,PrrG 4g T .e 7AN.t $, �.' W�i s H/C-uD ;• i 4� Z ' "AG'E.2T/F/EO 'j�G OT pL.4�/ t� LOG.GT/ay Fib ---w .�'�---G'•. / t"�{ -_ . .. eErV TZ:7LV PROM 1 LE , ..C IQA,dl.4rsi .�E,2Fs�c� r CE.er,CY Tf/�4T THE.,moo �. :,SHoW�/ 31 Z $ S- �_yE.�Eov'.GOMfP�Ys W/l�/7i�E.S�1��•,c,/is��c ,B.exr�,e ' � Ti-14 ,2EGisr�.ecl..Ga�vo.St�,2Y�yo,P,S I TDW.s!of eYrcGc' �l.�s.� . G95 o us z 5=...8:�. � � T•f/!t P�.t /s �YoT-13ASEo o/v.�.v rs%sT.tz- d�EiYT.Sv,2�/EYQit/O T//E aGFS.� 14>0957 05 Commonwealth of Massachusetts Executhre Office of Environmental Affairs � � x Department of Environmental Protection o� ciEO T � wlnle�Frnor Trudy Coxe 199, David mrnie hs sk"w� � c0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A S t CERTIFICATION Property Address:XD00 Gyc�� C;Roo,i 6/'9/6'U/I�eAddress of Owner: Date of Inspection: //-9S (If different) (2e1-jv(P�,11� Name of Inspector:TO,&j ;r7' Company Name, Address and Telephone Number? ,./ /Q,/zy' ap ve CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: �3( 7 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 sew to the buyer, if applicable and the approving authoriq' INSPECTION SUMMARY: Check A, B, C, or D: A] S�YSTTEE PASSES: I have not found an information which Y htch indicates that the system violates any of the failure criteria as defined to 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. lrevieed 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(817)sse-1049 • Telephone(617)202-UN Z Printed an Recyekd Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ProperlyAddress: 1000 Ole)S)4?9e/ �PO(2 di Owner: EIC,090, �L ei'ljS f4e Q d Date of Inspecliom /G B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soli absorption system and is within 100 feet to a surface water supply ui tributary to a surface water supply. _ The svmen, 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 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 6/15/95) 2 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1600 Owner: 621eal7UI- Date of Inspection: /O 95- Dj SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or,more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a,tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 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 further information. i (revised 9/i5/9s) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /060 old Owner: e/E'QhQr 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. t""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. The system does not receive non-sanitary or industrial waste flow i-The site was inspected for signs of breakout. t'i All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. vThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b�, non-intrusive methods. 6---The facility ov:rcr land occupants, if differen! from ovvneO were provided with information on the proper maintenance of Sub. Surface Disposal System. frevie*d 8/15/9S) 4 y.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:I&W Qk Sr 3'e�o'2d, Coo/1-U'Ae Owner: eiAwl)of' QO/ Date of Inspection:&) FLOW CONDITIONS RESIDENTIAL- Design flow: •!-IVgallons Number of bedrooms: "Z. Number of current residents:-- Garbage grinder(yes or no):1l/0 Laundry connected to system)yes or no):-)�S Seasonal use (yes or no): O Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL: 1,4 Type of establishment: Design flow:__gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of inform ati n: / System pumped as pan of inspection: (yes or no).21ZO If yes, volume pumped: gallons Reason for pumping: TYPE OfWSTEM 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Ao7te ( Sewage odors detected when arriving at the site: (yes or no) fsevieed 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1000 01d S."a 1P AU QC)' C-0 Owner:'e/B2/10l' Date of Inspection: /0 SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: ✓concrete _metal _FRP —other(explain) Dimensions: 32 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3y /r Scum thickness: 7N Z � Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liqui level in relation to outlet invert, structural integrity evidence of leakage, etc.) f' Q OCr 62 G ,, In Q V, Vw- a" S � 11 foel— GREASE TRAP: /T (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of «ism in hotinm of outlet tee or baffle: ' Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Iravis�d B/15/95) 6 - J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /00() G�d Sy'��6(f. ¢�j OQC), Owner elLoglr e- A"Ov�-,S)zeF') Date.of Inspection: QS— TIGHT OR HOLDING TANK:!Y 4 (locate on site plan) Depth below grade: Material of construction: ,_concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design f1ow:-----_�_gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:,, (locate on site plan) - G Depth of liquid level above outlet invert: �.c'0/'�in� leue/ Comments: to if level and &stribu!ior, is a ua!, evidence of solids carryover, evidence leakage into or out of box etc.) �y`O J � PUMP CHAMBER:4a (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Itrevised 1/15/95) 7 inflow (cesspool,.must fie bumped as part of inspection) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM d) } INFORMATION (continue Property Address: /Ow old S�Jr. e�Gczd, 6,12 Owner. 08Q17C)I' ilr S 164-6j Date of Inspection: /p //serf- 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:' v leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (qote condition of soil, signs of hydrauli failure, level of ponding, condition of ve tation,etc.) Cif C CESSPOOLS: ,�— (locate on site p an) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:�/ (locate on si plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) frevised 8/15/95) B 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION (continued) Property Address: /Wo a13 ,-�9G: yf/Oac), oev -01�11& Owner: �i7Or Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' T F p� o DEPTH TO GROUNDWATER Depth to gmundwater.—LZ_feet method ofdeterminaQon or approximation: /�I;Tel /'� v (sevseea B/15/9s) 9