HomeMy WebLinkAbout0051 PARK AVENUE - Health E= 2
AVENUE, CENTERVILLE
12
N
UPC 12543
Mo; 53LO
HASTINGS, MN
No.... _V Fitim Zo.
THE COMMONWEALTH OF MASSACHUSETTS
APPROVED BOARD OF HEALTH
��� TOWN OF BARNSTABLE
Xpprtr—amft for Diripwial Wurk.6 C onfitrurtilvn Permit
Application is hereby made for a Permit to Construct ( ) or Repair l4 an Individual Sewage Disposal
System at:
,57 , ,'5VW AIZ.'V 06 �2vtux 7 4-
Location- Address or Lot No.
J ----------------------sr7 ��� ....................
O rncr dre s U/J n
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms._._.__..___..�' ____________________Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures .... .......................... . .
W Design Flow................
............................ per person per day. Total daily flow................. ......... ...............gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter---------------- Depth................
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No____________ _______ Diameter____.___._...___.._. Depth below inlet.................._. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
`~ Percolation Test Results Performed by..................................:....................................... Date.......................................
aTest Pit No. I................minutes per inch Depth of Test Pit.____._..____.______ Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -----------------------------------••---•--•---------------•-------•-•--•-•-•-•--•-----•-•----...............---------------•----------........---.......__..
0 Description of Soil........................................................................................................................................................................
x
....---•------------------------------•--------•---------------•------------.._....-----------------•------------------------------------------------....----------...._........-..--------......_------
w
UNature of Repairs or Alterations—Answer when applicable._.. .............. .............�..... _ ......................
X�..............
��-----lN�-= L ....7...................... --_ .........i:------.L . ...................
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has
�bbe/is,
d byt
oard health.
Signed ....................... ----------- --------------------
ApplicationApproved By ........t .. .c..�.�.,,,.� ----- -------------------- .................................................... --------..
J Dace
Application Disapproved for the following reasons: . ....... . ........................................................................................................
...................... ....................................................................................................................................................................................... ..................................:.....
Dace
PermitNo. ....... ...3..-.f�. .. ..................... Issued ....................................................................
Dare
r -
TOWN OF BARNSTABLE -�
LOCATION SI SEWAGE # S3- 3
-VILLAGE ASSESSOR'S MAP & LOTS=d/�
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY / '
LEACHING FACILITY:(type) /U' LT ,`VcA4 V (size)
NO. OF BEDROOMS J PRIVATE WELL O nRIiC WA� Tim?
BUILDER OR OWNER -�
DATE PERMIT ISSUED: f 7/�
(p 3
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No i
Rey. 3,2
r�
TOWN OF BARNS TABLE
LO'ATION ` GLC�C. SEWAGE #
VILLAGE �✓{���� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY !
LEACHING FACILITY: (type) —� asize)
NO.OF BEDROOMS e�,
BUILDER OR OWNERL lS�
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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) < 6 Feet
Furnished by J 0\-\" &qc
��Y j • F ~ _
eA
o �ac
-f TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE p` l ASSESSOR'S MAP LOT O/02
c1YSl�EGTG/'P S
NAME PHONE
SEPTIC TANK CAPACITY/000 !
LEACHING FACILITY:(type)NO. OF OF BEDROOMS 3 PRIVATE WEL OCR WATER
BUILDER OR OWN�fUti./<C- SK4'e�2Z--
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED- Yes No
(�
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0
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THE COMMONWEALTH OF MASSACHUSETTS v
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Cgonyliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� )
"
by .............................................................. 7!7SCJCTi1-.Ai............................................ ...........at ............................................ �...........�� � �-.. .V44 U�_............C.�.�
......... ......... . ... . . ................
has been installed in accordance with the provisions of TITI,E 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .._ .-... _�..�-_._.. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE , j
SYSTEM WILL FUNCTION SATISFACTORY.
i;y C�
DATE.........................
.. ............. - _........ Inspector :: � �' ' > ----- • t --
f
THE COMMONWEALTH OF MASSACHUSETTS _
BOARD OF HEALTHfl
�3 2a TOWN OF BARNSTABLE ._
No.........::........... FEE.........--•----........
Uispaual Works Tunotrudinn VarA t
Permission is hereby granted.............. G?_��...... ......... ----- ------
to Construct ( ) or Repair ( .�)_an Individual Sewage Disposal System
at No........................................................ ... ••----i/i �c/::_.. '1�/c'.�C. C �^37 /�IJ)I I
Works
Street �� 7
as shown on the application for Disposal Construction Permit No... _�_-___.,.� Dated............................... .......
eBoard of Health
DATE.................---�..�.-.�.-:3 (../
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
f
t
.............
THE COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH c,-)oE= OI,�-
TOWN OF BARNSTABLE
Appliratinn for Uiripnial World. Tontitrnrtiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair ('14) an Individual Sewage Disposal
System at:
..............................•-•-•-- ---•-----• --•---------•-•-•--••-......._..._..._... ------------_...! ..._..L... ...... .......................................
Location-Address // f 1 or Lot No. �7 I
......r.. - ........................ ��,,C.- /'.` ./e�1 V`. .cam :�r!._�...� �1.` .................
Owner L° Address
...................................................� "<Cuc�7J_......_7f� `� �-�--- t� 2C�.._..../01m �L�S
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( j
a Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) Cafeteria
Other fixtures .
W 1 Design Flow.................�5___5...............gallons per person per day. Total daily flow................ ...._..........gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width...........--... Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------- - -------- Diameter......----_------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
t�
ODescription of Soil........................................................................................................................................................................
U
W
U Nature of Repairs or Alterations—Answer when applicable. /�ti J-' !! __.Z,90,D..C,.A....... .�?.7..C..-:T-?�!!!C
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been)iss d by the board
d000ff-health.
Signed .... - - ..--v!--..J :...........................ram_.. —
te
., .. ..-�., ,,,. _ .........................v.................Application Approved By ........
h_�s. ..-. I
..... .P.. .
te
Application Disapproved for the following reasons: .... ...............................................................................................................................
...................................................................................... .......::............... ..................................................................................... ........................................
I Date
PermitNo. ....... ..................... Issued ....................................................................
Date
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 John Septic
D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt,Governor 4 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART A Pre,r VEQ
M ^• nn �( ;vO,,
Property Address: 51 PARK AV.CENTERVILLE 4 ' `�"� a� " Address of Owner: T 4 1g98
Date of Inspection: 11/17/98 ®�� (If different) 04wOFgv'A N
Name of Inspector: JOHN ORACI MR.HENSON HEAOyD$v
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number: A
E Z
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:
x Passes This Inspection Is based on criteria dented In Title V
_ COnpubmit
Passes code 310 CMR 16303.Ny findings are of how the system is
performing at the time of the Inspection.My inspection does
_ Neeer Evaluation By the Local Approving Authority not Impyany warranyor guarantee ofthelongevltyofthe
Fail septic system and any of Its components userul Ilfs.
Inspector's Signature: Date: linn99
The System Inspector shall 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:
x 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
Co7hpliance(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 OO7197)
One Winter Street • Boston,Massachusetts 02108 a FAX(617)556A049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 51 PARK".CENTERVILLE
Owner: MR.HENSON
Date of Inspection:1111719s
_ Sewacte backup or.breakout or hiah.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:
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
_ Backup of sewage in 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
cesspool.
SAS is in hydraulic failure.
(revlsed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 51 PARK AV.CENTERVILLE
Owner: MR.HENSON
Date of Inspection:11f17►99
D]SYSTEM FAILS(continued)
Yes No
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).
Numbers 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 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. 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
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.
(revleed 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 51 PARK AV.CENTERVILLE
Owner: MR.HENSON
Date of Inspection:1111719E
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — 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.
-x— — 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)j
(revised 04127)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 51 PARK AV.CENTERVILLE
Owner: MR.HENSON
Date of Inspectlon:11117198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 g•p•d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: 4
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:(last two(2)year usage(gpd):
nfa
Sump Pump(yes or no): No
Last date of occupancy: nIa
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present: (yes or no) No
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: we
Last date of occupancy: nra
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SYSTEM WAS LAST PUMPED ON 21240 INFORMATION FROM OWNER
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:U gallons
Reason for pumping: nla
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:
SYSTEM WAS INSTALLED IN 1993
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04r27)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 PARK AV.CENTERVILLE
Owner: MR.HENSON
Date of Inspection:'11117r9s
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age nra . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L8'6" 5'7"W4'io^
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness:"'
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 17"
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 ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rda
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:Na
Date of last pumpingr
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.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2-6"
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction Iine:TowN
Diameter: nla
Frsimments: (conditions of joints,venting,evidence of leakage,etc.)
(revised 0427)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 PARK AV.CENTERVILLE
Owner: MR.HENSON
Date of Inspection:11117i99
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: rda
Capacity: We gallons
Design flow: Wa gallons/day
Alarm level:—rda 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: x
(locate on site plan)
Depth of liquid level above outlet invert: LIQUID LEVEL wmI BOTTOM OFPIPE
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
DISTRIBUTION 13 STRUCTURALLY SOUND
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Ye:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
He
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 PARK AV.CENTERVILLE
Owner: MR.HENSON
Date of Inspection:11!'17198
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:
Na
Type:
leaching pits, number: Na
leaching chambers, number:41NFLUTRATORs
leaching galleries,number: Na
leaching trenches, number,length: Na
leaching fields,number, dimensions:Na
overflow cesspool, number:nla
Alternate system: rda Name of Technology:_Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
THE LEACH FIELD SHOWS NO SIGNS OF FAILURE,SYSTEM IS FUNCTIONING PROPERLY.
CESSPOOLS:
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: rva
Depth of solids layer: Na
Depth of scum layer: Na
Dimensions of cesspool: r0a
Materials of construction: Na
Indication of groundwater: Na
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Na
PRIVY:
(locate on site plan)
Materials of construction: Na Dimensions: We
Depth of solids: Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Na
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
51 PARK AV.CENTERVILLE
MR.HENSON
11117198
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)
I
AF I�
C
� a
P�0 31
Page ! of 10
(revised 04r2T19T)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
51 PARK AV.CENTERVILLE
MR.HENSON
11117198
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
page 10 of 10
(revised 04)27197)
I�
BORTOLOTTI.CONSTRUCTION, INC. F 6
765 WAKEBY ROAD,MARS'I'ONS MILLS,MA 02648 0 1996
508-77.1-9399 508-428-8926 FAX: 508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. *Q
PART A � ��
CERTIFICATION
Property Address: ^ _ e —6112 Ile
Date of Inspection Inspector's Nanic:_�/6a— --
( 7er's Name and Ad ress:
CERTIFICATION STATEMENT*
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my'training and experience in the proper function and maintenance of ou-site sewage
disposal systems. 'file System:
Passes
Conditionally Passes
Needs Further E Illation By dig Local Aproving Authority
Fails
Inspector's Signature:
The System Inspector sha11 submit XOPY of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYSTE,)4 PASSES:
1 have not found any inforniation which indicates that the system violates any of(lie failure
criteria as defined in 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 comple-
tion of the replacement or repair, passes inspection.
Indicate yes, nor,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 sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup 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):
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w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)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 FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with 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
the 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 e[luent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged 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 LyQT due to clogged or obstructed
pipe(s). Number of times pumped
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�I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check-i the following have been done:
v Pumping information was requested of the owner,occupant,and Board of Health.
None of the system components have been pumped for atleast 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.
�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.
f/The system does not receive non-sanitary or industrial waste flow.
_e- The site was inspected for signs of breakout.
IZ All system'components,excluding the Soil Absorption System,have been located on site.
_&,LThe septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
petted for condition of baffles or tees, material of construction,dimensions;depth of liquid,
v depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
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I — -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
tZThe facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C _
SYSTEM INFORMATION
/ FLOW CONDITIONS
RESIDENTIAL*
Design Flow: •, �7 gallons Number of Bedrooms: Number of Current Residents: ac '�--
Laundry Connected To System: VE'S Seasonal Use: /I/0
Garbage Grinder: dry Y
Water Meter Readings, if available:
Last Date of Occupancy: o
COMIVIERCLAIJINDUSTRIIAI.•/ Q
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank.Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENE INFORMATION
PUMPING RECORDS and source of informaW�yon r�7r
System Pumped as part of inspection:4� If yes,volume pumped: gallons
Reason for pumping:
TYPE,OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any)
Other(explain):
APP O TE AGE of all c ingen ,date ins (if known)and source of information:
/lc '
Sewage odors detected when arriving at the site-
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J
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade:07 " Material of Construction: concrete metal FRP Other
(explain)
Dimisions:_e, 6',►'� ',Yg'' Sludge Depth:_,s�/ Scum T�ckness:,-,�)
Distance from top of sludge to bottom of outlet tee or baffle: ,33
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 liquid
level in relation toAutlet invert structural hiteglity, evidence of leakage,etc Q
GREASE TRAP:
Depth Below Grade: Material of Construction:_concrete metal FRP Other
(explain)
Dimensions: Scwn Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet lees or battles, depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Otlier(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float'swilches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:
Comments: (noteAlSyel and distribution is ual,evilence of solids car over, evide}'ce of le age into
or out of box, c.) �C'i`LX.c lei X `� S' QOL oow- "� ' /tioU�o
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
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: Leaching chambers, number: Leaching galleries,number:_�Z_
Leaching trenches, number, length:
Leaching fields,number,dimensions:
Overflow cesspool, number:
Comments: (note condition/o�soil, sigi s of Iydr ulic failure level of ponding,condition of vegetation,
etc.) .
CESSPOOLS: (/
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 soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY: 1
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
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I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
krar 6\ A�S-e_
ate ' i
DEPTH TO GROUNDWATER: ,
Depth to groundwater: / .7 Feet
Method of Deterrjunation or Approximation:
Q
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