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HomeMy WebLinkAbout0063 RIVERVIEW LANE - Health C63verview Lane, Centerville UPC 12543 No. 5� •0��57{ONSJ��o- HASTINGS, MN L 0 10N SEWAGE PERMIT NO.. C�T _ i yg--g 1/ji' Ly � AA1l; VILLAGE IINST A L ER'S NAME & ADDRESS -7'e/{ C x-E7 � BUI-LDER OR OWNER . IM C- ,4i�)V C'c n/ s7' Cc:, 4l2 I DA T E PERMIT ISSUED .. DAT E COMPLIANCE. I S SUED 1 ................... f i Ei Rccas y�oo� . T3'ED0.00M STD RWr6E NEW M g91g2 72 (IYx z�) BCVfiooM �12x 2e) C2Z'x Z.6) O 00 o lo: eu�a: ..even ev. eevmeo wuwwo Nuwem r I r J — NCW/ s°vtl�c.rss-ro I OE+-oWb Fl.�o/L Fl F �U17Zm �\TCFl e1r L {�jJnU l�ohl �IIPnJbX�/ I' �,12. �lo'I,n 1^� I I iti44. ST OA LvING itwM i eu�s: vvrtovw er: _ un: NN E EX 1ST �,OLLM yE7,,T- Z-",IL -9,)bec YLii C-Ox -PLY,,,Oo3> 3 ti CW-rR I KI 6, L'T Zaoiz 51d M(,LVZ K-30 T-"3L Zxa Q-OLI N 1, TOASTS 0. s\�A-o I-11 X14 O.Q. 3 R, O.S.-a .212 x Ib H CA, 4-S- "T't k C- S'ST�-- 'UzN%'77 3/L-lo G i cr E\,-tvr)Noi 3V ,_N S C,,.Sr IrOQ WL IFS SV9 A+.) Al t Roor z i I� i� it �y?�vL- ji I D& 2/13'y x`l LIL HE1t7i m ILAZr it?-00 cm 19/y x 97,'W t V 4,""ty Z44arLu navmm . Awn(p NYMl6N �� Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Core taeawy GOVWW David B.Strubs Argoo Paul Cellucci Conrntrsiorn► U.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 63 Riverview Ln, Centerville, MA AddramofOwner. James Buckley Date of Inspection: �/—/�^ (If different) Name of Inspector. W.E. Robinson SR 5 0(3) 7 7 5-8 7 7 6 Company Name,Address and Telephone Number. W.E. Robinson Septic Service P.O. Box. 1089 Centerville MA 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-side sewage disposal systems. The system: Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails ^ q Inspector's Signature: / Date: ��� / -7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A]7SYS , PASSES:ve not found any information which indicates that the system violates any of the failure criteria es defined in 310 C11fIt 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: jIndicayes, e or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes pection. no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined",explain wily not) The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or enfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank asapproved by the Board of Health. 1/03/95) I One Winter Street 9 Boston,Massachusetts 02108 a FAX(617)556-1049 9 Telephone(617)292-5500 i J Printed on Recycled Paper J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropertyAddresx 63 Riverview Ln, Centerville, MA Owner. James Buckley Date of Inspection: 4/`1 K^9 B)SYSTEM CONDITIONALLY PASSES(continued) _ Sewage backup or breakout or high static water level observed in the distribiution box is due to broken or obstrueW 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): 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) FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the pu lic health,safety and the environment. 1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A 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) SY TEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) D INES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND 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 within 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 1000 feet but 50 feet or more from a private water supply well, unless a well water analysis for eoliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) THER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Riverview Ln, Centerville, MA Owner. James Buckley Date of Inspeotion: 41 D) SYSTEM FAILS: b ' 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 his determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the •urs _ 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 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 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 YSTEM FAILS: The llowing criteria apply to large systems in addition to the criteria above: The m serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public heal and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a public water supply well) The owner or perator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddreaw 63 Riverview Ln, Centerville, MA Owner; James Buckley Date of Inspection: Check if the following have been done: ping information was requested of the owner,occupant,and Board of Health. _,114110'ne of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates dgr' that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _Ao built plans have been obtained and examined. Note if they are not available with N/A. fl'he facility or dwelling was inspected for signs of sewage back-up. _L-,�he system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. t/All system components,excluding the Soil Absorption System, have been located on the site. 1/I'he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of bates or tees, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. LWhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. .1,. `Le facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 63 Riverview Ln, Centerville, MA Owner. James Buckley Date of Inspection: 'e/-15r-1 1 FLOW CONDITIONS RESIDENTIAL: Design flow:6LJy gallons Number of bedrooms: Number of current residents: Garbage grinder(yes or no):-/—,-0 Laundry oonnected to system(yes or no):y S Seasonal use(yea or no):A-Lb Water meter readings, if available: 1995 - 6 96 - 52 , 000 gals. Last date of occupancy: COMMERCIALANDUSTRIAL 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 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and urce of information: System pumped IG part of inspection: (yes or no)_, If yes,volume pumped: gallons Reason for pumping: TYP10S STEM ic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yea,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)A (revised 11/03/95) 6 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) propertyAdd,.= 63 Riverview Ln, Centerville, MA Owner. James Buckley Date of Inspection: SEPTIC TANK./ (locate on site plan) 1 Depth below grade: Material of construction: ►!concrete_metal_FRP_other(explain) ) 1 O Dimensions: -1" f�?o�-• ��. ludge depth: sDistance 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: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth o liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) d `v =,.► " G E TRAP:_ (locate site plan) Depth bel w grade: Material o construction:_concrete_metal_FRP—other(explain) Dimensions: Scum thicker Distance fro top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: — Comments: (recomme tion for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, eviden ,etc.) (revised 11/03/95) 6 f J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address: 63 Riverview Ln, Centerville, MA Owner. James Buckley Date of Inspeotion: L/—/S'9 '7 TIGHT OR HOLDING TANK— an( an site plan) Depth low grade: Mate ' of construction:_concrete_metal_FRP—other(explain) Dime ns: Capaci Rallona flow: gallon/day Alarm 1: Comma (ooadi ' of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: V (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of eoliths carryover,evidence of leakage into or out of box,etc.) � Il PUMP' BER:_ (locate on plan) Pumps in wor order:(yes or no) Comments: (note condition f pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddre&s: 63 Riverview Ln, Centerville, MA Owner. James Buckley Date of Inspection: L/!5-4 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:L leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool, number: / Comments note condition of�aoil, signs of hydraulic failurejlevel of�onding,co dition of vegetation,etc.) re— L �T O h CESS IS:_ (locate site plan) Number configuration: Depth-top o liquid to inlet invert: Depth of so' layer. Depth of scum layer: Dimensions of pool: Materials of ruction: Indication of water: infl (cesspool must be pumped as part of inspection) Comments: ote condition of&oil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY:_ (locate on site p ) Materials of co n• Dimensions• Depth of so Comments: ( ote condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Prope,tyAddress; 63 Riverview Ln, Centerville, MA Owner. James Buckley Date of Inspeotion: �� 5 SKffMH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' _ b � S 1 � f i J DEPTH TO GROUNDWATER Depth to groundwater:/,.�—4feet method of determination or approximation: t S 4 � (revised 11/03/95) 9 7 No..._.J./ .._.... Ynic THE' COMMONWEALTH OF MASSACHUSETTS y, BOARD OF HEALTH Svc I•eA"�ti ;. ..........OF.....,.c i.�/ �`' �4...(. .......--- Appliration -for, Ropooal Workii Tomitrurtiou Vautit Application is hereby'made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: Location.Address 27 L r Lot N. , Owner Address ............ ....... = Installer Address U Type of Building Size Lot--,,, -Sq. feet Dwelling—No. of Bedrooms-----------.__tea............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 0.' Other fixtures d ------- ............................................................_---------•----•--- W Design Flow.............51--_-___�� gallons per person ger day. Total.�ly flow------���-----------------------gallons WSeptic Tank—Liqutd capactty ......._..gallons Length_- _: ____ Width- __."`_...._.. Diameter-----.---------- Deptivc---�.._. - x Disposal Trench—No--------------------- Width.................... Total Length___.-__-____------ Total leaching area-------.------------sq. ft. Seepage Pit No....../----------- ameter.,f ... Depth below inlet__-/0.......... Total leaching are. ------sq. ft. z Other Distribution box ( Dosing tank ( ) '—' Percolation Test Results Performed by.._�' c _ � ..� .............. Date---61 �.�__.__-:.... a Test Pit No. ---minutes per inch Depth of "Pest Pit....IV.__..... Depth to ground water..----—------.------ f� Test Pit No. 2.e—o' .....minutes per inch Depth of Test Pit--- --- Depth to ground water---- __.___----- --------------------1-1----------------------------------------------------------------------------------------------------------------------------------- - O Description of Soil-------------- ----- fps --` � ----------- ---------------------------------- V ------------------------------------------- . w x -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V;, -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 Pe board Vheh. Signed, ...-•-•--- Dat ApplicationApproved BY--------- /C..................-........................................................... ................... e--- ---------- Date Application Disapproved forte following reasons---------------••---•--...._.......-•--•-•--•--......_....---------------•--.._.....---•--------.----.---•----•-- --------••--•-----------------------------•-------•-------------------•---•-----------•-----------.--- -------------- �f � - ..--...................... Permit No.------��1-d 5:�lg.................................... Issued.----- "_��P'7 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ tf- .. .......................O F...... . .. ..... . . ............ . .... ................ r 1, (01pxfifiratr of (lampii�t�rae THIS IS TO C TIDY a Dis osal System constructed ( r Repaired by --- --► ---•- �. -------- ^ at------•--�"--C/-/-- ',�- !"•nstall-er�� --•lfir!_I�✓ :0" ,!1►�!••� r r}y/- -•-•--- f has been Installed inaccordance with' the proyisions of article XI of The State Sanitary Code as described in the application for Disposal Works ConstWi.ictk)n Permit No __;_j _ ________________ dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE- v �---- Inspector-------------- ------------ ................................ ✓ TH; ,COMMONWEALTH OF MASSACHUSETTS BOARD OF HHEALTH k No......................... f�, r. FEE -•--••-- %spngal- orkii_ CIT, r,trurtioat rri�ttit permission is reby granted - ................................ l - ...- �' rr to Construct r Repair ( } n Individual Sewage Disposal System ...► , Street ��.... ... , -- ------ Date--- . as shown on the applicarion for Disposal Works Construction P rmif No. _ s ,�__.1f..___�_ ___ __ " " �,. I ----•----- --- •-!/` ............................................_ ri s oard Health ...�►'� DATE.--------------------------- -- FORM 1255 HOBBS & WARREN.'INC'., PUBLISHERS r i No .. J THE COMMONWEALTH OF MASSACHUSETTS lk BOARD OF HEALTH � .- AAlip i,Winn -for DiiiVusal Works Towi#.rurtion Vamit Aplkeation ><s Hereby'made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at } _ Location_Address Lot No ner ,ry ,nddresR4 ,/��Q y Installer Address ,� UType of Building Size Lot_..4;'%t'.�_:__Sq. feet Dwelling—No. of Bedrooms.._-_------------113_________________________Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) G4 Other fixtr es -------- --- ----------------- -- W Design Flow ':�ti'' ....... rllons per person ae,, da;- Total dayly flgw..._._� .._-___._..___gallons. WSeptic Tank-TLlquid capacity/ �galIons Length_--OS/k•. Widtli_+4-_V.. Diameter............:--- Depths--- . x Disposal Trench—No_ .................... Width---- Total Length--------____fir__.. Total leaching area---.,_.__._-..____-_sq. ft. Seepage Pit No.,___...�_..._...__ D ameter__/ --------- Depth below inlet-_-__/_kV.......... Total leaching area _.sq. ft. z Other Distribution bo�c (1 Dosing tank ( ) '-' Percolation Test Results Per rmed by. ------------- �------->'"�." _____________ Date... 4V -------- -- Test Pit No. 1.. ___minut per inch Depth of Test Pit � ........ Depth to ground water ....^�^:_.._..... . G>~ Test Pit No. 2.4l.....minutes er mch D th of Test Pit.___/` __..____ Depth to ground water- �"'-._.___... ..• !/ Rio r ---7............................................................................................ Description of Soil_---------------__ _.. ..________..-... V ......... ..... ...: � ss' f °' _=_�x'''"9 r !cam`- '__ ✓ i' .� ' �!' t .,e W U Nature of Repairs or Alterations—Answer when applicable----------------------------------- -----------------------------------------..._.______.___-__... ----•-------------------------------------------------------------------------------------------•------------------•- -----------------------------•--•--•----------------------------------------_._.. 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