HomeMy WebLinkAbout0089 POND VIEW DRIVE - Health 89 Pond View Drive, Centerville
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UPC 12543 a
No..�3LOR -CO
HASTINGS, MN
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RECEE1VCB
COMMONWEALTH OF NLASSACHI:SETTS � OCT 8 199
EXECUTIVE OFFICE OF E\VIRON\1E"NTAL AFF �°RS TOWN �
F r NEAL BADEPTABLE jo
DEPARTMENT OF EN-VIRONN E\TAL PROTEC �111
ONE WINTER STREET. BOSTON. M.4 02108 b i e9=•':i C �
! G 9
WILL1A„F WELD TRUDY C0)M
Govemc- Se:rctarn
ARGEO PAUL CELLUCCI DAVID B STRUIE
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions.
PART A
fir,-�Qo� vtew 'Okpe CERTIFICATION
Property Address: 7��-��`171 I �.�+VvC tiv, �tM A Address of Owner: �kILA lAtS $���� (- I �^4t��1�
Date of Inspection: ° lG 191 (If different)
Name of Inspector: �F-C
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:1'2-/La III-Ar'a En A-# r-1-7.1 0-1 P 1A 4-.L_1
Mailing Address: 2 p jS=x C 3zf!4 H e-C
Telephone Number: r5e4z
T
CERTIFICATION STATEME\T
I cem) that I have personals-, mspected the sewage disposa' system at this address and tha: the iniormation reported beiov. is true, accurate
and corolete as of the time of tnspe^,,o-.. The inspection was perrormed based on mN training and exDerience to the proper iunc lon and
maintenance of on-site sewage disposa systems. The system:
• � pastes
_ Conat,onaii� Passes
tieecs Furtne- Eya!uaron(5-vthe Local Approving Au;nonr)
F•
1 t+e c
Inspector's Signature: Z1.1 Date:
The Syster Inspect0' sha" submit a copy of this inspection reocrt to the Approving Authortty within thin, (30, days of completing this
inspector.. It the system is a share, System o• ha a design floe` of 10,000 gpd or greater, the inspector and the system owner shall submit
the repo^ to the appropriate revor.ai odlce of the Department ci Environmental Protection. The orng:na! should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authorin
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 C.MR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS: - •° r r�T %W,-A� e�� Z°� L
t T. Z l t tv`7
` .
-
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.
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 exfiltrat)on, 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.
(rev;.Dad 04/25/97) Page 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION' (continued)
Property Address:
Owner:
Date of Inspection.
DJ SYSTEM FAILS:
You must indicate either "Yes- or No
\Xm
to each of the following
-
I have determined that the violates one or more of the following failure criteria as defined in 310 CMR 15.303 The oasis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessan• to correct
the failure. j
i
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of elffuent to the surface,of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Staac liquid level in the dis;rbbution box above outlet invert due to an overloaded or clogged S.4S or cesspool.
Liquid depth in cesspool is less•than 6" below invert or available volume is less than 112 day flov.
b
Reouiredi pumping more than 4 times in the last year NOT due to clogged or obstructeo pipe's .
Numi�er of times pumped _. {
An, pon,on o'the So" Absorption 5 stern,, cesspoo! or privy is below the high groundwater eievano-
Am por::or. of a cesspool or privy is ikithin 100 feet of a sur-face water suppiv or tributary to a surface water supply.
And portion of a cesspoo' or prise Is %%IEJtin a Zone I of a public well.
An\,pertic- of a cesspool or pmv is waKin 50 feet of a private water supply welt
d
Anv port,or. o:a cesspool or privy is less than 100 fee; but greater than 50 feet from a private water supply well with no
accepabie Ovate, qualm anahvsis. If the welf,has been analyzed to be acceptable. anach copy of well water analvsis for
coliform bacteria vo!a;ile organic compounds;, ammonia nitrogen and nitrate nitrogen.
a
E] LARGE SYSTEM FAILS:
You must indicate e;:her "Yes" or "No" as to each of the following.
The fol.ioN;ng crae,ia app% to large.sysrems in addition to,the criteria above:
The system series a facilitl with a design flow of 10,000 gpd or greater (Large System: and the system is a significant threat to
public hea'th and safes 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 fl_ I compliance with the groundwater treatment r
A ogram
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office o the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Proper . Address: Q!� ?LyJ
Owner: ti ,(H
Date of Inspection:
ci
FLOW CONDITIONS
RESIDENTIAL:
Design tloN (�G1i~?_g.p.d../bedroom for S..A:S—'rw%.>� i% P�d(�vaS�� �rcy� L1 b�c1�o�+�+ ass-►..,��l`�3 �wV,(ur.
Number of tearooms '2-1_
Number o:current residents- CoZ,r A00�VA 03
Garbage g,, der (yes or nor
Laundry cor—ected to system (yes or no' 4-4
Seasonal use Ives or no,:Q`3
Water meter readings, if available (last two :2 year usage tgodf: (�
Sump Pump Ives or not N
Las; date o-*occupanc-,-
COMMERCIAL'INDUSTRIAI:
Type of establtshmen:
D?sign ffo�% eahonsda%
Grease trap present tees or no
Indusma! 1lasie Holding Tani; oresent -ves or no
Non-santtan Naste discnargec to the Ta,e 5 s\•stem ives or no_
\%ater meter readings if availabie
Las:pa;e o; o '.6;;21-c.
OTHER; .Describe
Last sate of occ.:aanc.• `
GENERAL INFORMATION
PUMPING RECORDS and source of tnformanor.
System pdriped as par, of inspection: tees or no Q .
If ves, volume pumped ' Ilons
Reason for pumping _
TYPE OF SYSTEM
_ Septic tank'd;stnbution bo)L;'sotl absorption system
Stngie cesspool
Overflow cesspool
Privy.
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technologv etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site. (yes or not,P(D
(revimed 04/25/51) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propem Address:
O,ner.
Date of Inspection:
TIGHT OR HOLDiNC TANK: N%-' -'Tank must be pumped prior to, or at time, of inspection:
(locate on site plan,
Depth below grade
Material of construction _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions.
Capacity-_ galions
Design flog gahons-da.
Alarm level A;arm in �%orK:ng order_ Yes. _ No
Date of previous pumping
Comments
(condition or inlet tee. conditior o- a'a,m and float•switches. etc.)
DISTRIBUTION BOX: �4&
docaze on site p a-.
Deg:'^. o- itcuid le%e' aoo.e outle: intie^ -%`CL'11,tT�IN� wIS
Comments p
tt ,te r le e! and dat b_: is eoua.' ev d�nce of solids carnover, e�idence of leakage tot� or out of box, etc.)
�� 1.7�L�/Li�C.
PUMP CHAMBER:
(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.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
a� SYSTEM INFORMATION (continuedi
Property Address: �`�± (��(,V.i !AIL
Owner: Kk
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reierences landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
yt
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(rev-sad 04!25!5") Page 9 0! 10
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*�*99. Plz -
LOCATION SEWAGE PERMIT NO.
,G 0 7- 4 A 'Po4cJ V l e.u3 D k
VILLAGE
('e,)7' i( t� e
e
I N S T A LL "'S NAME i ADDRESS
] Gberzi. O yrz Cc)
.. - 014K wdcr-1
BUILDER OR OWNER
DATE PERMIT ISSUED � � 7
DATE COMPLIANCE ISSUED �� _1A .�,_ �
t
T
a7 ®'
33 '
1
(� THE COMMONWEALTH OF� MASSACHUSETTS /� i'�•"� r BOARD ®F HEALTH
........... oF..... �,1 &6 ----------------
'� Appliration for Uiipaiial Warks Tomitrur#ton ramit
"Application is hereby made for a Permit to Construct ( . ) or Repair ( ) an Individual Sewage Disposal
System at
• ...• ....... y d .. 11 ...................................................
c ion•Addre �• or Lot No.
Ow r Address
W ..__.... �................................................. --.....-•-••••-----•--•------•-••--....._................................................--•_.....
Installer Address
Type of Building Size Lot.............i.� .Sq. feet
Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' IOther fixtures ............................
W Design Flow................`.55....................gallons per person per day. Total daily flow.......................... .......gallons.
WSeptic Tank—Liquid capacity__ "- --gallons Length WidthA,_-1d__- Diameter________________ Depth...S.:1...
x Disposal Trench—No. .................... Width_...__._...____._.. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------I_.....__.. Diameter------�_.-___.__ Depth below inlet............... Total leaching area..... ! ...sq. ft.
Z Other Distribution box (� Dosing tank0-4 ( ) ff Percolation Test Results Performed by. iCT.. _t._b�y_ _.-_ e u!.JgcJ S__.P.��.: Date...... ?] i_� ............
1 Test Pit No. 1......Z-.....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........................
a ( ;
0 Description of Soil..........
W --------------------------------------------------------------------------------------------------- ---------- ------- --•-----•---........•••-•---•-----------------....-----•--••-----------•-.....--
VNature 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 TIT L- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sied- - -------------- - ----------------------------------
Z-1
Application Approved BY - rlt 0-'
J 1
Date
Application Disapproved for the following reasons:.................---••----•---•-•----•-•---••... .............................................................
..._•-----_....•••-••--•--------••-•--.....•----•-••----_._....-•----•---•----•.......................... ----- - --
.---------------------------------------- --------- --------------------------------------
/_�-/ 7� Date
PermitNo......................................................... Issued. . ............................................
Date
M
7- No.... •---•• �y........ ........
r THE COMMONWEALTH OF MASSACHUSETTSv
BOARD OF HEALTH d
-- .."---------------- OF.... �� ���!�... t.
7..............................
; ppliratiou for Uispwial Workii Ton.strnrtiun frratit
Application is hereby made for a Permit to Construct ( ) or Repair '( ) an Individual Sewage Disposal
System at
................ J:.... I (a ti. dDii1> C-c-i t
...�.�.... .... �...t. ,�... -- .... ....................................................
L ation:Address or Lot No.
- A
_ ..... .........................•. ..........-•.........................:........._.dd.... .........--
.--- - � ress
W
Installer Address i �.y•y
UType of Building Size Lot...... ....4.`.•1.....'---.....Sq. feet
aDwelling-No. of Bedrooms............------ •_--___.__--•__-------Expansion Attic .(;` ) Garbage Grinder ( )
aOther—Type of Building .....................s.......I No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures --------•---•-------------------------------- �.
35-30
W Design Flow................ ..... ..____gallons per person per day. Total daily flow........................ --------gallons.
WSeptic.,Tank'—Liquid capa*tyJC&X .gallons Length.-..•:C .... Widthfi'�::fC)'-._. Diameter................ Depth..' ._.........
x Disposal Trench';-1 No. .....:...........:.. Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.........------.__.<,Diameter.__--j:......... Depth below inlet.....CR........... Total leaching area.... t"3---sq. ft.
Z Other Distribution box'( Dosing tank
Percolation Test Results Performed by.�`?��'s�._� .i���'=..'_�.��!�.J�".'S�:�_._!�°ir. Date...- �'� .-D �
Test:Pit Nb. 1--_-_---Z; -:___minutes per inch Depth of Test Pit-------A ...... Depth to gro
und water........................
(T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 . . ---------------------------------------------------------------------------------------------
-------
-----------------------------
-...............
--- •--
O Description of Soil------....t.r _�Z.------�--'AWt>`� .� -- - ..
If'
U ,If
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 TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ................................
Date
Application Approved BY ---------------------•--
Application PP on Disapproved fo �e f ollowa g r dso s !f- ..'------.........-.............................................................................
........-•--•-•---------------------------------------------------------------------------•--••-----------•••-••---•-••--••----•---•-•-------------•-----••••--•-•-•--•------------------•--••-••-•--...
Date
PermitNo........................................................- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......). ..........OF...,.w.e.". .........................................................................
rrtif WAX?6ftout lianrr
THIS ISK70 R. IFY, That the Individual Sewage Disposal System constructed U )-or Repaired ( )
j.../...r.......
Installer
at ..... = - •. r' ...
h e >trstaA $ Fe hevisis�fi � State' s escribed in the
application for Disposal � orks Construction Permit N .._- -_____-------------- dated_-..__ ___ .._____-. __..._........._...._...
THE ISSUANCE OF THIS CERTIFICATE SH�WI 'CONSTRUED AS A&LWAW*THAT,THE
SYSTEM WILL FUNCTION SATISFACTORY.
/ 70
/�F — •2 /�� --•------------------•---•---- Inspector--••---•-----------------------------•-•---
DATE--•-----(• --•• -•--1------------ �•...............................................................................•------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
W.F ,;,��� FEE
...................
Gi la r tr w" n rrntit zS'=
Permission is hereby granted..•--- --�= .....•....-- ltt f
to Co 'stiuct�f�„ ) or Repair ( n Individual Sewage Disposal System
JVA
as own on the applicatioyi�for sposal Works Construction Permit IVo __"'"....... Da
....... .................
/fA�YJ •____ �r._A________________ .._._ .
DATE =...=...........................................................
... , .
FORM 1255 'HOBBS & WARREN. INC.. PUBLISHERS
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20'-6" 20'-6" I' 2P-0" NOTE:
I; CONTRACTOR TO REFER
TO WFCM 110 X 5 AND
CHECKLIST FOR ADDITIONAL
HIGH WIND TECHNIQUES
_ NOTE: RELATED TO THIS PLAN 6,."j
EXTRA 5% SHEAR WALL Ci
ON THIS FACE DUE TO ,Y (Ir. 6,;R d,- B1 E O
3 � TRANSOM
� w
OCT3 Plat cc
ST c� kiI, �' J� Q
- -- —---- ' x;
STUDS I k Ill
-- I EA SIDE I _
DIVISION J
— --- — --- o -- I NEW EXT
CATHEDRAL CEILING I c�HOW
EXPANDED MASTER BEDROOM I 11'
-- OAK w
DECK--— - --- -- 3 FULL I I in w �-
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SHEAR WALL COMPLIANCE:
4'-3" W- 38% OF EACH WALL RUN
VERTICAL SHEATHING WITH
0-0" 8d NAILS 3" EDGE/12" FIELD
(4)16d NAILS PER FT BOTTOM PLATE
62'-0" Lm 11% OF EACH WALL RUN
r VERTICAL SHEATHING WITH
FIRST FLOOR PLAN 8d NAILS 3" EDGE/12" FIELD .J0t3: oeoa
DRAWN
SCALE: 1/4" 1'-0" (4)16d NAILS PER FT 50TTOM PLATE __ KW
DATE: 10/S/08
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EMBEDDED 7" I
EXISTIN SPACED 44" O.C. Q G 12" FROM CORNERS
BASEMENT WASEIERS 3"x3"xi/4"
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2'-q"
32'-6"
FOUNDATION PLAN JOB: 0505
SCALE: 1/4" m 1'-011 DRAWN BY: KW
DATE: 10/8/08
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