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HomeMy WebLinkAbout0065 OXNER ROAD - Health 65 Omer Road Centerville P 193 126 ��� � /J J�gECYCtFp�o UPC 12543 No. 3LOR - - co HASTINGS,MN E V C \ a TOWN OF BARNSTABLE LOCATION L015 XN V(L SEWAGE # VILLAGE C&t+� (LV ��'�—� nn ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. 6 ✓ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER &C;,-Q$= S c� PERMITDATE: 9 If 4 7 COMPLIANCE DATE: / I � 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 facility) Feet Furnished by fir" �ij�..� � �Grr�" E� � t _ _ _ � ( o . .. ` U/jj No. � `��,� Fee S THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: c Yess PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Migaar *pztem Cougtruction Permit Application for a Permit to Construct( )Repair(Nfupgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /'_ Q�(/��e Owner's Name,Address and Tel.No. Assessor'sMap/Parcel 1 FJ Installer's Name,Address,and Tel.No. S Designer's Name,Address and Tel.No. �1-a5 b a S 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 33 L gallons per day. Calculated daily flow War 41 gallons. Plan Date Number of sheets j Revision Date Title v Size of Septic Tank 1-50 Type of S.A.S. Description of Soil N,gture of Repa`irs or Alterations(Answer when pplicable) S ` \ 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 nvironmental Coo and not to place the system in operation until a Certifi- cate of Compliance has been iss S ne Date Application Approved by 1 Date 19 Application Disapproved for the following reasons Date Issued Fee -' ` " '' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETT& 0(ppli ation for ig ogar *raem ton truction Permit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address,or Lot No. O r Je cxr�(�,a8 Owner's Name,Address and Tel.No. Assessor's Map/Parcel2h�C��v l` Yl 1 C 2-. N avt1�,-�-a�. 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 330 gallons per day. Calculated daily flow yS gallons. Plan Date Number of sheets I Revision Date Title Size of Septic Tank l 56 0- Type of S.A.S. &wo �T Zr'Z hc\n Description of Soil N turef Pep or Alterations(Answer when pplcable) - Gt�` CX� 1 l b►'\ S C- i Date last inspected: Agreement: a 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 nvironmental Co and not to place the system in operation until a Certifi- cate �* cate of Compliance has been iss y4 , ne Date `� Application Approved by Date A/ " Application Disapproved for the following reasons Permit No. Date Issued -------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (tertfficate of (Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( ) Repaired( )Upgraded Abandoned( )by d� -e>C -C, e(�S at CCIIJ _e__L has been constructe_d to accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 7 5/�_�dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Gl 1 f Gl n Inspector ti ------------------------ ------------- k No. 7 e/ Fee 0 THE COMMONWEALTH OF MASSACHUSETTS i� PUBLIC-HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS t 30igpont 6p.5tem (Con9truction Permit Permission is hereby granted to Construct'( )Repair( v<Up rade( )Abando ( ) System located at 6� S C)X V C � V' ,c)� 2kJ i ��'�— 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 permit. Date: 9— // /9 Approved by l i NOTICE: This Form is to he I'M fol• the Repair of mailed • • � " Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FQR A DISPOSAIL 1VOIZKS CONS7'RUGHON PE RN1111"OV1'1'II V1' DESIGNED I N_1 hereby certify that the.application for disposal works construction permit signed by me dated "t —��s�� , concerning the located at �.� S U?CIV� L�--TQ-4 mks all of the property i! following criteria: i • There are no wetlands within 300 feet of the proposed septic system • There arc no private was within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the ItAching facility ein use proposed There is no Incr ease in now and/or Chang p Posod • There are no variances requested or needed. SIGNED: DATE: ~� r LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN vr'itAPcivS i i,ELc`i:t�'i�' 'c"R IAltach a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan, this plan should be submitted). t t � ' J TOWN OF BARNSTABLE LOCATION_ D)CN E Quo AQ SEWAGE # 7-r 49 VILLAGE_ C toY�T�(LV���� ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO.Q�� ��d�o.• -s SEPTIC TANK CAPACITY LEACIMG FACILITY: (type) (size) ' NO.OF BEDROOMS 3 BUILDER OR OWNER �iy1LP� h/ow�h� PERMITDATE:— OMPLIANCE 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 facility) Feet Furnished by 0 jCATION SEWAGE PERMIT NO. I L L A G E -v I N S T A L L E R ,S NAME i ADDRESSkq / B UILDE R OR O NER I$DATE PERMIT ISSUED n 9 IODATE COMPLIANCE ISSUED . ` / �t 3S' 4 b � ��" C1 .0 ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD ' OF HEALTH ...................... ....................O F......................................................................................... Appliration for Uhipniittl Marks Tonstrurtion Vrrufit Application •s hereby made fora&Prmi to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a ...... .. ..... ..... . . . ...................................... -•---•........•---••........••---.._..--••---••-•••--•-••••-----....•••-••-•-•••-•••-••-••-•-•-_.. tion- dress or Lot No. .... .... ...................................... -.._...-•--•••--••--...-•-----••-•--•••--••....----........_..._._••••_...............-........... Ow er Address W Installer Address Type of Building a Size Lot...................... ................... .....S feet U Dwelling—No. of Bedrooms.__..___.c.�___._._..-..........:..........Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) QOtheL fixtures ....._.__..-•------------------------------•--•----......._..__....._..._..._.__..__._._.._---......_.....----------......._.......................---• W Design Flow.•�_.. _v� ________________________gallons per person per day. Total it ow__._._....___ /_. _. ....._._.. Ions. WSeptic Tank—Liquid capaci�e,10 s�••gallons Length................ Width___ Diameter..f,�__________ Depth--- --••--.- x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........../------ Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date______.....__------- .._.---------------- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ----------- ----------------------- •....... -........................................................................................................ ODescription of Soil........................................................................................................................................................................ U ------------------....................................................................................................................................................................................... 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 TITLE 5 of the State Sanitary Code— The undersigned f rther agrees not to place the system in operation until a Certificate of Compliance has ee d by t e gne - • .......................... ........................... ....................... .... .._....... .... • Application Approved '-------............ -------------- ..... -------- ____•-•......__.... �1 p- Date Application Disapprove r following r ..... -••••••....__••-------------•_•••••-•••••--•-••••---••--•-•••---.......--•-•••-..:•-•---•-....•-••--•••••••••-•--•----•_-•-•-••-•---------.._---•----•••••--•-•-•••••--- •_---.••------••••-••-•_-••-- Date PermitNo......................................................... Issued_........................................................ Date No�. .... Fxs......��............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................... ..............OF......................................... Appliratinn for UiiipuiiFal Warkii Tomitrur#inn 1hrmit Application is hereby made for a Permi to Construct ( ) or Repair ( ) an Individual Sewage Disposal System �� - -----------------------------•----•--•------------••--•--- f� ! L ation dress or Lot No. �.............._.... ....ram Ow Address W ................ ....................... .............•----•-----........•....-----........................................................ Installer Address d Type of Building Size Lot............................S fe V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinde rvlp aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Othe fi tures Design Flow..2......... ............... - r : ...._.__._ ------ ...........�.........__. gallons per person per day. Total ai flow............. ---------0 ..._ lons. Septic Tank—Liquid ca acitv/l gallons Length................ Width- �y-..__ Diameter._� _._.D ------..W x Disposal Trench—No. .................... ��idth.................... 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 ( ) aPercolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........:.............. . Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------------------------------------------------------•----------.................----•......................................................... 0 Description of Soil........................................................................................................................................................................ x U ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•----------------- 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 TITU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ei issued by the beard_cof=health. Ign ............... 35��.......Application Approved lrt� =- !!_ .•......... Application Disapprove - or following'reasons:.......................................................................................... --------------------•-•-----------•------•------------••---•----•--------...------------........----••--•--------------•---------------------•-------------•--- ...----------.....---.... Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (Irrtifirate of Tuutph anrr THI Is/-9, 11'CERTIFY, That the Individual .ewage Disposal System constructed (paired ( ) �eby.........' D.........; . ....... _..._.. ..__Installer ..........................•---.....__.__._.__.........._.___........................_.._...._ has been installed in accordance with the provisions of TkTI,B 5 of The State Sanitary Cod -as escribed in the application for Disposal Works Construction Permit ............. dated_ jf!.� THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRJVED AS A GUARANTEE THAT THE SYSTEM WIL� F"CTION SATISFACTORY. DATE.........1.IZG 1....... ....... Inspector... .........................•---.......-•---...........•.........•...-------•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH K J le' ...........................................O F....................... ........................................ d ............. ......... No..�:...rf�........... FEE............................ �tu�ru 1 ku �nnu#ritr�inn �rruti� -hereby granted------ •---------------------------•-------•----•-•------......•--•-..............•-•-•- Permission i rtr to Construct (_( foor'lRepair . ,) an In�jvad ial Sewage Disposal System atNo....-/-- L._ ...............................Street---.........-;;P -------•-------------------•------_-------•--............. as shown on the applicati or Disposal Works Construction Permit -'.... ._..._. Dated.......................................... ....... ..-• • ----•----•-•--•-•••--._...-••••••••--------•----.....••••-••-•-•.............••...... Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON SHEET OF 2 T l /X? �� e �S3 - ?�'oFF�,u ZOi 47S 0 z _ O 48.4 LoT 40 ELLEY a 773T 1 Gh G/STt�`/�(/�/Q. SV -------------- SEWAGE DESIGN- - PLAN LOCATIONt DATE ���/ • . . PLAN REFERENCE .ZT.�. . . . .._ . .... . . . . CIVIL ENGINEER ol PETITiONE � � _ �`����\k oFM A 02 TH M tiG l (" •. THOMAS E.KELLEY CO. o EY ' .lj�/, ,r�?.{41!.. .,�.s�1�.�-•'• - ENGINEERS—SURVEYORS a v, o.24 "G LONG POND DRIVE G15TEQ� 4�� f lay: gotTIU 3rA3PLA'IOLn MAD.4. �F`tS/ONALEa�`� SHEET- Z OF Z- SHEETS TOP OF FO NDATION , . CONCRETE COVER ° CONCRETE COVERS • t •-, �nr �mnr✓Ir - e 4' CAST IRON 12"MAX, 12"MAX. .77m • 4 OR SCHEDULE 0 • 4"SCHEDULE 40 P.V.C.(ONLY) P.V.C.. PIPE PIPE MINIMUM I LEACH ' PITCH 1/4'PER. PITCH 1/4"PER.FT. PIT CIRCULAR PRECAST," :J - LEACHING �IN �g T a ` o ELfx•.9.¢... INVER INVERT o . e:� PIT . SEPTIC -TANK zz DIST. EL.. % .2 BOX EL58e,2 . A�>= o INVERTT ��40 GAL. INVERT `r o' EL. ,.IQ.�.. INVERT ;•' ww %:�. 3/4'�TO I1/2 EL�t8,42 EL , �`� WASHED v e w STONE .t' .' 10, MINIMUM ---4 --WDIA. —*i �— NO 20` MINIMUM — ° PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE fo �66 OIL LOG/�� WITNESSED BY : DATE . 1 . . .... TIME.2,:3p . Ti,�v�'�. BOARD OF HEALTH f/A/BJ TEST HOLE I TEST HOLE 2 T ,�. E�, �ENGINEER ELEV.-&,.?,. . . . . ELEV. Q a g.S�yG DESIGN DATA ' t S. a oK NUMBER OF BEDROOMS . . . . . . I �t U TOTAL ESTIMATED FLOW � .//. GALLONS/DAY. wepf4me) BOTTOM LEACHING AREA /�'/Y". SO.FT. /PIT 7Z•t PJI�V16L /44 SIDE LEACHING AREA . .�T�.�t St?fF? SQ.FT/ PIT " / GARBAGE DISPOSAL.. .". . .(50% AREA INCREASE) TOTAL—LEACHING- AREA-Go4)4 - . SQ.FT PERCOLATION-RATE . •. . . A? MIN/INCH !4�Q.WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATF3�R4 SQ.FT. NUMBER OF LEACHING PITS APPROVED . . . . . . BOARD OF HEALTH DATE. AGENT OR INSPECTOR , p1&4 CIVIL ENGINEER OF PETITIONERTH THOWS E. KELLEY .24260 r ENGINEER— SURVEYOR p E`G1S7Six� � /•r(44-� /�%% 3" LONG POND DRIVE �fsS/ONALE�G\� �rSOUTH YARMOUTH, MASS. . . . . . . . 02664' SHEET. OF i 47 3 47S Togo<Fir�y 410 .EL=So.O ,95w Ep� f � t 48.4 ,LOT ¢o SN OF � o KELLEY Bo.00 su� SEWAGE DESIGN PLAN LOCATION ",, SCAL.E,I . .:. .-t . DATE . ������• . . -PLAN REFERENCE 10 . . .. . .... 0.58.� il� sj_ CIVIL ENGINEER PETITIONE TH . ...� ����r�••.a / '' � TFiOMAS E.KELLEY CO. ..4% �fY . .�S �7.s-/• SNOINEERS—SURVEYORS 4260 D S4f LONG POND DRIVE sotym XARMOLTiN.M.AM SHEET Z OF Z• SHEETS 1 TOP OF FO 4DATION CONCRETE COVER °• CONCRETE COVERS �4CA IRON 12"MAX, 12"MAX.DULE 40 4°SCHEDULE 40 P.V.C.(ONLY) P.V.C.. PIPE PIPE- MINIMUM LEACH CIRCULAR � PITCH 1/4"PER. PITCH 1/4 PER.FT. PIT PRECAST ' LEACHING —INY�BT co ° Q :... o EL. 9Q... INVERI INVERT w PIT . o'. SEPTIC TANK EL.. �3. 2 DIST. EL, Z . >x :•: INVERT BOX ` ' o� EL . IQ.�. �D.O.O.. .. GAL. INVERT INVERT '' wa Q �'�. 3/4TOII/2 ;. WASHED ELF w STONE Ao .' Id MINIMUM W DIA. - q T NO 20 MINIMUM +_ PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE OIL LOG WITNESSED BY '. DATE . • TIME.�t 1 �A ��. �/ '.� I• BOARD OF HEALTH TEST HOLE I TEST HOLE 2 ��,1//� E��.� f'ENGINEER ELEV. ELEV.�1�•.Q . . . . . !`7�/7•.�IJLLr���. . . . . .E���j�T/� DESIGN DATA : aoK NUMBER OF BEDROOMS' . �F I TOTALESTIMATED� FLAW . . . . . . . . GALLONS/DAY / Le"A /Yf , BOTTOM LEACHING AREA .74!pl SO.FT. /PIT SvBSatL " 72'' lu 6,e.9v�L SIDE LEACHING AREA . .145t SPfP SQ.FT/ PIT GARBAGE DISPOSAL . .". . .(50% AREA INCREASE) TOTAL LEACHING AREA ( SQ.FT PERCOLATION RATE . •. . . .� MIN/INCH LEACHING AREA PER PERCOLATION RATOZIROSQ.FT. MO.WATER ENCOUNTERED f�rI/', NUMBER OF LEACHING PITS .014. ./. APPROVED . . . . . . . . . BOARD OF HEALTH : 1A. . DATE. . . . . . . . . . . . . . . . L-d T�-�-®,� AGENT OR INSPECTOR �� CIVIL ENGINEER �H OF PETITIONER TH as G THOMAS E. KELLEY 242bo ENGINEER—. SURVEYOR p�GIS546 LONG POND T�P����� VE SOUTHOYARMOUT RI H MASS. ASS/ONA1.�v . . . . �f�P.WsIG.. . . . . . . . . 02664 4' t COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i� SveJ RECEIVE® SEP 1 5. 2004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM FORM PART A CERTIFICATION A `9 3 j Property Address: I 'ARCEL, I Z Alp k1r.. l-- oT 40 Owner's Name: Owner's Address: Date of Inspection: Name of Inspector: (please printpp1glas A.Brown Company Name: I)ounlas A n Septic Inspections Mailing Address: p0 R.x 145 CentervilleTelephone Number: A 02632 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 mainienancg of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Ce Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority- Notes and Comments **.**This report only describes conditions.at the time of inspection and under the conditions of use at that . time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/3000 page I -d 413t 2m) Qa� Page 2 of 11 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �&k V Owner's Name: 3'0e No«9j j�o Owner's Address% Date of Inspection:-9-a'T—O LI Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: one or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or.not determined(Y,N,ND)in 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 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 I— Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: © e V L 11i Owner's Name: ZT i,N Owner's Address:_. le Date of Inspection: -LLI C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment, 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is five 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: r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �C �cPf D o tE' ct Owner's Name:_ C» /VctJya+ Owner's Address: Date of Inspection: -*-Z -p L/ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool I bischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or spool ✓Liquid depth in cesspool is less than 6"below invert or available volume is less than%i day flow ✓hequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped c/ y 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. Any portion of a cesspool or privy is within 50 feet of a private water supply well. /Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less•than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X/d (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to.each of the following: (The following criteria•apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR Page 5 of l 1 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ►O Owner: J Date of Inspection: LPOL-7- 14 Check if the following have been done.You must indicate`yes or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Y Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ! H- ve 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, tfie 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: Ye✓ 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 Cv1R 15302(3)(b)] 5 . Page 6 of I1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:—C, �d A C� S Owner's Name: Owner's Address: P Date of Inspection;�•- ti RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): t� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd-x#of bedrooms) LJ yo Number of current residents: _ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):�[if yes separate inspection Laundry system inspected(yes or no): A)* required] Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(gpd)): N — g I,000 Sump pump(yes or no): Last date of occupancy:_C&2{Cj} COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow,(based on 310 CMR 15203): gpd Basis of design flow(seats/persous/sgft,etc.): Grease trap present(yes or.no):— Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPIE�RF SYSTEM eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —Privy ____Shared system(yes or no)(if yes,attach previous inspection records,if any) T lnnovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from.system owner) —Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes o 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:. rW A)e< Owner's Name: Owner's Address: Sar�.� Date of Inspection: - r-C7 - BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: 1/ _r Material of construction:�`eoncrete_metal fiberglass___polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):-(attach a copy of certificate)Dimensions: I OC* C,C 16-i Sludge depth: /2/ Distance from top of sludge to bottom of outlet tee or baffle: a G Scum thickness:_22 Ge Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of o tlet tee or baffle: How were dimensions determined: R140 .p Comments(on pumping recommendations,inlet and outlet tee or baffi6 condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _ 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 outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: . Comments(on pumping recommendations,inlet and outlet tee_ or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 5- Owner's Name: Owner's � Address: A F> Date of Inspection:s—d`7__D1/ 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: aaLlons 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 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leaka a into or out of box,etc.): PUMP CHAMBER: O` (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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / Owner's Name: Ovar./ Owner's Address: �--�- Date of inspection: �=(�� SOIL ABSORPTION SYSTEM(SAS):_pocate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: aching trenches,number,length: > aD x y X 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.). c l 60 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 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner's Name: )Foe ✓l�vd�,/�f Owner's Address:_ ga,r. •e Date of Inspection: -.;I 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. BL-I n 4 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:-Jr-,5 OX Owner's Name: Owner's Address: Date of Inspection: SITE EXAM Slope:. +o bCAC� y014-0 Surface water:. Check cellar:JD f%j Shallow wells &3Cn�,,9P Estimated depth to groundwater jot-feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Norm Aoc�,er Ao sor b,,v- (CPAD O"XD c,wve.f- c�Co�Ferc� 9 0 43 � �u� a.�z{- A Page 10 of 11 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _e /v i & Owner's Name:_ 70.e /t,�J y�(f�,�✓ Owner's Address:_ 50-. r Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or ! Benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. /)w��D .5� C;E N"CE R V I I tIlA.L.E.3 FTFEE: DEF"ART110,41' Id-J.-FASE STREEI-T ADDIRES,,Sl CIF IRE L F-E �2-' VT1 L(11,G,E,I., DATE: TIME'. C)F/ ICI LEA�Sft--': .......... DATE & TIME C"IF F . D F FS T I W "Y PROMA, RELUA SED ES T E D CRJANT T C 0 F�*,R.E C-I*I V E ("i C",11-1,Q 11 1:F' A Y ...... N CYT I F I*'C'A T I D N t%f(.'-!Tr0l',JAL RESPONSI-."' CENTE'R F.,/I Y E S 1'--,ID E J D C Q. I Y[--o F "I r4o 1-�A'r E- T I ME.J.-r 1'.1 Sp I I L C'0--QRDTNA*F[-IR F./.1 NO BIG(-IlRT'll 01C HECit."H-4 ["A leF.S I I NCI DAT T I I'l v� F1 A 0 R MAISITIR F I 'YE L NO A T E T I M Fl.� 1000-1 C)THER Akk* G ............ ............ C- --t...........t.rv% ........ ........... ------- ...... f.C3 ar Co t�lu-,�,.,U- P--A-Z..txTz:,) 6,cxr o�a I ..,.............. ........ -------- REPORT Dy- I-41HITE CORY FIRE DEPARTMENT W DECE P11,411" Kh' HEALTH C11-0-MIll FORM # S 8 PIV \J cis o �