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HomeMy WebLinkAbout0130 PRINCE HINCKLEY ROAD - Health 130 PRINCE HINCKLEY ROAD, CENTERVILLE A = 172 200 z 10 '36 SEWAGE W A E PERMIT NO. � L • CAT G Lot 127 Prince Hinckley Rd. 28-481 VILLAGE Centerville, MA. INSTA LLER'S NAME i ADDRESS Alfred Fuller West Barnstable Road, Marstnns Mi 11 g, MA- 0 U I L D E R OR OWNER Alan E. small,,_ Tn c. Box 536 Centerville, MA. 02632 DATE PERMIT ISSUED 8/30/78 DAT E COMPLIANCE ISSUED ' -, i No..........Y 0 Fimc.............................. THE COMMONWEALTH OF MASSACHUSETTS ' BOAR�����H - --------OF. .................................... Appliration -for Bhipu,ittt Workii Tonstrurtion Vrrmft Application is hereby' d for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy �� %Z -7 • _-- -- . ------------------•-----------------------.......... .........................................�.---- -- tio=, ,f): n.Addres r Lot r ..... .............................•..-- Ownera�, Address - ----------- --- •.. ................ --••----------.----- -- -- --••-•-------- •------------/ ........................................... Installer Address d Type of Building Size Lot.-._J__. _ _____Sq. feet Dwelling—No. of Bedrooms..__.__��...........................Expansion Attic ( ) Garbage Grinder pa-, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ..__ _ Design Flow.....14 ..d. �f'.�______________gallons per person per day. Total daily flow_______ __.._ gallons. W �_44i_• ----•------ W Septic Tank—Liquid capacity .gallons Length................ Width................ Diameter-----.---------- Depth..------_--__. lL xDisposal Trench—No.-------------------- Width-------------------- Total Length-------------------- Total leaching area..-.--.___--_--_-_sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below ' lZ .... ... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosingt nk ~' Percolation Test Results Performed by._ _ . �- a- 7--- g . Date......:. - - 7 Test Pit No. 1----------------minutes per inch D pth of Test Pit-------____--------- Depth to ground water...--_----._-.--.-_-- �L4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.--._---_.-..-_------. Description of So>1_____ .__ 1__a...�._.�.­....... ---T-' ---- -------------------------------------------------------------- --- ----------------------- W --------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual ewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The unders' ned further agrees not to plat ,the system in operation until a Certificate of Compliance has be s ed by bo d of healt �� ed. ...... - -------- - ---------------•------•------------•-------------- -•--...... -----------•------- Application Approved By----- --• .. ..... -- -••-------- ---�'---- =Dat� Date Application Disapproved or the ollowin reasons:---•-------------------•-•-•-•--••-•----•--•-- -•-•--------------------•--••---•--••-----•--•--. PP PP t � 9 --...-•-•----------------•----------......------------------••-•-------...---•-•---------•----------------_•----------•---------------------------•-- -------------------------•------------•----.-•--- Date Permit No............................ 3 i Issued. ---------- Date No.......- ..... FRic..........Z................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH ..OF7 ....................................... pphration -for DixiVaiittl Oorks Tons#rurtiott Vrrmit Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ,System at•:r-- � ,1,� .-{v t, .,. �.w :: `...�.....---••-••-_---•---•.-••..•-••••.•._-- .........................-�•-----.•_ -_- -- . -/- • Location-Address•,,, -or Lot ��! /� Owner�r • `" Address 1`1�" .............................. .................................................----------------------- ......-----_......---- ! Installer � Address Type of Building Size Lot------- . .........Sq. feet .-I Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons..-________--_------_-__.-- Showers ( ) — Cafeteria ( ) a' Other fixtures __---.__------- -------------- - - d -------------------------- Design Flow...........f_�_� --- `�- ' g. P P P Y Y gallons. W Mons per person per day. Total daily flow--------=----``__.____..__.... - ..._...- WSeptic Tank—Liquid capacitry!!V-!.�'�gallons Len-th---------------- Width---------------- Diameter-----------.---- Depth-----__.--_---- x Disposal Trench—No.-------------------- Width-------------------- Total Length-------.------------ Total leaching area......-_--..........sq. ft. Seepage Pit No--------------------- Diameter___-____--_.-.._-_-_ Depth below}•nlet____ _._ Total leaching area_--------.---:__--sq. ft. Z Other Distribution box ( ) Dosing tank ( e�PA 'r '-' Percolation Test Results Performed by.- "` l�< .. Date_ ».--�-/-----_`„S�' ?'� a � Test Pit No. 1----------------minutes per inch D pth of Test Pit--._---.-_-_--__--_. Depth to ground water----------.............. Lr Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.---. --__-.____---- D Description of Soil----- - - " •• "'_,l"" � -11stm' --..... x •-------------- --------------•---------------------__----_.--------------------------------------------------•--•-----------------.--------------------•-•--•--------- ----------•-..--------- 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 Article XI 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. ---•-• --.................................................. •--------- ------ Date Application Approved B ' Date Application Disapproved.for the ollowing reasons:.:.. -•----------------------- ate PermitNo..............................................---------- Issued------------------------------ &-L------------ Date THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF ALTH ............. ...........................OF.... ....................✓..'`...`Z. ""'.,......................... rdifiratr of ff.'umpliaurr TH I C FY, the Individual Sewage Disposal System constructed ( r,_Repaired ( ) by -------- --- ------------ - ••------ i, Installefi ✓�` am """ 'J - ot -r'-- _••-� -�----- has been installed in accordance with the provisii?ris of A I The State Sanitary Cod as described in the application for Disposal Works Construction Permit No.- -._ dated '���` ? ' : T.HE' ESSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED ,SA GUARANTEE THAT THE SYSTEM WILL FUNCTIOPJ SAATI FACTORY. 'L• DATE.............. ..... LJ-..•-/--- ----•-------••----_..... Inspector.:...--. ...... / .. .. .THE COMMONWEALTH OF MASSACHUSETTS N BOARD Lk:✓ HEALTH ......... ........ OF. ...........-..... Z....N i t---- FEE........... Bi'livolial rk n Mott Vrrmit Perm' ission rmy granted---------- <------- ...... •----------• --------------•--•••--• J�,v,, to Constr' t ( ) or Repair ( a Incjtvidual Sew, Disposal s In a =� � ... Street as shown on the application for Disposal Works Construction Per /�f d.... � ` ----- 3 d 7�_ Board of Health ..................................................... DATE.. ............ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - - r � i_l0 C-�A2S.[aG.� t�Ri�tv�1� 2'�d►L`( 1*LOW a lib +� 3 = �?b �.pD. 13 t.aSi-=- 1000 6a.L. PAS AL P iT - U'SF l U©o G.aL. ,tyr-WALL. AlZ rA. = tso S.P. 'BcrrTOM Aye _ ST-. KE:� 1W=. A So s.f?v. P�r_0 -.V TC>T',&L 6.-PD. N3 j ToTQL. -c),&tL`f P!✓QGDL&T10Q fzlaTE : it.1 2mIQ 02 LASS• Q._ _ ,,� ►�lb. IQ-? ( /JT To? F-uo =tc>o.v 4 Lo AA I o00 5 etso r c. 4'P.p� DKT l W. G.QL. -t .► ,:t; Sepric I o iuv TQ ►C l000 g •4 lNV- 1w. ?, Sa as GAL. �G a L�AGH a P�T .; 1 I' SA QU WAIWED G�;6.�Jec1,. STONE. C"t,� aleb CF�T1r 1c.t� Pl..c�'T' trL./S.�i �a�ra PtZU�tL� - - ..._._. L b Gl�,T t o t•J �l:lJ T��'t..t-G ►,.t n G r tz T I V=-{ `r -(AT- T I-t C-- 70 J abA rl D f. 5"C>o ►.y A.t-1 R.c�lj C E= 't-W- Z: Lo ,awry •>eTL,n�t� �:r-�y��I�EMEuT.; c) a+I -To w►� F,�2 W 57A r Lc� � r>A't'G °� t 1 � -0C` i/ o tZcGlS�re::i,�t� i�IJG 5U2.v'�Yat�S �("1-�t5 C71_AI-1 t JOT A/7{`V? CA4 4W C�STC�'�/11,1 t= c� /t�Cr�S�i• 71.1Gl LX-> artz BORTOLOTTI CONSTRUCTION, INC. to %n, 19 jg 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 99 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: ' Date of Inspection: / Ins c is Name: Cnv is Name po Address: p CERTIFICATION 4TAT >`: N T. 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 on-site sewage disposal stems. The System: Passes Conditionally Passe Needs Further atio B e Local Aproving Authority Fails Inspector's`Signature: Date: j�y S The System Inspector shall stibmit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. 1f the system is a shared system or has a design now 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 STIMMARY• A)SYS'1LEM PASSES: , �� I have not found any information which indicates that the system violates any of the 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 confortidng 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): - 1 - r t -' IN 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"HEAL'TH 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 FAELS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CUR 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 efluent 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 G"•below invert-or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last•year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- 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 i tributary to a'sur6e"a 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 if the following have been done: ✓Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for alleast 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. �built plans have been obtained and examined. Note if they are not available with N/A. e facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. All system components;excluding the Soil Absorption System; have.been located on site. ✓The septic tank manholes were uncovered,opened,and'th6 interid of.the septic tank was in- 'spected for conditio"'Wof baffles o'r tees,material,of construction,dimensions,depth of liquid, 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. -3- I PECTION FORM SUBSURFACE SEWAGE DISPOSAL SYSTEM INS PART B CHECKLIST(continued) The 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 ' a . . . - PART-C.-SYSTEM INFORMATION . FLOW CONDITIONS DeF1 RESIDENTIAL* S�ow Q gallons Number of Bedrooms:o Nun r of Current Residents- Garbage Grinder: Q0 Laundry Connected To System: 4&2Seasonal Use: Water Meter Readings,if Table: Last Date of Occupancy: - O MF.R AlAND ST IAi _ ,�(� , Type of Establishment: ._ 4 Design Flow: - gallons/day Grease Trap Present: (yes or no) Indtistrial 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: GENERAL INFORMATION PUMPING RECORDS and source of information: aml A/� System Pumped as part of inspection: ,�<) If yes,volume pumped: aallons Reason for pumping: TYP"F SYSTEM: _/V Septic Tank/Distribution Box/Soil Absorption System- Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): PROXIMATE AGE of all omponents,date installed(if known)and source of information: . ..<< O S ge odors detected when arriving at the site: -4- _. . . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - ... . GENERAL INFORMATION (continued) SEPTIC TANK: ✓ Depth below grade: Material of Construction: concrete metal FRP_Other (explain) Dimisions: —'X ' X Sludge Depth: -Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 3 Z 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 to elitlet invert structural integrity evi ence of leakage,etc. a / ii j GREASE TRAP: 'Xi6 Depth Below Grade: Material of Constniction:_concrete_nretal_FRP_Other (explain) Dimensions: Scum Thickness: ;X. Distance from top of scum to top of outlet tee or baffle: '. Comments: (recommendation for pumping,condition of inlet and outlet tees or'baffles,depth of liquid, level in relation to outlet invert, structural integrity;-evidence.•of leakage, etc ) - TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:__concrete_metal_FRP_Other(explain) Dimensions: Capacitv: gallons Design Flo«: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alann and float switches, etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if I el and distribution is equa eviden of solids carrti`over,evidence of l ge into or out of x,etc.) az PUMP CHAMBER: ....... n. Pump.is'in working'order ., Comments: (note.condition.of purnp-chamber,condition-of pumps.and appiirtenances,,etd.) -5- i SUBSURFACE SEWAGE DISPOSAVOSTEM 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: Leaching :trenches,number, length: Leaching fields, number,dimensions: . Overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure level f ponding,condition of vegetation, etc. - /i /i CESSPOOLS:�I� 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: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,}condition of vegetation, etc.)- -6- J N ' 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. . 'b .3 DEPTH TO GROUNDWATER: i Depth to groundwater: / Feet Method of Determination or Approximation: —rrl oil -7- .,X