HomeMy WebLinkAbout0056 SETH PARKER ROAD - Health 56 Seth Parker Road
Centerville
A= 170- 180
a
SJ� �
UPC 12534
�.2-153L
No. U Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplication for -Misposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair(V) Upgrade( ) Abandon( ) ❑Complete System dividual Components
Location Address or Lot No. S to S ET1A Pay RKcR Rb Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel I-1 O 1 S O SA L,/R Tofs r- ANb 1=L-vIR R L)1 C L4l o
Installer's Name,Address,and Tel.No. SOS'`t�l"1 ' $ Designer's Name,Address,and Tel.No.
{,oac.n-T (3 o-f. Cu-
3c�3
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) W . gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
TNSA-k1� N't,0 D33 R10 egox W- - / ► ikttf A-mp, Cpvt2 GfertioF-
CIn4-V%�e 1'')n t � we r�n D- 13�x p�D P►'`"
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. -7
Signed Date
Application Approved by Date
�7
Application Disapproved by Date
for the following reasons
Permit No. 2-y (- 2 7 Date Issued
---------------------------------------------------------------------------------------
�i
t z?d
i
No. � 4 4 . 2- Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
. Yes 1
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
2pplifatlon for ]Disposal *pstrm Construction 3perm t '
��` � A
Application for a Permit to Construct( ) Repair)( Upgrade( ) Abandon( ) ❑Complete System L❑,I4idi_,,�--vidual Components-rt
Location Address or Lot No. 56 S E IIA Pa P-K r.R RN Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 10 ,Q O �n �"'' it i P Tr,f�t �F L v l►; l 10
Installer's Name,Address,and Tel.No. SCE-LJI1 ' 4 Designer's Name,Address,and Tel.No.
(0�\1An.N �RtH ��rl(1 NAJti�� d�fr(I�{ I
Type of Building: VT
Dwelling No.of Bedrooms (lei Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �l/J✓� gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
-Nature of Repairs or Alterations(Answer when applicable)
�I �N 1�-Al 1( N C,y I�; f� x bi• / r1 k<v Il-N b O yr(L lC a) C Ee N L
/ F y,✓1 �` 1`,�cX n N 1'� 1"T
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in,
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. -7
Signed ._ ..� Date / If 2'
Application Approved by ') , rA � 1� Date /G --2/
Application Disapproved by Date
for the following reasons
m Permit No. 2 U)(— ,2- 72 Date Issued ��' f
THE COMMONWEALTH COMMONWEALTH OF MASSACHUSETTS
�d BARNSTABLE,MASSACHUSETTS
C� . Certificate of Compriante
I THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by Oor
at_ A-r rYst', has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2GZ-j - s^72 dated
Installer Designer
#bedrooms hl /k Approved design flow jV /{- gpd
'The issuance of this permit"s"h�al/l�njot be construed as a guarantee that the sysfein°�willfunct"io �dsigjned.
Date / / J� /C.,7t- t
- . .._^-- _
No. -
�-.2 2 ? 2- Fee 27
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
;Misposal bpstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
_ System located at7
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the,date of this permit.
Date "�—A Approved by
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 56 Seth Parker Rd. IL4(0
Property Address
Salvatore Dichio
Owner Owner's Name
information is Centerville MA 02632 April 21, 2007
required for
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. t
Important:
When filling out A. General Information forms on the COPY
� r
computer, use
1. Inspector:
only the tab key
to move your David D. FlahertyJr., R.S.
cursor-do not Name of Inspector y
use the return
key. Flaherty Environmental Services
Company Name s"
� P.O. Box 81
C:) Irr'
Company Address
Yarmouth Port MA 02675
�RA1 City/Town State Zip Code
508-362-1657
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 16.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
zJ i ; L �.
April 22, 2007
Ins ector's Signature Date
The system inspector shall submit a copy of this inspection reportt 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.
t5insp 56 Seth Parker Centerville(2).doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21, 2007
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:
B) System Conditionally Passes:
❑ One or more system components as described in th `Conditional Pass" section need to be
replaced or repaired. The system, upon completio of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in t ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 ye rs old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substa al infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the a sting tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pas nspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating th the tank is less than 20 years old is available.
ND Explain:
❑ Observation f sewage backup or break out or high static water level in the distribution box due
to broken obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass ins ction if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp 56 Seth Parker Centerville(2).doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M .y 56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21, 2007
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a ye r due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the and of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Requir by the Board of Health:
❑ Conditions exist which requir further evaluation by the Board of Health in order to determine if
the system is failing to prot ct public health, safety or the environment.
1. System will pass un ss Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the s stem is not functioning in a manner which will protect public health,
safety and the envir nment:
❑ Cesspool r privy is within 50 feet of a surface water
❑ Cessp I or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System ill fail unless the Board of Health (and Public Water Supplier, if any)
determine that the system is functioning in a manner that protects the public health,
safety a environment:
❑ he system has a septic tank and soil absorption system (SAS) and the SAS is within
100 fe t 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
sup ly.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
s pply well.
t5insp 56 Seth Parker Centerville(2).doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y� 56 Seth Parker Rd.
M
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21, 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less t 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 anal is, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presen of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other ailure 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
❑ ® 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.
t5insp 56 Seth Parker Centerville(2).doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
u. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M ' 56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 t system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"ye or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is ithin 400 feet of a surface drinking water supply
❑ ❑ the syste is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the s tem is located in a nitrogen sensitive area (Interim Wellhead Protection
.Ar —IWPA) or a mapped Zone II of a public water supply well
If you have answere yes"to any question in Section E the system is considered a significant threat,
or answered "yes" ' Section D above the large system has failed. The owner or operator of any large
system consider a significant threat under Section E or failed under Section D shall upgrade the
system in acc dance with 310 CMR 15.304. The system owner should contact the appropriate
regional offi of the Department.
t5insp 56 Seth Parker Centerville(2).doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
w ti: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
s 56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21, 2007
every page. Cityfrown 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?
E ❑ 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)]
t5insp 56 Seth Parker Centerville(2).doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
41M - 56 Seth Parker Rd. .
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21 2007
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): '06: 211 gpd; '05:
313 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: present
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/s .ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank resent? ❑ Yes ❑ No
Non-sanitary waste disch rged to the Title 5 system? ❑ Yes ❑ No
Water meter readings if available:
Last date of occu ncy/use: Date
Other(descri ):
t5insp 56 Seth Parker Centerville(2).doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
4 u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp 56 Seth Parker Centerville(2).doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
v w: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 50
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
joints good, venting adequate through house, no evidence of leakage
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:
1000 gallon
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle
31"
1
Scum thickness
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
13"
How were dimensions determined? sludge judge, tape measure
t5insp 56 Seth Parker Centerville(2).doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M y 56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21 2007
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.):
maintenance pumping recommended but not required at this time, baffles ok, tank seems structurally
sound, liquid level appropriate, no evidence of leakage
Grease Trap (locate on site plan):
Depth below grade: eet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of ou et tee or baffle
Distance from bottom of scum to b ttom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping re mmendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to utlet invert, evidence of leakage, etc.):
Tig/an
Tank(tank must be pumped at time of inspection) (locate on site plan):
Depe:
Matuction:
❑ ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp 56 Seth Parker Centerville(2).doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21 2007
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumpin Date
Comments (c dition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
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.):
dbox seems level, evbidence of minor solids carryover, no leakage apparent
Pum/workinrder:
plan):
Pump ❑ Yes ❑ No
Alarm ❑ Yes ❑ No
t5insp 56 Seth Parker Centerville(2).doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: (1) 6'x6', 2' stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ 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.):
soil good, no signs of hydraulic failure, no ponding, vegetation typical (lawn), stain line 12"from
bottom
t5insp 56 Seth Parker Centerville(2).doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
Comments (note condition of soil, signs of draulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction-
Dimensions
Depth of solids
Comments (no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp 56 Seth Parker Centerville(2).doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
T lj?l c W1141
�- j :�,j
D2 t'u F w
C
l�
301
t5insp 56 Seth Parker Centerville(2).doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 56 Seth Parker Rd.
Property Address
Salvatore Dichio
Owner Owner's Name
information is required for Centerville MA 02632 April 21 2007
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: 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: 8/4/1986
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:
>10' no groundwater encountered during perc test on April 17, 1985 (Baxter& Nye)
t5insp 56 Seth Parker Centerville(2).doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
LOCATION 1 SEWAGE PERMIT NO.
VILLLAGE
$ INSTALLER'S NAME&ADDRESS
fiL C�
O BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED (o
as'
34
0
._. Fss...4.��.....�......`..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HE L
l-k /go ----.-. -/ .........OF.....--. ................' ............................
Appliratiou for Dhipaiial Works Tomitrurtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemat ». ••-• .................... ..
• •...........................--- ..... o Lgn-Adde N
___________n .......................... ............- . ..... •........... ................................
a Ow —„ Address
... ..--- ? s...
resInsta Add Type of Building Size Lot___ feet
Dwelling—No. of Bedrooms............................................Expansion,Attic ( ) Garbage Grinder ('
` q Other—Type of Building No. of persons____________________________ Showers — Cafeteria
P4 Other x urea------------------------------
w Design Flow__________ ___ ________________._gallons per person per day. Total daily flow........ _®..............gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
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 ( )
PercolationTest Results Performed by.................................................................--•----• Date.........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -------------------------------------------•-----------.....---•----------.........--••------••••---.........................................................
0 Description of Soil........................................................................................................................................................................
x
c,
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 TLITIE 5 of the State Sanitary Code— The undersigned fu ier agrees not to a e the system in
operation until a Cer cate Corn Ii has been is d by the b of h th.
Signed. ------------------•---• •••--
Application Approved By____��� _ �
i _ Date
Date
Application Disapproved for the following reasons:-------•----------------------------------------------------•---------------------------=-----------------_-----
..•••-••-••-••---•••••-•--•-••----•-•-•••-•••-•----••---•-••--•...---••----•----•••-••---•••-••-•-----•---•--•-•--•••••---------•--•---------•-•••....................................................
Date
PermitNo.. » Issued.......................................................
Date
............ .... ........�...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,.OF HEALTH,
........... '- .............. o F.../".........`.. ..w....
Appliration for Dispuual Works Tomitrurtiun rrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System 0/ r`
IR at on Addr �.+ X or- of No
s �
r 2 ti. ..... VF ` �`--_-_--'----_:-:
Owr Add--ess
.•............... ---•--.r.. � .....................
.._..
..........+E° a .... ..�-.'I..............................................
Installer $ Address
d Type of Building Size feet
Dwelling—No. of Bedrooms...............__......_.__.___.._...._.....Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
� OthereUtures------------------------------------------•--------•---.--------•--•-----------.....-----......------.. .......
-- ............................
W Design Flow.........:...........:....................gallons per person per day. Total daily flow............._..............................gal
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No------------------ Diameter.................... Depth below inlet-................. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by..................................•-•-----------•-----------•------•------ Date---------------------------------------.
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --••-----•-•------..._..•----•--•-....------•••----------------••-•-•--................----•-----•-.----•---------.....---...-----------....................
0 Description of Soil........................................................................................................................................................................
x
W
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 Tr!I ,4 51 of the State Sanitary Code—The undersigned further agrees not to piace the syste in
operation until a Cer *-cat f Com h e has been iss red by the PpaId of health.
(n/ Signed._..................................................." �f �- �' T�
D _....
'- -• � Date
Application Approved By..e............ - ------------
Date
Application Disapproved for the following reasons:................................................................................................................
-•---••--•------•-•....•-••---•--------•----••-••--•-•-----•------•-•-•-•-•-----•.............•---.....--•--•---•--......••-----•------------•-----•--•----------•----••-•--••----------•--------------.
Date
Permit No... -. .... .......!�?_� Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ...............OF........ pa". �--'�'C....................
AT
Qrrtifirtttr of Tuutpliunrle
THIS ...TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.-------------- ---- `- �
'-"'•^� -'-----taller -----------•--•------•-----
- --- ---..... y_c ..( ---......`� ' , ....------ - �----------------------------
at
has been installed in accordance with the provisions of j of The State Sanitary Code s descr•" ed in the
application for Disposal Works Construction Permit No._'245j^^-..—.'._�••�.._��,�,'a.. dated__._.__.__::4'' 7;�-4- -`-sue---,�-'---------
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE
SYSTEM WILL F NCTI N SATISFACTORY. � A ,
/ �Z ... Inspector... ................... . Y
DATE......------�-•------....- ----•--••---•----•................... -----•----•------•----•----....._......---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�r ' _ / _1...4 1................OF..- `-- .. . --.-. --?� . --:.........
C� FEE....... =�.r'...
Dispnou1 urk dun rttr Ilan rruti#
Permission is hereby granted........ -"� 3 ........ '==-------•------------------------•--.....------.....-•---•--------•---...
to �Construfc/tom/ (r) or Repair,-(_)^��a►}n In//d�ividual�Se.�=ayge Djsposal'System,
GtNo..•--J-_• _:C.'.r�-�............... �-. ..wY"'... ,(I . �{. �./".! ...............-...........................v. .___.y.............. ....... ._______._.__....._..___._...._.....
street j
as shown on the application for Disposal Works Construction Permit N 6=_<�_ Dated.._ .�al._t�...._........
k � - �� --_
Board of Health
D A T E �4 !
FORM 125�1 Hof & REN. INC.. PUBLISHERS
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