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HomeMy WebLinkAbout0092 RICHARDSON ROAD - Health 92 RICHARDSON ROAD, CENTERVILLE A=210129 �l/l J��.CYCffp� y� llll UPC 12534 No.2153LORr HASTINGS,MN D Commonwealth of Massachusetts M` �1d �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 92 RICHARDSON RD �Ta Property Address CAP R I O rye •a Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. City/Town State Zip Code Date of Inspection .,., Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out 5/ # r7 forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Citylrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification 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 maintenance 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-23-15 s ector's Signature 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. ****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. �0VY!Page-VS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION THIS REPORT DOES NOT PREDICT HOW THE SYSTEM WILL PERFORM UNDER THE SAME OR INCREASED USE. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for 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 existingtank is replaced with a complyingse tic tank as approved h P P PP 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. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent 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: 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 ❑ ® Discharge or ponding of effluent 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 clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. Citylrown State Zip Code Date of Inspection C. Checklist 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 ❑ ® 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? ❑ ® Have 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, excluding the 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: ® ❑ 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 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3per assessing DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. City/Town State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A SEPTIC TANK D-BOX AND LEACH PIT Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d SEE BELOW 9 ( Y 9 (gP ))� Detail: 2013---------198 2014-------237GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. CitylTown State Zip Code Date of Inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1981 PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?.(attach a copy of certificate) ❑ Yes ❑ No Dimensions: APPEARS TO BE 1000 GALLON Sludge depth: t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING, TANK HAD A GREASY COATING ON THE INSIDE AND COULD USE PUMPING. OWNER STATED NO GARBAGE DISPOSAL Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM ,•�'° 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. Cityfrown State Zip Code Date of Inspection D. System Information (coot.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert off Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE, SOME SIGNS OF CORROSION TYPICAL FOR ITS AGE. BOX WAS VIEWED BY CAMERA Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: I ❑ leaching trenches number, length: ❑ 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.): PIT HAD 1 FT OF WATER AT TIME OF INSPECTION WITH SEVERAL STAIN LINES THE HIGHEST ONE ABOUT 3 FT FROM BOTTOM 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 ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. wM 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M a 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 92 RICHARDSON RD Property Address CAPRIO Owner Owner's Name information is required for CENTERVILLE MA 02632 9-23-15 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 2 of 2 1 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=210129001&seq=1 9/23/2015 f Assessing As-Built Cards Page 1 of 2 LOCATI 11 9-"-44UXw17 e'l?ze SEWA<.GE PERMIT NO. VILLAGE INSTA LLER'1S1 NAME i ADDRESS BUILDER OR OWNER A DATE PERMIT ISSUED z DATE COMPLIANCE ISSUED k _LdT I �3- � �7 y6 i I http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=210129001&seq=1 9/23/2015 l l07, ( am) 17 ��►. ry p ,t 171 29S S. �+�\ Ae •® �, 40 i 7 zsdjol CD co 1.1 / APPROVAL UAJZ;W)? SU8D1V1S1OAI CoA(rRO4 1-,4 w NOT A?-=Q U1Rao BA)?IVS7AB1-,r PLA/VNINa .490ARL7 DATF �� TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTE ' 1 (t(~,�)/J(U,•,,J ONE WINTER STREET. BOSTON, MA 02108 617.292.550 A � �/p WILLIAM F.WELD /`O TRUDY=C 7iE Govemor "~ 104, $ecic ARGEO PAUL CELLUCCI y OF Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F R y �`lyO61T 4490'�+ICo��ioncs PART A q 7 CERTIFICATION o Property Address: l d ' c " '� 5 0 Ra. �v1�c"4ddress of Owner: j y Date of Inspection: y�o2 g.(� (If different) • Name of Inspector: Troy W 1 1 ams `_), " 'L,u A 5 „ ti PC/ 1 am a DEP approved system inspector pursuant to Section 1S.340 of Title S (310 CMR 15.000) �QN��� ] /� M Company Name: Troy Wi liams Septic Inspections Mailing Address: 19 Hummel Drive - South Dpnniss MA 02660 0a63-� Telephone Number: (SOP) 3 8 5-13 0 n CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails /J Inspector's Signature: �v+, �i�J� Date: & The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. 1(the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 1 S.303. Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: 4///� 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 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. trwiud 04/25/91) P.q• 1 of 10 P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 92 Richardson Road, Centerville,MA Property Address: Linda Harding Owner: April 28, 1998 Date of Inspection: 61 SYSTEM CONDITIONALLY PASSES (continued) A/4 Sewage backup 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). Describe observations: broken pipe(s) are 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 SO feet of a surface water Cesspool or privy is within SO 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within SO 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 SO 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) OTHER r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: . 92 Richardson Road, Centerville,MA Owner: Linda Harding Date of Inspection: April 28, 1998 D) SYSTEM FAILS: N �� You must indicate ei;,.er "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 into 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 SAS or cesspool. 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number 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 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 front 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. El 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 above: 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. ir...i.•d 04/25/9'i c..,. ..i .� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B. CHECKLIST 92 Richardson Road, Centerville,MA Property Address: Linda Harding Owner: April 28, 1998 Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ No —K/ Pumping information was,provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least 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. V _ As built plans have been obtained and examined. Note if they are not available with N/A. JL/ _ The facility or dwelling was inspected for signs of sewage back-up. _I[ _ 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 the site. The septic tank manholes p o es 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. 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 System. Existing information. Ex. Plan at B.O.H. JL _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (I 5.302(3)(b)1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 92 Richardson Road, Centerville,MA Owner: Linda Harding Date of Inspection: April 28, 1998 RESIDENTIAL: FLOW CONDITIONS Design flow: -';() g.P.d./bedroom for S.A.S. Number of bedrooms:_ Number of current residents: Garbage grinder (yes or no):_y1CS Laundry connected to system (yes or no):�S Seasonal use (yes or no):_fio Water meter readings, if available (last two (2) year usage (gpd): c17 =3f1,>,,o y4/t, Sump Pump (yes or no): No Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_ gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title S system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of Inspection. (yes or no)_No If yes, volume pumped: gallons Reason for pumping: TYPE QF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Chher APPROXIMATE AGE of all components, date installed (if known) and source of information: CA S Sewage odors detected when arriving at the site: (yes or no) �GD (r•�f••d 0 /15/971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: . 92 Richardson Road, Centerville,MA Owner: Linda Harding Date of Inspection: April 28, 1998 BUILDING SEWER: /\114 (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:, (locate on site plan) Depth below grader Material of construction: Zoncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:_ ?C 9 X,; yz�o 6 u Sludge depth: �/„ Distance from top of Judge to bottom of outlet tee or baffle: Scum thickness: 11v, C-7e41 Distance from top of scum to top of outlet tee or baffle: (7 Distance from bottom of scum to bottom of outlet tee or baffle: IY How dimensions were determined: l�ro 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.) PC) c--,, - - 4- / I�T- .5- h J 1 c p J GREASE TRAP:_4//1.9 (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: (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.) 11—i—d 04/25/91) D�a• 6 of 7n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 92 Richardson Road,Centerville,MA Owner: Linda Harding Date of Inspection: April 28, 1998 TIGHT OR HOLDING TANK:N//9(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: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_V (locate on site plan) Depth of liquid level above outlet invert: t Comments: (not if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) L2 i PUMP CHAMBER: IV//9 (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.) 1 r�v1•mod 0�/75/9�1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 92 Richardson Road, Centerville,MA Owner: Linda Harding Date of Inspection:April 28, 1998 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:2� C� leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length:_. leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.) "L. iv. U �..S p � G✓ v i.L P fG mot. < r ! )P✓' i/J^G C G✓, �' u.+ CESSPOOLS: (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r•vls•d 04/,25/97) p•4• ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 92 Richardson Road,Centerville,MA Owner: Linda Harding Date of Inspection: April 28, 1998 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) 1 /A• 3 , 3 /d0�clw Il�h y$. s ' l�'I 3� (-Ii-d 04/25/97) ` Pav• 9 of to SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address. 92 Richardson Road, Centerville,MA Owner: Linda Harding Date of Inspection:April 28, 1998 Depth to Groundwater��L Feet �.0 adjusted high groundwater level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record VObservation 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 V/ Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) t u c.�J ✓ s vi �,. f b r L. cj l� of r� U J-L 4,JL ✓ �2.J e , f� /�o✓ '.h� i.J rim-7 Gt� 1 �-'U Qi [ (r—i.•d 04/25/97) ➢ay. 10 ..� i� r Permit Number: Date: Completed by:� i C, S HIGH GROUND-WATER LEVEL COMPUTATION Site Location: �-� l� i L ,/l S , �� Lot No. Owner: o-r ck Address: Contractor: Address: Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date 12 0i oe f G month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: O Appropriate index well.............................. lw,2q . ...................... OB Water-level range zone ............ STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to ? water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level zone (STEP 26) determine water-level adjustment ...........: ............................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 11 ........................................ /� era 32'-0' m x r 4 STORAGE : ; I !el, x n x �P N SECOND FLOOR PLAN ADDITION AT CAPRIO RESIDENCE 92 RICNARDSON RD. •.MTERVILLE •MA UAIL II/2/00 AAWN Y Pr-G SCALE SECOND FLOOR PLAN DRAWNG NUMBER 0) X X-O' GARAGE 9 4 9 r a --- — ————— ——————— _ I LA DRY ROOF( --- - --- ----- Q; Q FAMILY ROOb `9 S 2'-5%"X X-0' 2-2'-6' EXISTING HOUSE Trr 'HER--- ADOMON AT C MUO RE COe-H IM RICHARD80N'RD.•'CENTEWME•MA DATE II/Z/per DRhWN.BY PFC SCALE I/e'•Po' MAIN FLOOR PLAN DRAWING NUMBJER r ; I I RIGHT ELEVATION ADDITION AT CAPRIO RESIDENCE 92 RICHARDSON RD, « CENTERVILLE • MA DATE II/2/00 DRAWN BY PFG SC ALE I/8"•I-O" RIGHT ELEVATION DRAWING ANUMBER y � IA'CDX plywood 'd eaphdt ahingl•a 2 RJO Inx.ldon 2)(10 IL'o.c. EEL 6•-TEEL BEAR ' RIS Inuletlon 4p. 2.6 well.✓t'Y COX plywood, tW.k erd whl t•o•db - - ahlrgl•a typ. _ TTPICIL 2.10 FLOOR SYSTEM, 3/4'Tao PLYWOOD"FLOOR 2.10 FLOOR JOISTS a 16'o.o.wr mew swim v solid bboa:ng .o owls 313bom F _ Icy IroulMlon/yp, FOILDAT10N I�RETE CROSS SECTION A-A -a 16'OCe a 6'DEEP CONCRETE FOOTING . ,I ADDITION AT CAPRIO RESIDENCE 92 RICHARDSON RD, 0 CENTERVILLE « MA DATE II/2/00 DRAWN.BY pFC SCALE I/811•11-0II CROSS SECTION A-A DRAWING NUMBER A— I LOCATIQN �ge SEWAGE PERMIT NO VILLAGE INSTA LLER'S NAME i ADDRESS Ni SUILDER OR OWNER DATE PERMIT I S S U E D 7 ? DATE COMPLIANCE ISSUED �� ,..� �� �-7 � 3 Fizz.... .0................ THE COMMONWE,tLTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratilan for Diipniia1 Works Corm xnrtinn ramit Application is hereby made for a Permit to Construct (>0 or Repair ( ) an Individual Sewage Disposal System at: ... :a.� t............��. h Q 4..... .. � _.........NI�.....-•-•--••......................•- .............. ---- .--- -• -- . Location• ddress Lot o ` Ll Owner Address !^1::.................................................... ..................••....._..... staller Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.................1.........__...__._._._...Expansion Attic (Y-) Garbage Grinder ( ) aOther—Type of Building __L?'t 4-_.__..... No. of persons.........1.................. Showers Cafeteria ( ) Otherfixtures --------------------------------------•------------------------------------•------- ------------------------------------------•---------------•---- W Design Flow........:_ ___________________________gallons per person per day. Total daily flow.__... ...................................` gallons. WSeptic Tank—Liquid*capacity_PCC..gallons Length---11C—..... Width.....f _.___. Diameter......L------ 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 ( ) 1 / a Percolation Test Results Performed by o _.._ 3�. .:Y` ........................ Date....d�ZAC6 1._Z�1......___.. EE a. Test Pit No. 1.�._�.......minutes per inch Depth of Test Pit___i?............ Depth to groundw�ta"ecl Test Pit No. 2_t-.?_....minutes per inch Depth of Test Pit-----l.L'........ Depth to ground water.&m)�t&.. ..................................................--•-----------••--• ................................_ Description of Soil ' 4 'n - � -------------------- .._.. -" •-------------------------•----•--------•----------•-----------------------•---------•-----....-------------_.............•-- 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'T':IZ 5 of the State Sanitary Code—The undersigned further agrees not to place the yste in operation until a Certificate of Compliance has been 'ss d�b�y If board o iealth. � Signed .. . • ......e--------------------------------------------------•- Application Approved By........... ----•-_--------------•- 1 �}/L --------- Date Application Disapproved for the following reasons:---••---------•-•-••----•----------•-----•.................•------------------------••-••--•••......•--•--...... Date PermitNo......................................................... Issued_....................................................... Date No.l.. ............. F:ms.............................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH .me�..................OF......... s ............................... Appliration for Disposal Works Tonstrurtiun thrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ................................... :: ....... ...... C -..................... -- ............................... + Location-Address oy Lot No. Owner Address ....._aka d A.� ............................................ ---••-----••--•-...---- -------•-•...... Ins er Address _ UType of Building Size Lot....i_1 ...Sq. feet Dwelling—No. of Bedrooms............I...............................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T ype of Buildin g _..........N'o. of persons-----------9�............... Showers ( � ) — Cafeteria ( ) P4Other fixtures ......................................................'............................................................................. W Design Flow..............5_��_........................gallons per person per day. Total daily flow..._........3_ .....................gallons. WSeptic Tank—Liquid capacity 1QC,:Qgallons Length....IS;I'__. Width.......54r..... Diameter--------L..'_- 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 b ..� ..... ? .� t-S..................... C /2' 17 a y..:. Date-•-----t----•------`-�- -----`'---------- Test Pit No. 1:...42-----minutes per inch Depth of Test Pit.....!Z.......... Depth to ground water..0 e 44 Test Pit No. 2.....4'._--..._minutes per inch Depth-of Test Pit...... .... Depth to ground water. - P4 ....••••...............•---.......................................................................-....... .. 0 Description of Soil......O'.---Z�-•----.L-o'-(Nr ... _.'. r.......---..CC J C`S4Y..._5 K. U " l --•------CA c�. .....�i^-�••................•-••---•--•---------------•--•----•-•-•--•---•------•-•-------•-•-•------....---...---••----------•- 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'TT LE 5 of the State Sanitary Code—The undersigned urther agrees not to place the system in operation until a Certificate of Compliance has been ' su d by�he boaj; ,A health. �� . Signed...... -- . ..__- ;-------------------••-------------------•-------------. ,ram, ----------------- Application Approved B PP PP Y ........................................ ---------------/-----------------_---- Date Application Disapproved for the following reasons---------------------------------------------------------------•---------------................................. .................................................................................................................................................................................................... ----- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 1'I BOARD OF HEALTH .z%. \...............OF......... .. \ . 'Pray-Q .m..................... GrtifirFatr of (toutpliFattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) • !_ �`pp . M, a .-43`^ Instal at-----... ........•---••--.P _ .n ......... an 34- �----me-_`as....------. has been installed in accordance with the provisions UV� y Pe State Sanitary Code as described in the application for Disposal Works Construction Permit ______`__-_-___-_-_.___---__- dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................•--- Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS (_ BOARD OF HEALTH Q6 ..1..��.u• .................OF...... . (�� sue........................ ......................... FEE........................ Disposal Works Tunstrurtiun rrntit Permission is hereby granted. ..... ........................................................... to Construct ( or Repair ( o) an Individual Sea,agcs Dip sal System »� at No...... i ....... ° Street as shown on the application for Disposal Works Construction.Permit No............ ... . Dated--_ -------------------------- ---------- ---••• y -- .................................................-------------------------- Bol of Health DATE............... ... .2..�� � ................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ' N , W F,� - 619 j 0 1 /� G 1tp ��. �0pari F e • i �l¢ s r GMw F� F ; _1113,. 31T 1111 N s h �c 37, ay Do 33 F � /cxa,. -Toh :a Rc 0 F f - LEGEND U tSTING SPOT E-L-EVATION 010 6AOFA9.� CERTIFIED PLOT P' AN F. ISTING CONTOUR 0 oaf Ro�aSs o® � EFINISHED SPOT ELEVATION 0.0 ' 9°�-,lI�YS P�I=® C®NTOUR 0 a ' fi BUNIKIS No.22162 O DROVED BOARD OF HEALTH oo �FGIST EP<;\��i e s ® M 3 OW OATE` AGENT _ s, 4 SCALE / w Y® , DATE :�c � ,;, LDREDGE ENGINEERING COr INd ` CLIENTF✓, �� 'f I CERTIFY THAT THE PROPOSED ® � o � '7EGtSTERE& 'REGISTERED 1 ,JOB NO. BUILDING SHOWr� ON THIS PLAN CIVIL LAND O RNSTABLE MAN O E ZONING LAWS : ENGINEERS,-: ENGINEERS,- i SURVEYOR4 C 1 D'FR� ®Y ' 2 V, iN NCH BY : _ SHEET __ _ OF DATE REG . LAND SURVEYOR ? .E/7f/ER 11-IE SEP77C TAA- /< OR 2® PT M//V. ARC M®RE rNA.N /Z &RLOW C716R C0NCk'R'-'-=- CopeAr /d pr. /�9/A/. •�t`dA.GL ®�= �PdOU IROlYfa�`� �O �RA®�.�.-iN EXTRA -- ®/Pd' NEAvy CA s7- CO/VCoQ�T�' � iey./M. P/7GH coli,�i�S� .: Y8",PER /F/N oR�vE awA y i':'o:' _ - ---f/ �� = . GRADE CCU VER CZ EAN .SANS _. e - 7T— _. 2'L AYER a .g C.45T J v o o 0 IRON PIPE �g 0 0 , CYAL. � ° o e 0l a e o e o e e� n W,45HFD 5727NE z- M/N. P/TGN D/SY, p�n - 0 0 oI e o • o o a e m 4q rA/V/C ®o X p Q o o c .314 a , v D e e oEFF6CP/VE r s • b WASf0 D/STONE � a eoe! o 0 o soee r.. o. ' ° o o ei • e o e e o o D o y — PRECAST SEE/-�t G E e G/T OR EQU/V , 0 0 o r o ® o • ® o o e I/v✓E,zT AT BUILDIW& 9.7.o FT ---- -- -- C(sEE-ruLA7 ION INLET SEPTIC TANK II(<9 F7 -�U_FT. v/�IA'I . ----- OU7LET SEPTIC TA)V.K _F3 �-o GROUNo WATES TAB4E /NL�T D/5T�/t9UT/ON SOX F� SECT101V aF oC/T ETDI.STRIABIMON BOX s'9 FT _� 1,V Z T LEACH I NG PS T �FT 7A- ,6 L.A7-16Al Fes -- -.-- L EACH11v6 /T' vl/►9E/V F10 Al A SCAT E : %4 = / ® � 1 D/A9EM5/off/ —:K—FT. DE5/6H CR I TEX/A 'Y F.T' A4,H 3 D/A7EMS/®N c /vu14SER OF®E,omoom5 TOTAL E:�7'/^1A-reD FLoAv_ 33® _�.��/D � oil - A/ SOILT.EST 2 �� . . -FLL�a! Cj7, 6 �EL�V DATE of S®/L TEST' � r I4NUM8ER aF 04C'HINC --- S/®E l�`ACt9/riG PEP$ ®/p SQ FY /_ ' ICESU.L7'5 k//T-NESS'ED BY ° Pr'v�e®LA-Ally RAro �/ / S s M/Iv,//Ncrr eBpY�OM/�41CN/MG P&1� P/T—� — . .Fp PERC01.AT/OA/RA7E AL-2 LEAa,-^6 M/N.1INCI �G -To�AL L,-ACHIACr ARC-1 S4 Fr. ` ti lain �� cp rr7'ANNi3reR Zr � t `.•' .E't e z �' +" ,: � la$giVlJ.'l�►�'./�ti7" � �4-E� J®� No.