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HomeMy WebLinkAbout0314 STRAWBERRY HILL ROAD - Health 314 Strawberry Hill Road Centerville P A = 248 136 S.lIll J�RECYCIEDCI UPC 12543 No. 53LOR osr_ o�5�"" HASTINGS, MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 314 StrawberryHill Rd n -��" -- - Property Address Bob Drisco. Owner Owner's Name t information is r�ry required for every Centerville Ma 02632 8/21/15 - page. City/Town State Zip -- Code Date of Inspection c r,�iti Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, 11,4 use cn!y the tab 1: Inspector: key to move your cursor-do not Michael DiBuon_o use the return - - - key. Name of Inspector DiBuono Sewer and Drain tea Company Name 8 Company Address return S Yarmouth MA 02664 City/Town State Zip Code 5087364-9587 S1.13522 Telephone Number License Number i B. Certification — - -------------- I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP.approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �8/21/15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 4j�a t5ms 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 314 Strawberry_HIII Rd Property Address Bob Driscol Owner --..- —-- Owner's Name information is required for every Centerville Ma 02632 8/21/15 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: The system contains a 1500 gallon plastic tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of. Health. ' * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i _ J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 314 Strawberry Hill Rd Property Address Bob Driscol ---- - .-am ---- _ _... - ..__ ......__ . _._._.._ - --- — .__._. .. .... caner Owner's Name information is required for every Centerville Ma 02632 8/21/15 - - page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): [] distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health).- broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety�or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a Surface water, ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 151ns•3113 1dle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts �� --_-- Title 5 Official Inspection Form h' -- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /r 314 Strawberry_Hill Rd Property Address Bob Driscol Owner - Owner's Name information is required for every Centerville Ma 02632 8/21/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of q private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or rnore from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 H 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 '/2 day flow 15ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 314 Strawberr_Hill Rd Property Address Bob Driscol Owner _. .--- .. _._ Owner's Na a me information is Centerville_ Ma 02632 8/21/15 required for every _._._ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l51ns•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 314 Strawberry Hill Rd Property Address Bob Driscol Owner Owner's Name information is required for every Centerville Ma 02632 8/21/15 page. City/Town 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? �C� ❑ 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? El ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑C ❑ Was the facility or dwelling inspected for signs of sewage back up? �Q ❑ Was the site inspected for signs of break out? �� ❑ Were all system components, excluding the SAS, located on site? El ❑ 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. El ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information --------- Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 �,L\ Commonwealth of Massachusetts a= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 314 Strawberry HIII Rd Property Address Bob Driscol Owner Owner's Name information is Centerville Ma 02632 8/21/15 required for every --_-._-. _-.- - -_. -.-._ page. City/Town - State Zip Code Date of Inspection D. System Information Description: The system contains a 1500 gallon plastic tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. Number of current residents: 2- - Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 years usage d 101 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: ------------. ..----__._ -___.__.. .- Design flow (based on 310 CMR 15.203): ____ - _-_--------.__.._._._.____-------__..--._. ...___._ Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): -- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non.-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - - -- 15ms•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts ru _ _ Title 5 Official Inspection Form - -- �'1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments g 314 Strawberry Hill Rd Property Address Bob Driscol Owner --- Owner's Name _..... ....-. _ information is Centerville Ma 02632 8/21/15 required for every ------- _ ._. ........ .. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: None provided Source of information: -----_ ----__.__--------------- --______.-----------_--.._._ Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: - gallons How was quantity pumped determined? ------ --- ..._.___---.___..._------_---.------------.._._-_..------.___._._-- Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe).- (Sins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 8 of 17 yr Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 314 Strawberry Hill Rd Property Address Bob Driscol Owner .. -._.._. Owner's Name information is Centerville Ma 02632 8/21/15 required for every __.__ __.__. page. CityrTown - ---- - - State Zip Codee Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 15 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer (locate on site plan): Depth below grade: 28 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): _.__.._.... Distance from private water supply well or suction line: - - - -- -- ---- feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throught the roof. Septic Tank (locate on site plan): 2 ft Depth below grade: _..._ ._.._.-------_. feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 Gallon Dimensions: Sludge depth: 3 t5ms•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Bey° 314 Strawberry Hill Rd --- - --- - - ---- - - -- _._.-. ---------------- - - - Property Address Bob Driscol n er's Owner .w -- - -_.. ..... -- Own Name _--__-._ .------- _..-- information is Centerville Ma 02632 8/21/15 required for every --...__.._._._ . _. . . _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 3 42" Distance from top of scum to top of outlet tee or baffle - - ---- ----- - - -- --- -- --- - Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection_ Grease Trap (locate on site plan): Depth below grade: fee NA t Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle - - - ---- ----- -- - Distance from bottom of scum to bottom of outlet tee or baffle - - - - - - - Date of last pumping: Date 151ns•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I? :- =1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 314 Strawberry Hill Rd Property Address Bob Driscol Owner Owner's Name information is required for every Centerville Ma 02632 8/21/15 Cit /Town page. Y 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.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: ---- - .. - - gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -- ------- -- - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins•3/13 1 iIle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 314 StraNberr Hill Rd Property Address Bob Driscol Owner Owner's Name information is required for every Centerville Ma 02632 8/21/15 __._._.. - page. City/Town - .o State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): At normal level Depth of liquid level above outlet invert - -- - - 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.): Distribution Box is level and at normal level with no signs of carryover or decay. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•3113 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 12 of 17 e\ Commonwealth of Massachusetts _ Title 5 Official Inspection Form s� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments as. 314 Strawberry Hill Rd Property Address Bob Driscol Owner Owner's Name information is Centerville Ma 02632 8/21/15 required for every _. ...._ ..__. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. -- - --- -- - ---- ® leaching chambers number: -2----- -- -- ---- ❑ 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.): No signs of carry over and no signs of hydraulic failure. 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 15ms•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal Syslem•Page 13 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 314 Strawberry Hill Rd Property Address Bob D ris co I Owner Owner's Name information is required for every Centerville Ma 02632 8/21/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No.signs of ponding or hydraulic failure. ---------------- Privy (locate on site plan): Materials of construction: ---------- Dimensions ---------- Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, coridition of vegetation, etc.): -------------------- ............................. .......... ................ -------------- t5,ns-3113 Title 5 Official inspection Form.Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 314 Strawberr Hill Rd' Y. Property Address Bob Driscol Owner Owner's Name information is required for every Centerville_______ Ma 02632 8/21/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 15,ns•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts v� r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 314 Strawberry Hill Rd Property Address Bob Driscol Owner Owner's Name information is Centerville Ma 02632 8/21/15 required for every _.._... .............__ - ... page. City/Town - _ - State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ ft 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: 9/15/2000 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: Test hole data on plan dated 9/15/2000 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51ns•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 16 of 17 ....... .... �tt�` 8- '1A 01 I WN 6 0'a MR, Z, mlmwlnm�-_2 -,i iigg, g, I-Wn"'ll."15%,U'll W Egg' RIM, 2 M D t M F All -mr kl.`�f WPM,T"I'll, it -A -07 AM 01 IRMO= g -I A"O g.'1111-1�11- ON A-- rg w v nlzima` 'k Al A IF- E ove r1l I Mil OW m IM, 'A -0,1 RM, Al M at pi IW- W momP, `Z, - - �,' --- ,-,"," N, �,--O -!,N mi MOP' 74 1r R -56 a -R,,2- mz 02 ggmgi M w "AIRV :g -p p4n Mg— �Mlk M "i n-A nft� —M HT MW L --- Commonwealth of Massachusetts _ W Title 5 Official Inspection F®.rm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 314 Strawberry Hill Rd Property Address Bob Driscol - - -- -----. . - --- ----- --- - - Owner Owner's Name information is Centerville_ Ma 02632 8/21/15 required for every ----- - --.. - -. __... .-- --- -- --- - --- --- ------. _.. — . _.... . page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 151ns•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 C01L110\'N;T-ALTH OF M,aSACHI:SET?S C _ n EXECL-MrE OFFICE OF DYMONAMN-TAL AF'F MS _ -DEPARTMENT OF ENVIRONMENTAL PROTECTION ' O\'E n'LCTER STRTi'.BOS:O\;tia 0210� t6I'�292-S.7tk TRIMY C0.LE Secret&-. ARGEO PALL CELLUCCI Da171O B STF:-uc . Governor SUBSURFACE SUBSURFACE SEWAGE DISPOSAL SYSTEM NSpECT1ON FORM PART'A CERTMATION Property Address: 314 Strawberry Hill Rd. Name of Owner a me c Tl r i c C o 11 Centerville Address of Owner: Date of Inspection: . Name of Inspectw:(Please Prin0 Wm. E. Robinson Sr. I am•DEP approved s asspeetor to Sscdm 15.3W of Title 5 9310 CUR 15.000) cempanyName: Wm. E. Robinson Septic Service MalingAddress: PQ Box 0 9. Centerville. MA Tek F, R to Number: 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 sew a disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: (/V v ;_, Date: The System Inspector shell submit a copy of this inspection report to the Approving Authority(Board of Health Or OEP)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 TM system owner and copies sent to the buyer.if applicable. and the approving authority. NOTES AND COMMENTS ,r •i . 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM PART A 661111ACATM Ieorttirttasd) "eopertyAdd►ess: 314 Strawberry Hill Rd. , Centerville Ziemer: Driscoll Date of Inspection: �`—�./—Q-t�•� WSPECTnON SUMMARY: Check (k)jr, C, O/ D: A. SY PASSES: 1 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. COMMENTS: 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 s,no, or not determined(Y. N. or ND). Describe basis of detenninatiort in all instances. If'not determined'.explain why not. The septic tank is metal.unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance lattached)indicating that the tank was installed within twenty 120)years prior to the date of the inspection: or the septic tank, whether or not metal,is cracked.structurally unsound.shows substantial infiltration or oxfihration, 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. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken,settled or uneven distribution box. The system will pass inspection if Iwith approval of the Board of Health). broken pipets)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 pipets). The system will pass inspection if Iwith approval of the Board of Health): broken pipets)are replaced obstruction is removed rev-se" 7 j 2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Iconbrumd) PropertyAddre:s: 314 Strawberry Hill Rd. , Centerville Owner: Driscoll Dale of Inspection: /,— —cry 2-I 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 15.303 11)(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 IAND 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. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 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 porn. Method used to determine distance (approximation not valid). 3, OTHER PaRc3of11 SUBSURFACE SEWAGE DfSPOSAL SYSTEM INSPECTION FORM. � PART A CERTIFICATION(continued) Property Address: 314 Strawberry Hill Rd. , Centerville Owner: Driscoll Date of inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: 1 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 fairure Yes No Backup of sewage into facility or system component due to an overloaded orelogged SAS or cesspool. Discharge or pondmg of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ Any portion of the Soil Absorption System. cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet 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 ccliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. LARGE SYSTEM FAILS: ou 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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The wrier or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional offi of the Department for further information. Papt4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Property Address: 314 Strawberry Hill Rd. , Centerville Owner: Driscoll Date of Inspection: Check if the following have been done: You must indicate either 'Yes' or 'No" as to each of the following. Yes No Pumping information was provided by the owner,occupant, or Board of Health. _ None of the system components have been pumped for at bast two weeks an&the system has been receiving werntal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. _ As built plans have been obtained and examined. Note if they are not available with NrA. _ The facility or.dwelling was inspected for signs of sewage back-up. _V _ The system does not receive non-sanitary or industrial*waste flow. ✓ _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes 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: _ Existing information. For example, Plan at B.O.N. _ Determined in the field(if any of the failure criteria related to Part C is at issue.approximation of distance is unacceptable! / I15.302(3)(b)) ✓ _ The facility owner land occupants.if differertt from owner) were provided with information on the aropermaintanaiara-0f SubSurface Disposal Systems. 2/J Page of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION 1rope0ty Address: 314 Strawberry Hill Rd. , Centerville Owner: DriSC011 Date of Inspection: FLOW CONDITIONS RESIDENTIAL- Design : SO m��g.p.d.fbedroo . flow Number of bedrooms Idesign): 3 Number of bedrooms factual):3 Total DESIGN flow V S Number of current residents: Garbage grinder lyes or no): Laundry(separate system) (yes or no):!'!-A; If yes.separate inspection required Laundry system inspected lyes or no! Seasonal use (yes or no):A U Water meter readings. if available (last two year's usage Igpd): _ 1999 62 ,000 gal. Sump Pump(yes or nc;:A Q 1998 60,000 gal. Last date of occupancy C MMERCIALnNDUSTRIAL: Type of establishment: Des.g flow: opd 1 Based on 15.203) Basis f design flow Greas trap present: (yes or no)_ Industr al Waste Holding Tank present: (Yes or no)_ Non-sa itery waste discharged to the Title 5 system: )yes or no)_ Water eter readings, if available: Last d to of Occupancy.- 0 escribel Last ate of occupancy GENERAL INFORMATION PUMPING RECORDS and source of information: /f—::I..J—0-<7 System pumped as part of inspection: (yes or nol.Z,o If yes. volume pumped:%gallons Reason for pumping TYPE OF YSTEM Septic tank,distribution boxisoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes OF no) (if yes. attach previous inspection records,if any) CA Technology etc. Anach COPY of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other i APPROXIMATE AGE of all components, date installed if kno wn)own► and source of information.. l ��•.-�6—�� Sewage odors detected when arriving at the site: (yes or no) SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEM•((FORMATION IC0n*w 0) lrgwrtyAddress: 314 -Strawberry Hill Rd. , Centerville Owner: Driscoll Date of Inspection: BU ING SEWER: Mocat on site plan) Depth elow grade:_ Mate►i of construction:_cast iron_40 PVC_other(explain) Distan from private water supply well or suction line Diamet r Comm nts: (condition of joints, venting, evidence of Isakage.etc.) SEPTIC TANK:JZ (locate on site plan) Ir Depth below grade:6 � Material of construction:_concrete_metal.fiberglass _Polyethylene_otherlexplain► If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(YesiNo) Dimensions: Sludge depth:_ r t Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: y 9 Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom of outlet tee or baffle c/9 Mow dimensions were determined: A, 1Ylie� ::omments: Irecommendation 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.) V &LJ 6-6 s�•o S L Q S yJW r��L' -0 o t `t✓ 7% GREI E TRAP: (locate on site plan! Depth b low grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensi ns: Scum th ckness. D�stanc from top of scum to top of outlet tee or baffle: Distant from bottom of scum to bottom of outlet tee or baffle: Date of lest pumping: Com rite: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evi nce of leakage. etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icandrared) brop"Add►ess: 314 Strawberry Hill Rd. , Centerville Owner: Driscoll Data of bspection: TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Iloeat on site plan) Depth *low grade:_ Materie of construction: concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimens ons: Capaci y: gallons Design flow:_gallonvday Alarm resent Alarm level: Alarm in working order:Yes_ No_ Date f previous pumping. Cc ants: Ico ition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_V (locate on site plan; Depth of liquid level above outlet invert: O Comments: (note if level and distribution is equal. evOenee of solids carryover, evidence of leskage into or out of box, etc.) y�z.cJ - PUM CHAMBER:_ (local on site plan! Pump in workingorder: (Yes or N o) Alar s in working order (Yes or No) Com ants: In1 condition of pump chamber. condition of pumps and appurtenances. etc.) •` Page 8 or i 1 r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 1combrallpid) 4openyAddress:314 Strawberry Hill Rd. , Centerville Owner: Dr1.SC011 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible:excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leeching chambers,number:, leaching galleries, number:_ leaching trenches. number, length: leaching fields. number, dimensions: overflow cesspool, number. Alternative system: Name of Technology: Comments: (note condition o1 soil, signs of hydraulic failure. 1 vel of pond/ing. damp soil, condition of vegetation, etc. 7 a 4 lbkL Z_ %L /JOW tSys CESSPOOLS: foocate on site plan; A Number and configuration. Ll/1 v'up Depth-top of liquid to inlet invert: Depth of solids layer: Jlepth of scum layer: Dimensions of cesspool. Materials of construction Indication of groundwater: inflow (cesspool must be pumped as pan of inspection; Com ents (note ondition of soil, signs of hydraulic failure, level of pondrng, condition of vegetation, etc.) PRIVY _ V liocate on site plan) Mater Is of construction Depth of solids: Dimensions: Corn ents: (not condition of soil. signs of hydraulic failure, level of pondrng, condition of vegetation, etc.) Pap(9 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM , PART C SYSTEM NiIFORMATION Icon inuact) 'rop"Address: 314 Strawberry Hill Rd. , Centerville Jwner: Sate of lnspeedQ-C i S C O 11 ll oZ/�e�d SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 1 0' (Locate where public water supply comes into house) pie, SA, 9 �S> j l 1• w s SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM PART C SYSTEM WFORMATION Ieon*MA ropartyAddrasa: 314 Strawberry Hill Rd. , Centerville Owrw: Driscoll Date of Inspae bon`� NRCS Report name Soil Type_ Typical depth to groundwater USGS Date wabsite visited Observation Wells checked Deep Groundwater depth: Shallow Moderate SITE EXAM Slope Surface water Check Cehir Shallow wells t Estimated Depth to Groundwater do'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.) D termined from local conditions ecked 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) Y° Y S':.S e 9 E Pare 11 of 21 COMMONWEALTH OF MASSACHUSETTS FILE COPY EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ` © �-I w 'I d DEPARTMENT OF ENVIRONMENTAL PROTECTION (SAP PARCEL LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM:; PART A CERTIFICATION Property Address: 314 Strawberry Hill Road p 1 Centerville,MA. 02632 Owner's Name: Ronald Driscoll to Owner's Address: 62 Derby Street —v Hingham,MA. 02043 z Date of Inspection: 3/16/2004 — r w m Name of Inspector: (please print) Brad J.White Company Name: Windriver Environmental Mailing Address: 107 North Main Street Carver,MA.02330 Telephone Number: (508)866-2576 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: / — Date: 3/16/2004 The system inspector shall submit a copy of his inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments System Passes ****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. Title 5 Inspection Form 6/15/2000 page 1 ti Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 314 Strawberry Hill Road Centerville,MA.02632 Owner: Ronald Driscoll Date of Inspection: 3/16/2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System Passes.No evidence of hydraulic failure. 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain.: T41. �r„......r 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 314 Strawberry Hill Road Centerville,MA.02632 Owner: Ronald Driscoll Date of Inspection: 3/16/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or'a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Titl. C Tnon +;—P—411 ciInnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 314 Strawberry Hill Road Centerville,MA.02632 Owner: Ronald Driscoll Date of Inspection: 3/16/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to 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''/z 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 X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described m 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• 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) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 314 Strawberry Hill Road Centerville,MA.02632 Owner: Ronald Driscoll Date of Inspection: 3/16/2004 Check if the following have been done.You must indicate"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 Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site'? X _ 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? X _ 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: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ 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(3)(b)] T';rlo G 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 314 Strawberry Hill Road Centerville,MA.02632 Owner: Ronald Driscoll Date of Inspection: 3/16/2004 FLOW CONDITIONS RESIDENTIAL 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):330gpd Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no): Yes Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)):N/A Sump pump(yes or no): No Last date of occupancy: Current COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 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/use- OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: System Never Pumped Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Soil absorption system Single cesspool _Overflow cesspool _Privy No 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: System was installed November 21,2000 per as built. Were sewage odors detected when arriving at the site(yes or no): No T;rto 1;r„.„A,.r;, Fnr.,,411 VIOA0 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 314 Strawberry Hill Road Centerville,MA.02632 Owner: Ronald Driscoll Date of Inspection: 3/16/2004 BUILDING SEWER(locate on site plan) Depth below grade:40" Materials of construction: cast iron X 40 PVC other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): Building sewer is in good condition.No evidence of leakage in or out. SEPTIC TANK: X (locate on site plan)(Inlet to grade) Depth below grade: 30" Material of construction: concrete_metal X fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 5'x 12' x 6' Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 47" Scum thickness:Flocking Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or.baffle:49" How were dimensions determined: Measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Inlet Tee and Outlet Tees in good condition.Septic Tank is in good condition.Liquid level is normal. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tifla S Tncnar4inn Tinrrn ail-ci�nnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 314 Strawberry Hill Road Centerville,MA.02632 Owner: Ronald Driscoll Date of Inspection: 3/16/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X if present must be opened)(locate on site plan)(32"below grade) Depth of liquid level above outlet invert: 0 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.): D box is level.No evidence of hydraulic failure.No evidence of leakage in or out. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T41. s T--t;n T7nr.,,411,;Monn 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 314 Strawberry Hill Road Centerville,MA.02624 Owner: Ronald Driscoll Date of Inspection:3/16/2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: X leaching chambers,number: 2 @ 5'x 9' x 2' 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 is dry.No signs of hydraulic failure.There is no evidence of ponding to the surface.Vegetation is normal and is grass. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): T;riA T„enurtinn�..,.,,�i�ci�nnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 314 Strawberry Hill Road . Centerville,MA. 02624 Owner: Ronald Driscoll Date of Inspection: 3/16/2004 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. Q -cc K .L g H � E 2 ►�`1 - 310' �� , 3� 10 i ~ Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 314 Strawberry Hill Road Centerville,MA.02624 Owner: Ronald Drsicoll Date of Inspection:3/16/2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20' feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed: 11/21/00 X 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: No Indication of groundwater infiltration.Taken from as built plans... T41a G T_o .,+in 17^—411 ci')nnn 11 TOWN OF BARNSTABLE LOCATION /t/ S /�:p �� b A R I'i SEWAGE # CEO G VILLAGE C 0- 76EA11 6 i ASSESSOR'S MAP & LOT9 #�?` INSTALLER'S NAME&PHONE NO. lt�e�eJi a3 < ? .? '� — SEPTIC TANK CAPACITY .. s 1 LEACHING FACILITY: (type) S^—a ,�Z I- (size) �.2 NO. OF BEDROOMS .) BUILDER OR OWNER.' =g PERMIT DATE: 7 `/f V° z COMPLIANCE DATE: 100 Separation Distance Between the: ry Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching�Fsacility (If any wells exist on site or within 200 feet of leachingrfacility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by y __ _ � L'� t`' `=^,��u .� � � \. �.r Y,� � � �� ,. P�� �.� f _ � TOWN OF BARNSTABLE I LOCATION 3iq STrA"V�y 14111 U- SEWAGE # VILLAGE ASSESSOR'S MAP & LOTd��� a� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY O'OD LEACHING FACILITY: (type) A-r G X 6 -_(size) /6% l NO. OF BEDROOMS d— _ 1 � D � BUILDER OR OWNER SuG`1 t L'l�ri PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private-Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac 'ng facility) Feet Furnished by Fol� J IA BAJ� a, , o A l3 a iasas ` - TOWN OF BARNSTABLE LOCATION - 57'A'A k1 e -,E X Wil-Z egk� SEWAGE# VELLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 1 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t SOS a / No. 1531 ►:% Fe v t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for Misspaoaf *pgtem Con!truction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Asje&or^SsA64)&prry Hill Rd. ,3 entervil e James Driscoll i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title—5 s ept i e—system Inn ef- a canis, d box and 4 heavy duty plastic 3 each chambers with stone all arp-un-a Date last inspected: pd� a/( bJlur r-01< 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 Certifi- cate of Compliance has been issued by thi ,do H�fh� Signed %f 7 Date Application Approved by Date Application Disapproved for the following reasons Permit No. "�� Date Issued _ TOWN OF BARNSTABLE mi LOCATION %�/ .S /��;d SEWAGE # el V =op VILLAGE �0 �- i G_1�II�'L,l,� ASSESSOR'S MAP & LOT l INSTALLER'S NAME&PHONE NO. "� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �� S-i—;? L. (size) ,i�:z-• .5., <1. ; NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 00 Separation Distance Between the: Maximum Adjusted Groundwater Table to the B ttom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leachingfacility) Feet Edge of Wetland and Leaching Facility,(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �. V -ZV� FPS%�_ � r� --'?`• F� No. ' THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS �� 0ppYication for Oiopogar bp.5tem Construction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. - 114 8 r wberry Hill Rd.�,3Centerville James Driscoll ssessor s ap) arce Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) - Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. _ Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand sr Nature of Repairs or Alterations(Answer when applicable) V t l e—5 S zl tic g v g t pm con l i s t ing as tank A hnx and 4 heavy duty plastic leach chambers �jf-h stone all nrrninrl Date last inspected: PO� � 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 Certifi- cate of Compliance has been issu d b t ' d ofU ah. Signed Date ,-`Application Approved by Date -Z4 Application Disapproved for the following reasons Permit No. Date Issued ---------------------------------- - ---- THE COMMONWEALTH OF MASSACHUSETTS Driscoll BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( )by wm, R, Rohi ncnn Septic Service at 314 Strawberry Hill Rd. ., Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Wm. E. Robinson Sr. Designer ��. The issuance of this ermitsh 1 not be lonstrued as a guarantee that the system will function as desi ned. p g Inspector � `a'�,'► /� d�,r,Yl1U. , �I j, ,j Date r —5-- ----------------------------- No.�` Fee 2 y j _ /j� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Driscoll ligpooai 6potem Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at31 4 Strawberry Hill Rd. , Centerville and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. a�- Provided:Construction must be ompleted within three years of the date of this ' Date: / �S � Approved by A 1 u6�s - NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) 1, William E. Robinson,S�eby comfy that the application for disposal works construction permit signed by me dated �'����`" 6--QJ , concerning the 4 property located at 314 S t-r a wh P r r)l Hill Rd. C P n t-P r v il ZTeets all of the Mowing criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soi is classified as CLASS I and the percolation rate is less man or equal to 5 minutes per inch. There re no wetlands within 100 feet of the proposed sexic sy�ent — The -no private wells within 150 feet of the proposed septic system There a no increase in flow and/or change in use proposed • no variances requested or needed. . ttom of the proposed leaching facility will ngt be located less than five feet above the ma.)dmum adjusted groundwater table elevation: [Adjust the groundwater table using the Frimptor method when applicable) • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed teaching facility will not be located less than fourteen()41 feet above the maximum adjusted groundwater table elevation, Please complete the following; A) Top of Ground Surface Elevation(using G1S information) B l G.W.Elevation +the MAX. High G.W. Adjustment DIFFERENCE BETWEEN A and B SIGNED : a �s.,:�� DATE: S I`'✓� [Sketch proposed plan of system on back). q.heam folds:cat .� r ... ��� � - � c i� 1. � _ .r i a .xt'� ' -- � a .. y '✓� 4 ... � a . _ �� ra. .i -.:�"�. .. Y e _ � r, _,,, --- FIZE ............ THE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH ----�OF............ ................. .................................................... Appliration for Uiiipoiial Workii Toaqtrurfion -Urrutit I/ Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syste;y at: r .............. .............................. ...... *................. . ........ ocation-Address A Own a Address Install Address feet Type of Bui ing Size Lot/ Dwelling-,KNo. of Bedrooms--------------- — _---_._.--.Expansion Attic Garbage Grinder Other—Type of Building -----------------_-------- No. of persons___.____-._--_-_-------._. Showers Cafeteria Other fixtures ...................... ------- Design Flow ................... ------------------------------------------------------------- -------- per person per day. Total daily flow---.-__-—--------------------------------gallons. Septic Tank t-Liquid capacitv-/"---Plons Length________________ Width..__.._.....-. iameter......... ------ Depth...._..___._.... Disposal Trench—No_ ---------- Widtli.:��-----�tal Lenp 4- otalkleaching area-----------------_sq. f t. ---------- el) e� Seepage Pit No------/------------- Diameter../_�........... e Total leacli'p' ig area---------- -------sq. it. Other Distribution box Dosing tank ( ) A Percolation fe's"t Results Performed by------- ----- -------------------------------------------------------- Date--------------------------------------- Test Pit No. I----------------minutes per inch Depth of Test Pit___.._..........__._ Depth to -round water...._-.-___-.__.____._.. GL Test Pit No. 2---_-----------minutes per inch Depth of Test Pit.--_-__________-_--- Depth to ground wat ----------- ----------- ----------------- ------------- ---------- a------ ..................... ------------ 0 ------ Description of Soil_------ ...... ---------------- --- -------1- 7__ ---_------------------- ......... �4 % - ----------- ---- ------ ­ - - ------- --- --- U ---------------- —------- ----tt------- ----------- ---:7y --—-------/--I.... -------------------------------------------_----- --------------------------- UNature of Repairs or Alteratio —Answer when aFF-cable--------------- ----------------------------------------•-------------------------------------- ----------- ----------------- ---------------------------------------- -------------------------------------------------------------------------------------------------- ---------------------------- 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 e by the board- of health. e. Sign -------------0 ............. ..... --------- ------------------------ /Date . .. ....... a_ Application Approved By - - - ------------- --- . ate te Application Disapproved for the following reasons:-------------------------------- ....................................................................... .............................................................................................................................---------------------­­- ------------- --------------------------------- Date PermitNo------!?N............................................. Issued..... .. ..../... . ...... . .................... t I- ------------ ------------------- --------- ------------------------------- No.._._... = Flns.......� ............. THE COMMONWEALTH OF MASSACHUSETTS OARD O H LTH -..� tr'? .....OF.......................................... - ----•--....-.......------------ Appliration -for Di,opoottl Works Tonitrnrtion Vrrniit Application is hereby made for a Permit to Construct ( or Repair ( } pan Individual Sewage Disposal Syst at: � � r •----- rY t j ocation-Address r Lot L` + t -------- OwnLr r Address !/ ----- - ---- Instal r Address Q Type of Bun ding Size Lot C —I... / q. feet U Dwelling—No. of Bedrooms__________________________________________Expansion Attic ( ) Garbage Grinder ( ) p, ,• Other—Type of Building ____________________________ No. of persons_____-_-___________-______ Showers ( ) — Cafeteria ( ) Other fixtures ------ ---------------------- -• - W Design Flow............................................gallons per person per day. Total daily flow................----------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width_.... Diameter---------------- Deepth-----_-_-_ --- 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-------------------------------------------------------------------------- bate........................------------ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit____________________ Depth to ground water--_- _---__-- ( Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__--___-______-_____.... Q+' -------------------------------------------------------------------------------------------------------------•--------------------------------------=--=----- ODescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ U :... W --•----------- -------- ---- ------=- ------------------------------------------------------------------------------------------------------------------------------------------------ --------------- V Nature of Repairs or Alterations--Answer when applicable.------------------------------------------------------------------_............................ ---•-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with tl e provisions of Article XI of the State Sanitary Code ' The undersigned further agrees not to place the system in operation until a Certificate of `ompliance has been ed b the b and of health. , Signed-L --=--=----- -------------------------------- Date ApplicationApproved BY -- - ...: -------••--•-=-•--------------------------------------------- ............................. ---------- Date Application Disapproved for the following reasons____________________•_____•-_-______•______•_______..__._._.___-_._._._..____._____.__._.....__.___._..__________ ---•--•-•-•-------------•---•--------------------- ..................................................................................... e Date Permit No.....�.9•--•--•-•-•••.......................... Issued....... �- ---- G` Da j THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH ....-....... ..........OF.......... .......................................�........................... ...-.-. Qrrtif irate of OVAIm hats r THIS I 0 CERUkY, That'the Individual Sewage Disposal System constructed X or Repaired"(" ) by.............. t ll`r .. ----- at_ 3.._.�._... -----•- -- '---L -------••----------------••••-•-- " has been installed in accordance with the pro ions of ArticleXI�gf d cVi] },� ye State Sanitary Code as ,t}�e application for Disposal Works Construction Permit No_________________________________________ dated---------.._._______..................... ..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE SYSTEM WILL F -NCTION SATISFACTORY. DATE y�--------------------------- Inspector ` THE COMMONWEALTH OF MASSACHUSETTS ..._...�.� BOARD . HEA H OF.- . / 9.✓ ......-. / No.. FEE---- ................... n Permission} ys hereby granted--------- •-- ----••-------•---------------•---• .----•------••---._._._-__.--•-------._.-_...-•---- to Co st uc X, or e r Sewa i os tem - �.+ ...............................treet as shown on the application for Disposal Works Construction ,er 't No.-_ ______J- - ated..............7:7�° .` _•_.--- oard f Health DATE / -------------------=---------------------•-• ` FORM 1255 / BBS & WARREN. INC.. PUBLISHERS 1 t �( • Fro.v • r ..�,....+✓'--ter '�'--�- .. ` S .LOCATION 5 E P MITI 1a0. VILLAGE - iwSTQ LER S ►J E ADDRESS bU1 DER 5 &"F- ADDRESS AOL DATE PERK IT ISSUED O A �, TE COMPLI t-ICE ISSUED ; �- Y"`` • ' F �I vw — �, �. � �' � at - l �� - ,` a. �� _ f 4 C.. ��o