HomeMy WebLinkAbout0542 SOUTH MAIN STREET - Health 542 SOUTH MAIN STREET, CENTERV.
A=186.049
I
f
lllllKKL4 S gS43 v (Z?'lip 3
UPC 12534 '
HASTINGS.UN
I
J,
A
No.. � Fx$.�6. .....
q
THE COMMONWEALTH OF MASSACHUSETTS
-. ..
172"
Barns, ible U ,de 'n Departmen%D%a OF HEALTH
1"*1V"*. 'OWN OF BARNSTABLE
'1 Slgeed ltratioR x Ui ipasal Works TonuUndion rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair 0�,4) an Individual Sewage Disposal
System at: H
��9 cS0 v.
................_.... ....... ........------............•• ••••-••--••••••--•---•---......_...----_..... .......-••------..._...........---.....--
oca on Address or Lot No.
` 1 .......'� ........... y ............. ::. •
............
060 wner
�j O�y�� �1,�, I -dress
.......-
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms..................._........................Expansion Attic ( ) Garbage Grinder ( )
`k Other—T e of Building g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a
Other fixtures_-•-••-•----•--------••---•---------------•-•----...-•--•---------••-•---•---•--•------------•-•-------•--------•--•---------....-•-----•-------•--
W Design Flow__________________. ....................gallons per person per day. Total daily flow........ .......................gallons.
WSeptic Tank—Liquid'capacity,-00_gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.........Z....... Width______ _________ Total Length._. _______ Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet__. ____ Total leaching area..................sq. ft.
Z Other Distribution box (D<) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
W
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0-4
fs, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
a .---••••---•--•----•--•-•--•-•-•--•••-----•-•-•---•--•-----••-•------•••----•-......-•------•--.._...--•--•-•---------•---•........ ........•••••-----•-----
0 Description of Soil...-------. ---.f I...c ._.
V .............................................................................................................................................................................
W
x -•---•-•--------------------------•-••-----------•----•--•------•---------•-----••-•--••-•--•--•--•---------•-------•---•----------••--------•-•-------••-----•-----•-•-•••••-•-•-----•--••-•-••-_....
U Nature of Repairs or Alterations—Answer when a plicableG'�?!e.e�/ -- 5 US
--
...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance be n issued by t board of health.
Signed ---------- - -- -............... ----------. ----- / ( �.
Date
Application Approved By .... -- -� !7�� ///J
Application Disapproved for the following reasons- .................................................................................................----------------------------------
---- .......................---------------------- ...........................-...........................................................
Permit No. .q.1 ..... -6.0
- ------ --- Issued ..-----------t 1 ... ..Date------
Drei
TOWN OF BARNSTABLE
LOCATION SEWAGE # �—� d'�
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAMEA PHONE NO.5gOIZ70-6&7 60&�7-
SEPTIC TANK CAPACITY /--�
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS \,—? PRIVATE WELL OR PUBLIC WATER e,
BUILDER OR WNE 'oa//AJ
DATE PERMIT ISSUED:
1 , 1
DATE COMPLIANCE ISSUED: i
VARIANCE GRANTED: Yes No
r- _ _.._ ____ _�
�'�
i
� ��/
i
� � - - - - -
��
� �- - - -
_' _ t
- ~Z- oil
.'
THE COMMONWEALTH OF MASSACHUSETT.S
BOARD OF HEALTH
1 - ,JOWN OF BARNSTABLE
Appliratiun for Diipuuttl Works Tuntrnrtiun rri mit
Application is hereby made for a Permit to Construct ( ) or Repair (�>e) an Individual Sewage Disposal
System at:
........... ••_... .....••---•... ........... .....-•--•---.....--•--•.......•-•---•--------•-•••---•-----•-----........----•---•••••••••-------
ocation-Address or Lot No.
l..... -.........................1�7r� ✓1Z4i..t.. 5? ...............
Owner
a Gl�" GQ/-t)S�j�UGs/lJ/J dress
._...---•-•........................:...................................................... ••---• •••---••---•-••••----....--•-•••••-•••--•.....-••••-.................••--•-•-
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures r
W Design Flow__________________.. ..._____._gallons per person per day. Total daily flow.._-._._: ____________...._______gallons.
Septic Tank—Liquid capacity/ gallons Length................ Width....__-�_.__.. Diameter................ Depth................
W Disposal Trench=No. ........Z....... 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test.Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------------------------------------------------
--•-------••••-.......
•-------
------------
••-....................
-----------------•----
O Description of Soil.......... __-_ ___L C!4 �__'f__.
U --------------------------------------------------------------•----......---------....----------•--------------•-------------•--------------•--•-----._.....----------------------------------------•-•-
W
x ••••-•••-•-••----•-----------•--•••---••••-••-•-••••---•••-----••--••••••---••----••--•-•---•••••-••----•-••-----••••-----•--------•-•••-••-••-•--••••-•••-•••-•-••--•-••-•-•••••-•-•-•.............••--
U Nature of Repairs or Alterations—Answer when a plicable_<� '' ..z�`� ___ k� ............................................� 1 S
/,Sao_ ® --% !�1��--; •- d}C........... ✓i f s--.•l�J/�'' : ^� ...._..._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by th board of health.
• Signed ......--..
Application Approved BY . .. --..' Dll
4 / Date/ I
Application Disapproved for the following reasons- .....................----- ----------------------------------------- --------------------------- -------------------r-----------
......................- -------------------------------..... .................. ...I.................... ..................------------------........------------------------------ ....t...... ..-r--..
�1C� 6�� !� �T/ ( Date
Permit No. Issued... -----.-.... .......... . ---- ............. .......................
.......------------- Date /` /
Y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifi ate of (foutyliattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ��
by.................... ---------.......I...................SL Dr Olo 7T7 CeA_k571 - 7eAj
---------------------..........................................................................................
Installer
at ............................................... �-.�o �Oc 3• ... ink .S`���i....... L �J [,UG
has been installed in accordance with the provisions of TITLE f The State Environmental Code as described in
the application for Disposal Works Construction Permit I 1;T .�. dated ......�..� � .-------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANT E HAT'THE
SYSTEM WILL FUNCTIONrWISFACTORY. - a
DATE ....... ..................................................................---- Inspector ....-----`.......--------....--............................------------------------- -----..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE a
No......................... FEE.v_................
Disposal Workii Tonartulian jigrutit
,c3O�GiZ elo-7l C-onl�T
Permission is hereby granted.... ------------------.---••••••••••-••••••••••••••••-•••-•-•-•••••-•--.....••••-.......•••......_....•-•-•--••-•-•---
to Construct ( ) or Repair an Individual Sewage Disposal System
,.at No................................................... ,2--------=_�Q4).............. �L4i.J........................................ dUi�L�
J Street Q�I—S,/7 / ^
as shown on the application for Disposal Works Construction Permit No_____________________ Dated_._._ . -!......
- `y h
/j � Board of Health
DATE............................ �•--•� /
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS
S.
f
0
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS �O r
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
1' f
TRUD COXE, 1
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Commissioner
Govemor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Address of Owner: 642 SOUTH MAIN ST CENTERVILLE,MA 02632
Date of Inspection: 6126/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 508-664.6813 FAX 608.664-7270
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:
X Passes
_ Conditionally Passes
_ Needs Further Evaluatl n the Local Approving Authority
Fails
Inspector's Signature: Date:6I29100
The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If th 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.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
Inspection does not imply any warranty?pr guarantee of the longevity of the septic system and any of its component's useful life"
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.
revised 9/2198 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Date of Inspection: 6/26/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the'Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all Instances.If"not determined",explain why not.
n/A 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 exfiitration,or tank failure is imminent.The
system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health.
Wa 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).
_broken pipe(s)are replaced
_obstruction is removed
_distribution box is levelled or replaced
n& 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
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Date of Inspection: 6/26/00
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 IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)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 of 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.
1�j
_ The system has a septic tank and soil absorption system
P p y tem and the SAS is within 50 feet of a private wat
er ter supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nta(approximation not valid).
3) OTHER
n/a
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Date of Inspection: 5126/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described 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
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
_ X Static liquid level In the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
- X Liquid depth In cesspool is less than 6"below Invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q.
- X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
- X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
- X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,
ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"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
- X the system is within 400 feet of a surface drinking water supply
- X the system is within 200 feet of a tributary to a surface drinking water supply
- X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner: JOHN GREENE
Date of Inspection: 6/26/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X - 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.
X - As built plans have been obtained and examined.Note if they are not available with N/A.
X - The facility or dwelling was inspected for signs of sewage back-up.
X - The system does not receive non-sanitary or industrial waste flow.
X - The site was inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X - The septic tank manholes 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:
X - Existing information,For example,Plan at B4O,H,
X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Date of Inspection: 6/26/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):
Total DESIGN flow: 330 gpd
Number of current residents:3
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COM MERCIALIINDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sandary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1991 PERMIT 91-660
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Date of Inspection: 6126100
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 18"
Material of construction: _ cast Iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: 4"
Comments: (condition of joints,venting,evidence of leakage,etc.)
THE SYSTEM HAS TOWN WATER.
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 12"
Material of construction: X concrete,_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1600G L 10'6"H 6'6"W 6'8""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
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.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
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.)
n/a
a
revised 9/2198 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Date of Inspection: 6/26100
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 912198 Page 8 of 11
l_C�_CATIO.N_ +SEWQC,E PERMIT UO.
r
_ _ It�IST LLER 5__1J�►NlE-___ADDRESS ___ _ _ __ _
_ _. .ATE_ _COMPLI_L�t�ICE - .ISSUED. _
r
�,y'�
�'
�i�� � .
..��
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 642 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Date of Inspection: 6/26/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(n/a)n/a `}
leaching chambers,number: (n/a)n/a
leaching galleries,number: (4)GALLIES W.2'OF STONE
leaching trenches,number,length: (0)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: nla
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH TRENCH IS 8'X20'.THE LEACH TRENCH IS FUNCTIONING PROPERLY AND SHOWS NO SIGNS OF FAILURE.THEY HAVE NOT HAD
MORE THAN 2'OF WATER IN THEM.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: nla
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
to
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Date of Inspection: 6/26100
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
P�tic IL
DNCK.
N! A �,
O U
O
1
A oy
z,
revised 9098 Page 10 of 11
W
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 542 SOUTH MAIN ST CENTERVILLE, MA 02632 M186 P049
Name of Owner JOHN GREENE
Date of Inspection: 5/26/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 10 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc,)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-10+FEET
revised 9/2198 r, Page 11 of 11
9�No.... (� 4/... Fps... . .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD JQF HEALTH
Appliration -for Diopoottl Works Tonotrurtion Prrotit
Application is hereby made for a Permit to Construct ( ) or Repair (44—dT Individual Sewage Disposal
System at:
e
A`S-A ///��� Location-Address or Lot No. a
...............................y................------------------------------.---------------- --------------------------------.-.-------------.-----....--------------------•-------------------
W I��C Owner /!"1 L Address ,
....... ._.................
In alley Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa,, Other—Type of Building __________________________- No. of persons............................ Showers ( ) — Cafeteria ( )
0.' Other fixtures ------------------••-----------•--------------------------------------•-•-•-•------------------------------------ ----------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ 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 ( )
aPercolation Test Results Performed by------- --- ------------•---•--------•••----•--•-•--•--•--•-----•--------- Date..------...............-- -------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water------.--.--..-.--.-----
(� Test Pit No. 2................minutes per inch Depth of Test Pit---------------------Depth to ground water------------------------
-------------•-------- ---•-----...---------------------...._..-•---..._..._...........-----.-•---•......................... •----........ ...............
GDescription of Soil-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
x
U
Z ----••----------------------•-••--------------------------------------------------- ----•-•----•......---•••. •--- -- ------
U Nature of Repairs or Alterations—Answer whenapplicable.---f-`"`_�. 5_r-,4- .�___________� '�__ Z)9)9C .
"� ---- -----�- -
------------•-------••-•----....-•--•-•----•-------------------•--------•...............�-Al
:------- 1aA_�-��re�.---------------------•-------------�-1 �------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board of h llth. p
Signed -----------
'"N Dat
ApplicationApproved By----------------------------------•---••-•-•----•-----•---•---•--•=------------------------•--•--
Date
Application Disapproved for the following reasons------------------------------------------------•--------------------------........-------------------------•----
----------•••-•-••-•--------•-----------------------•---...-•------------------•--•.._..•••--•----------------------•---•-•------••••--•----------------•--••-•----•-------••--------------••---•------
Date
Permit No......................................................... Issued...,l _ ..C- 7 .
Da e
___- ------------------
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
3�
�
No...... . Fmic.. ..�..."�..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ApVtiratiun -fur Bi.q,Voual Workii Tonmrurtion Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair (e,_)—an Individual Sewage Disposal
System at: - d
0 " Location-Address or I:ot No.
----------(...................7•..........----.. ner-----•----------•-------••---------------- ........... ..................•.......... dre...-•- ....................................
f- Owner Address/ ,,
Inaller Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
a4 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
A'' Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity........--..gallons Length---------------- Width................ Diameter_..............- 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 ( )
aPercolation Test Results Performed by......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit..............----.. Depth to ground water-------.-------------...
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------...._.....-.
a' ------------------------------ ..............................................................................................................................
ODescription of Soil--------- .....................................................------------------------------------------------------------------------------------------------------
V -------------------- ----------------------------------------------------------------•-•-••-•-----------••----•-----------••--•-•--------••--•-------------------------------------------------------
W
x ----------------------------------------------------------------------------------------------------------- --- ----------------------------------------------------------------------------------
,, r
V Nature of Repairs or Alterations—Answer when applicable!!!!!.-..: .. ................ ._�'_.�~...._...Z r rV A.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed • ..................................................... ----
Date
ApplicationApproved By---------------------------------•-•......-----------.......................................... ----------------------------------------
Date
Application Disapproved for the following reasons:................................................................................................................
..................--------------------------------------------------.-...------------------•------------...-....----------•---------•-•----------------------- ••-------------------------------------•-
� Date
Permit No. Issued..- '--'-`, '' ....--`-................••--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
74
...... ......:�...""".......O F.... ..:-:-..........................................................................
Qrrtif irate of fuontpliatta
r
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (—)
b c_f { - -7 l
y.............. - ••••--......... ------- _ •------••---•••----•-••----••----------------•-•-••--------------•----••-•-••------•-------•----......••-•-•......------••-•-•-----•---
{ ' Installer
....' l� .. k .... •Y
at......:Le---------- ._� � �. _ r
has been installed in accordance with the provisions of . -re XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N .... ..... ------------ dated--.._ —.y=. T................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FU CTION SATISFACTORY.
DATE. •-�------- ------------------------------•---------.------ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.--•----•----•-----••--• FEE..
�i��u�ttl. urkCnon�tr�trtiun �drrntit
Permission is hereby granted........
............................................................
to Construct ( ) or Repair ( 'an,-Individual Sewage Disposal-� System
............................ ................................................... -----------------------------
Street
as shown on the application for Disposal Works Construction Pe it No��-,Z-2 Dated...=-..` .7 S. ...............
r.� / _ Board of Heal �
DATL - / --- --- ----------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
f
� �