HomeMy WebLinkAbout1015 OLD STAGE ROAD - Health 1015 Old Stage Rd. , Oentervil
A= 172. 161
Tneam
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UPC 17534
No.2 153 OR ,
KASTINOS.UN
i
YTOWNOF BARNSTABLE
:LOCATION /2 !r" (21z,Z a.= /7o SEWAGE # 97- 709
VILLAGE h ri_h) 4 ASSESSOR'S MAP &LOT /72 161
INSTALLER'S NAME&PHONE NO.' y77-03el9 Jose OW /7t /.3�yr•^sS
SEPTIC TANK CAPACITY /BD# G,vl
LEACHING FACILITY: (type) 2-S 00 4i4/ C i,�.s,Agio-s (size) 2,r X
NO.OF BEDROOMS 3
BUILDER OR OWNER doup/ r a,4rkFr
PERMTTDATE:./ / ' U7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching faccii ) Feet
Furnished by .Gg a `;.e e4iG40"
B
e � h
r w ,
r�
�� 12 ��
No. ,Y ,Fee,THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1/
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Rpprication for Oigpogar 6potem Congtruction Permit
Application for a Permit to Construct(-Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 10/,j (9/ 3-r,4j% a Owne 's,N �JAddress/V d Tel.No.
Assessor's Map/Parcel /
179 14-/ O
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer w en a plicable) %/ ' I i<z / r4 C
��64 r41o��
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been ' sued by this Board of Health.
Signed Date /Z
Application Approved by Date /2— /2—
Application Disapproved for the following reasons
Permit No. �' 09 Date Issued /2 —/Z — 7
No° 1 / ` ! Fee J U
` THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer: ✓
PUBLIC HEALTH DIVISION- TOWNYes
OF BARNSTABLE., MASSACHUSETTS
_j 50plication for Bigaaf *p!tem Congtruction Permit
Application/for a Permit to Construct( &<epair C Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /0 15' Q! sTM�N� Owne 's Name,,Address d Tel.No.
Assessor's Map/Parcel /
6r--n,'I'll,
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: "
Dwelling, No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures `
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil SNg �1
Nature of Repairs or Alterations(Answer wh n a pIicable)
� fl/s1�F�r cs/iTbi 4+' Sro�s,c !9i^vdH 2 /� '
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been i sued by this Bo d of Health.
Signed Date
Application Approved by Date7
Application Disapproved for the following reasons
Permit No. 7-7 O Date Issued 12 - / 7
/� THE COMMONWEALTH OF MASSACHUSETTS
17 a � BARNSTABLE, MASSACHUSETTS
QCertificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( Repaired( )Upgraded( )
Abandoned( )by ✓o e
at A0 L LQ Avow _.4 1 i,r ✓/$ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 7`7o 7 dated /Z"/Z' 9 7
Installer �ess/J�i l�,z I��,�rDS Designer ./os h /7� /3igr.►vS
The issuance of this pe t shall not be construed as a guarantee that the Sys ill fu c,'on designed.
Date 7 Z ' L3�:7 Inspector
———————————————————————————————————————
No.1 Fee SD'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwi5po5al *pgtem Construction Permit
Permission is hereby granted to Construct( vrRepair )Upgrade( )Abandon( )
System located at D/ !) Ti9
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.
Provided: Construction must be completed within three years of the date of this a it.
Date: / Z Z ( 7 Approved by Fe;,- t4•.
A
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
1, ,JO., �� j�� &A-0:y ; hereby certify that the application for disposal works
construction permit signed by me dated /2 /2--9/ ;concerning the
property located at 10 �� U�� 1T4- /m meets all of the
following criteria:
ieiere are no wetlands located within 100 feet of the proposed leaching facility
, There are no private wells within 150 feet of the proposed septic system
v There is no.increase in flow and/or change in use proposed
There are no variances requested or needed.
I'/ If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will wl be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) G4
B)Observed Groundwater Table Elevation(according to Health Division well map) -J.;�
SIGNED: DATE: - y�
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER N _
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
q:health folder:cert
ro�
0
TOWN OF BARNSTABLE
LQCATION 1Qlr l7/�� �r�aa�= /2d�cf SEWAGE # 97— 709
j VII I ACE ASSESSOR'S MAP & LOT /Z1 •- &,1
!' TALLER'S NAME.&PHONE NO.
INS
SEP I :TANK CAPACITY /aoo G pl
LEACHING FACII,TTY: (type). I-
MS
(i,o%.CLi,�r.��i'rs (size) 2 r X/
NOOF.BEDROOMS 3 i
BMDER OR OWNER C l Ou11 er 19orkt-cr
PE:.. --DATE: _/:� - -Z COMPLIANCE DATE:
Separation Distance Between the:
Max-mum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private;Water Supply Well and Leaching Facility (If any wells exist
:oa site:or within 200 feet of leaching facility) Feet
Edge:.of Wetland and Leaching Facility(If any wetlands exist
within 300 f et of leachi faci ' ) Feet
Furrii�,heti'by
G ��ry11S
I
.{
Town of Barnstable
Department of Health, Safety, and Environmental Services
STAB Public Health Division
EMM'� 367 Main Street, Hyannis MA 02601
�EDM�61
Office: 508-790-6265 Thomas A. McKean, RS, CHO
FAX: 508-790-6304 Director of Public Health
Mrs. Melissa Childs December 2, 1997
1015 Old Stage Rd.
Centerville, MA 02632
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 1015 Old Stage Road, Centerville was
inspected on November 10, 1997, by John Graci, a Massachusetts licensed septic
inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Soil absorption system was in hydraulic failure. The"pit has been full to the
cover."
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within(14) fourteen days of
receipt of this notice.
You are also directed to bring the septic system into compliance within thirty(30) days of
receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
s McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
• Department of Health, Safety, and Environmental Services
MM& Public Health Division
Eon" 367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO:
ro DATE:
AIA-
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
n dA- -a 7
The septic system owned by you located at Jol o� � �w s inspected Noy f°i on by 76k4
a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• 5a �:s► - �� G, �,,1��. �c Line. �, �� P'
o"
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of
receipt of this notice.
You are also directed to bring the septic system into compliance within thirty, (30) days of
receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health v
gv=im�riawuesi.a«
Commonwealth of Massachusetts
Executive Office of Envirolunental Affairs
Dept. of Environmental Protection
rad
One winter Street,Boston,Ma. 02108 John Septic
D.E.P. Title V c Inspector
kip P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD _ 17 Z , W (508)z564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor Ac �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ORT A
lC
CERTIFICATION �O1/ �®
Property Address: 1015 Old Stage Rd.Centerville Address of Owner: C TO o BggNs8 �99T �j
Date of Inspection: 1115197 (If different) y�FPIAze
Name of Inspector: John Graci Melissa Childs:Box 2175 Centerville
1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes This Inspection Is based on crlterla dented In Tttle V
_ COndlflOn I y saes code310CMR16303.wtindings are ofhowthesystemis
performing atthe time of the Inspection.My inspection does
_ Needs F th Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthelongevttyoftie
X Fails septic system end any of Its components useful life.
Inspector's Signature: Date: 1V10197
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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] SYSTEM PASSES:
_I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal, is 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 04n7197)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1015 Old Stage Rd.Centerville
Owner: Melissa Childs:Box 2175 Centerville
Date of Inspection:1115197
_ Sewaue backup or,breakout or high.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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 soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
x 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.
Yes No
x_ Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(reylsed 04127ST)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1015 Old Stage Rd.Centerville
Owner: Melissa Childs:Box 2175 Centerville
Date of Inspection:1115197
D]SYSTEM FAILS(continued)
Yes No
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
x Liquid depth in cesspool is less than 6"below invert or available volume is less than 12 day flow.
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
—x Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
x Any portion of a cesspool or privy is within a Zone 1 of a public well.
_x Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. 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:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
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 conditions exist:
Yes No
x the system is within 400 feet of a surface drinking water supply
x the system is within 200 feet of a tributary to a surface drinking water supply
_ x the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped 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.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 1015 old Stage Rd.Centerville
Owner: Melissa Childs:Box 2175 Centerville
Date of Inspection:1115f97
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_x_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
__ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System,have been located on the site.
x 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.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b)]
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1015 Old Stage Rd.Centerville
Owner: Melissa Childs:Box 2175 Centerville
Date of Inspection:1115197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 g•p•d./bedroom for S.A.S.
Number of bedrooms: 2
Number of current residents: 3
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(Iast two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: Me
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present:(yes or no) Ne
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings, if available: Na
Last date of occupancy: n1a
OTHER:(Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped In August
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: Na
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc. Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date Installed(if known)and source information:
1977
Sewage odors detected when arriving at the site:(yes or no) No
(revised 0427)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1015 Old Stage Rd.Centerville
Owner: Melissa Childs:Box 2175 Centerville
Date of Inspection:1115f97
SEPTIC TANK: x
(locate on site plan)
Depth below grade: e••
Material of construction:x concreate_metal_FRP_Polyethylene—other(explain)
If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Le•e"H5'7"W4'10"
Sludge depth:4"
Distance from top of sludge to bottom of outlet tee or baffle: 23"
Scum thickness:7"
Distance from top of scum to top of outlet tee or baffle:s"
Distance form bottom of scum to bottom of outlet tee or baffle: 11"
How dimensions were determined: Measured
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.)
Septic tank and ell components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: nra
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nla
Scum thickness:nia
Distance from top of scum to top of outlet tee or baffle:ria
Distance from bottom of scum to bottom of outlet tee or baffle: nia
Date of last pumping,
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.)
n/a
BUILDING SEWER:
(Locate on site plan)
.Depth below grade: 14•
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water.supply well or suction linetown
Diameter: 4"
Qmments: (conditions of joints,venting,evidence of leakage,etc.)
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1015 Old Stage Rd.Centerville
Owner: Melissa Childs:Box 2175 Centerville
Date of Inspection:111`5197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: r4a
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nra
Capacity: rda gallons
Design flow: rda gallons/day
Alarm level:_nla Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nla
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_ves
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
rda
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1015Old Stage Rd.Centerville
Owner: Melissa Childs:Box 2175 Centerville
Date of Inspection:1115197
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits,number: 1,000 gallon octagon[each pit
leaching chambers,number:We
leaching galleries, number: We
leaching trenches, number,length: rda
leaching fields,number,dimensions:rda
overflow cesspool,number:n1a
Alternate system: rda Name of Technology:_rda `
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
The leach pit le pant the effective depth of leeching.The sae Is In hydraulic fallure.Pit has been full to cover at time of Inspectlon itwas 112 full.
CESSPOOLS:
(locate on site plan)
Number and configuration: nla
Depth-top of liquid to inlet invert: rda
Depth of solids layer: Na
Depth of scum layer: We
Dimensions of cesspool: Na
Materials of construction: rda
Indication of groundwater: nia
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
rda
PRIVY:
(locate on site plan)
Materials of construction: nla Dimensions: Na
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
rda
(revised 04127)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
1015 Old Stage Rd.Centerville
Melissa Childs:Box 2175 Centerville
1115197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
A
Decic
04
G 5
Q� AA 7�
�c
114
(revised04)27ST) Page ! of 18
.` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
1015 Old Stage Rd.Centerville
Melissa Childs:Box 2175 Centerville
1115197
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
i
(revised0027197) sage 10 of IQ
LOCATION SEWAGE PERMIT NO.
.l o7 /06- 01-P
VILLAGE
I-NSTA LLER'S NAME & ADDRESS
R � Gar,�ii �?i� • sJJ�IRsorvs ��'«s•
t UKDE R OR OWNER
DATE PERMIT. ISSUED 47_ 7�
DAT E COMPLIANCE ISSUED
L
1
6-_
33� 33
.242�
uNo. � ... Fxs..... ...�............
TWE COMMONWEALTH OF MASSACHUSETTS
rlrsw.
BOAR® - F HEALTH .
......fit_.._.. OF........ ......:........ :.... _a-.=... �`...........-------....
ApplirFation for BhipaaFal Works Cnomitrurtwi n Errant
Application is hereby made for a Per it to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at• .o- 4/�.... -. s;0t_ V
....................................
• LocationwAddress 7-........ ................
6 T......... or�yI of No.
tR• ..... -. -.........................................
� '+`Ades
------------------------ -----------' � .... -dr....-s--------------------------------------------
Installer Addr
Building ess
U Type of lding Size Lot___ 0° .....Sq. feet
Dwelling—No. of Bedrooms___--- ................................Expansion Attic ( ) Garbage Grinder (,oV)`o
`4 Other—T e of Building No. of persons............................ Showers
a YP g --•------------------------- P ( )--- Cafeteria ( )
Other fixtures .
w Design Flow.....���.:'"��. _` _________________gallons per person per day. Total daily flow..... _ ........................gallons.
WSeptic Tank—Liquid capacit ..P.gallons Length................ Width................ Diameter................ Depth................
xDisposal Trench—No..................... Wi th.........._.._...... Total Length..............:..... Total leaching area....................sq. ft.
Seepage Pit No.....rodm.. Diameter.. .. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (-k) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 .----------•.... ---•-•--------------------•---------•----•------'--- -----••--....------..................................................................
0 Description of Soil...........................
x �........_.
c.� ---------•-----------------------•••------------. - -------•--- -'---------......---•------•----•----...-----••-•-----------••-------------••---'------------
w
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------• --•-'--------------'•--•-----------•-----•-••-•-------......---------.---------•--...-----•----------••---------------•------------•--------------•--...-------'----.......-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLE 5 of the State Sanitary Code— The undersign d further agrees not to place the system in
operation until a Certificate of Compliance has been�issu�ed by thetboard o health.
Signed. Al. ................. ...................
.•-•-
ll Date
Application Approved By------•--•- - ft---------------------------- ------ •-----....--•------------------.-----
Date
Application Disapproved for the ollowing reasons-------------•-------•-••-•----------'--•----•---------'-------•-------------•---------...--------------•----
....................................................................................................................................................................... ..................................
Date
Permit No.---..... ............................... Issued....--. 7
Date
«No...... ............... Fizs...... ._ ......
• r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t -4...............OF...... r. ",:r_ _.._... ......._................_
Appliration f nr Ili4pn, i al Works Tnnitrnrtion Prrutit
Application•is hereby made for a Perrmit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at: >1
Locatwn Address or Lot No
/�
............ ._... ..a S`:.:�.^' ..ai°:A:............................. .N rF't
................. ............ .4r. ....... a. ..............._.............._._._..._.._._
�•"® ner T Add`r"ess
:g �ifi�'e! ....................... ......
a
{ Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ................ No. of ersons____.______________.__._._._ Showers
a YP g ------------ ---••--•----.P ( ) — Cafeteria ( )
� Other fixtures
w Design Flow_____ ' '' .._11..............gallons per person per day. Total daily flow____`'1 `
.......... .............
WSeptic Tank—Laqu>d capacit; _ _ .gallons Length................ Width................ Diameter........________. Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.... . ' s_. Diameter.__ ; :.' _ Depth below inlet____________________ Total leaching area..................sq. ft.
Z Other Distribution box ( Dosing tank ( )
aPercolation Test Results Performed by................................................................. Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a
O Description of Soil............................•. { -f •--. 7 .................••--•-
c ---------------------------------------------------------•......------.---------•--••-•--••--•---------------•---••-----•---.....•._...._......-----•------•-•-•••.
w
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
..-•--------------•-----------•----••------•--------•-•------•-•----------•----•---•-----------......_._.._.....••--•------•..._...----••-------•------....• ...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:i:LL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i'"s ed by therboard ofhhealth`
Signed ": .._...........
Date
ApplicationApproved By.............. .j -•-•---•-••--------•••--•----.._..-•-----------------------•-•--•------- ........................................
Date
Application Disapproved for the fol owing reasons:................................................................................................................
--------•--------------------•-------••-•-----------------•-•---------------•-•------------••----_..._..........._....---•-•-•-•--•---•-------•.....•••-•-•--------•----------••---------•-•--------•----
Date
Permit No.......... -iV- •-----•--------•-------------. Issued...... el. ...
Date
�LL ,
c
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J.
...............................
•( M1
Trrtifiratr of Tuntplianrr :z
THIS IS TO CERT�FY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.......................Ot4, EE.f.•----....A-A4✓ �Ph_._._.......--------------------------------------..........
Irtaller
at.................l�/-•---•--..(IA-•----._.�.�'�y�!�._.. �G �---•------__`�����=��.... .� --------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit.�'.o.__, ___7 !'!,,t�____________________ dated-__.._--___ V__.,q-_27___.__.________.
THE ISSUANCE OF THIS"CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....' ` ................................... Inspector..._ -
--- -------------------------•--•--•-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF`:HEALTH
�1...........................................OF......... �U1rhl
No............... ....... FEE........................ .
Disposal nrki5 Tnrnitrnrtivat rrntit
Permission is hereby granted................. �!!f ._...._f �G� .___________._
..............................................................
to Construct ( tf) or Repair ( ) an Individual Sewage Disposal System
at No. /---------- '�,ti{`.-•-��?_'I -- ,!'�e r` AP&L""
._..__ ._. .. ---•--•.
Street
as shown on the application for Disposal Works Constructio .,nu Dated.._......................................
.,,.�.
41
1 Board of He t
DACE....../../...... ---------•----
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