HomeMy WebLinkAbout0057 WASHINGTON BURSLEY WAY - Health -7 Washington Bursley Way
Centerville
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1
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town [which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: �� Q•� Fill in please:
of '" APPLICANT'S YOUR NAME/S: r G-rl On 4
B SI E $ /,47
�nZ YOUR HOME ADDRESS: cS"
N " TELEPHONE # Home Telephone Number r76
t'
NAME OF CORPORATION: oeel j!
NAME OF Pi1EW BUSINESS TYPE OF BUSINESS G-r n io u� I L,6j.
IS THIS A HOME OCCUPATION? YES NO � i �2 l/
ADDRESS OF BUSINESS ��S r.✓'�S� /'MAP/PARCEL NUMBER O I [Assessing]
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — [corner of Yarmouth
Rd. & Main Street] to make sure you have the appropriate permits and licenses required to legally operate.your business in this town.
1. BUILDING COMMISSIONER' OFFIC
MUST COMn_.' ° WITH HOME OCCUPATION
This individual has been ' or f any per r uirements that pertain to this type of business. ,..
RULES AN,_ ; , i d S. FAILURE TO
�uth ed S' aturre n COMPLY i .`' ",.,_�."I IN FINE
C MMENTS ! ?&
d' -P
2. BOARD OF HEALTH
This individual has been info a of a permit requirements that pertain to this type of business. MUST COMPLY WITH ALL
HAZARDOUS MATERIALS REGULATIONS
1,, Authorized Sig re**
COMMENTS: fay VlrtOcPr�%�e� r-l�Q-i✓l/`�/GP,2 yLu 2{'� )T� � / � `=eJ
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
Hazardous Materials Inventory Sheet Checklist
Date
L—Physical Street Address-Check database to ensure it exists
7"—Working Phone Number ,
Actual Amounts - ( ie. gas being used to fuel machines, thinner to
clean brushes all count as hazardous materials-no blanks)
_ X Storage Information -location of storage, how long is storage for?
If none, note that.
Disposal Information -where and who? If none, note that.
Applicant Signature - understand what is listed and noted
—��Staff Initial -any questions, know who to ask
Vehicle Washing/Rinsing? -give a vehicle washing policy and
explain it
Attach the Business Certificate with your sign off and comments
**The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
D ate:0710j/�6
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: � Doi a-✓�G' ��c y�,s 4.�% .�!' � c> C,-
BUSINESS LOCATION: f ~/' �� �f:�/_e c� 6`y' INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER:
CONTACT PERSON: v / I'
EMERGENCY CONTACT TELEPHONE NUMBE � MSDS ON'SITE?
TYPE OF BUSINESS:
INFORMATION / RECOMMENDATIONS: Fire District:
io
Waste Transportation,/�a►�/K � �jr.'ed ast shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: �i �� i/� �d Sc� JLicensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals(Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals(Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (cr osote)
.2 Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt&roofing tar PCB's
�L' Paints, varnishes, stains, dyes Other chlorinated h' drocarbons,
f r thinners (including carbon t rachloride)
Any other productsith `poison" labels
7NEW
,�
❑ USED �-- w
(including chlorofor ,formaldehyde,
Paint&varnish removers, deglossers `""" hydrochloric acid, o er acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous(please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS pplica s Signature Staff's Initials
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 5V•' 57 Wahington Bursly Way
Property Address
Imo*
Frank Coombs
Owner Owner's Name
information is Centerville t/ MA 02632 8-22-15 required for every =-
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the comuter, 0�+<tHnnurr�r
use only the tab / ���� �jH OF Mgss
19/D Z_
1. Inspector: ya,.• "'"' q
key to move your ;
cursor-do not JamesD.Sears ?�Qr• JAMES
use the return Name of Inspector SEARS
y CapewideEnterprises,LLC
Company Name %' .��•
153 Commercial Street ���i�F 5 INS?
Company Address ►nnnnut
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8-25-15
l4qnsZo,rts 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.
atp-� VS
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'( 57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. City/Town State Zip Code Date of Inspedion
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 is a 1000 Gal. Tank and pit
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):
t5ins•3f13 Title 5 Official htspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
"t 57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°< 57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is Centerville MA 02632 8-22-15
required for every
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
WA ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in eed is less than 6"below invert or available volume is less
than %day flow P/T
t5ins-3113 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
yy< 57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
i
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.
15ins•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
57 Wahington Bursly Way
Property Address
Frank Coombs
Owner owner's Name
information is required for every Centerville MA 02632 8-22-15
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?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y` 57 Wahington Bursly Way
Property Address
Frank Coombs
Owner owner's Name
information is required for every Centerville MA 02632 8-22-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description;
The system is a 1000 Gal. Tank and pit.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage 2013-124,000Gal
g ( y g (gpd))' 2014-35,000GaI s
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. cityrrown state Zip Code Date of Inspedion
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
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, diilil1 soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
up
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1977 Permit # 77-81
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 34"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.):
Pipeing is 4" PVC SCH-40.
Septic Tank(locate on site plan):
Depth below grade: 22"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
6"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
` 57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. Citylrown 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
1"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-TapeSludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank at working level. Tank and cover's at 22"below grade. In let old wall type baffle,outlet baffle.
No sign of leakage or over loading.
I
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No Box
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. Precast pit w/2'stone. Pit and cover at 2' below grade.2'water in pit.
No sign of overloading or solid carry over. No high stain line.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
57 Wahington Bursly Way
Property.Address
Frank Coombs
Owner owner's Name
informrequired
is Centerville MA 02632 8-22-15
required for every
page. Cityrrown 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
via
i
0 3
4
15ins-3113 lids 5 Official 6upection Form:SLfturtam Sewage oisposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°y< 57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
/VO
�
P g 9 12'+
Estimated de th y t �-hi h round water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
on file at B.O.H.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
12' no G.W. Bottom of pit at 8'. Bottom of pit at 4'above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
57 Wahington Bursly Way
Property Address
Frank Coombs
Owner Owner's Name
information is required for every Centerville MA 02632 8-22-15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r
LOFCATION SAW PERMITJ ��EJ_A
t
VILLAGE
INSTA LER'S / NAME & ADDRESS
BUILDER OR OWNER
DATE PERMIT SUED � , 27
F
DATE COMPLIANCE ISSUED -,. ��_ 77
r
9�'l �
s�- a�
N&......
Fmc ................
...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HEALTH
................_OF---- .......................................
Appliration -for Bhipoiial Workii TonMrurfion Vrruift
Application is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal
S stematv
..... ................................................................ ----------------- ---------
Locati 0. -Address o Lot Nq_,�. ...... ...
rJ
..............................
................. . ........ ---4LZ-------_----------------- -----------------_--
rl�.'n e r
? Address
-------------------- ----------------__-------- ------------------------------------- ..................
Installer Address
Type of BuildinL7. Size Lot.././.5- ---Sq. feet
lu
Dwelling ZNo. of Bedrooms.--__--_-- -----_----------------------Expansion Attic G Xage Grinder ( ) A/16
PL4 Other—Type of Building ----------------------------- No. of persons...._____--_______-_-___--__ Showers Cafeteria ( )
a4Other fixtures -------------------------------------------------- -------------------------------------------------------------------- ..............................
Design Flow 66..... ons per person per day. Total daily flow.........—Q-477P`-----------_-gallons.
Liquid capacity- ------- - Ions Length................ Width................ Diameter........._----- Depth----------------
P4 Septic farik�------------
I/ �_ __ - ic
Disposal Trench Widlh_�--------j--------- Total Length..............._.... Total leaching area....................sq. f t.
-------------------- '
- I-' below I t area Seepage Pit No --------- Diameter Depth b I in e Total leachin - ------- ----------sq. f t.
Other Distribution box Dosing tank
Percolation Test Results Performed by------------ ....... ..................................................... Date------------------------------------....
a Test Pit No. 1----------------minutesperinch Depth of Test Pit..-.--_____--_-_-.-- Depth to ground water.-----------------------
(4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-.---__---_---______ Depth to ground water------------------------
----------------- -------- ---------------------------
-- -------- ------/A
0
Description of
------------
�oil Y...
U ...... _//--------a._e' ------- Y_71-------;-*I-,----------------......... -------
------------------ -----------------------------------------------------------------------------------I-------------------- ----------I.......... ........ --------------------------------------
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigiied further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board'of health.
x
S'
19 --------------- ................ ---------- ------------------
ate
Application Approved By.---". ------_'__V.... .. .......... 7.7_---------
41�----------------------- -Date
Application Disapproved for the following reasons:................................................................................................................
----------------------------------------------------........ ---------------------------------------------------------------------------------------------------------------------------------.........
IA._ "?_/0 Date
PermitNo......................................................... Issued.. .....................................................
Date
--------------------------------------------------------- ------ ---- ----- - - --
No_____________ f_:_-.-_.. .... =�... .........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® 'OF HEALTH
........OF
Aplifir"a#ion -fur Uitivpwl JUVI rk C on"5#rUr#ioti. jjrrniit
Application is hereby made for a Permit to Construct ( ) or Repair ,( ) ;an"Individual Sewage: Disposal
System at
14
•-_-.._.._-••• ----
I
.. . Xk -_-:/.. �1.� ---•_Locatto ^...../% �� t , ��_,.-. �or 0._.7/0
Owner / - Jr �L.1.lddress
------! �,c'L�------- 'l---•---`. �.-------------r+X � - - • '__ ! w'J...__.__ __..
----- _____-- __
- - Installer --- `; - -Address. -
Type of Buildin Size Lot..A � _Sq. fe t
U }
Dwelling lNo. of Bedrooms _ -------________ _ ____Expansion Attic ( ) Garbage Grinder
Other.—Type T e of Builciin ;._ __-_ Showers. Cafeteria
a YP g No oi.pct�on' ( ) — . ( ) i
a
Other fixtures --- - -- -- ---- - - •-=---- {
Design Flow __- ___g.l ns her person per clay Total duly flow :__::_ -�� __ --gallon;: 4.
W 1 J - :
1 Septic Tank 7 Liquid c Ili city_ .ons Length_______ ______ Width-............... Diameter_. .......... Depth................
xDisposal Trench—No ___ Width � Total Length ,___--"- Total leaching area. _---- sq. ft.
Seepage Pit No.. C-__-__ __, Dizmeter. 11___!'-JJ. Depth below inlet ____ ___ Total leachi Iret. .------------- sq. ft. '
z Other Distribtition box ( ) Dosing tank ( ) G ��� -
'-' Percolation Test Results Performed by.. -----....................:__ Date..---------.------ ------------------
Test Pit. No. 1_ ______ ______minutes per inch .Depth of Test Pit_ ----------------- Depth to ground writer......................
.-
f1, Test Pit No. 2......-----------minutes per inch Depth-of Test Pit__ ..........___ Depth to ground water... .__- _-____-_-- .
` ` (` r
Descripiion of Soil -..�� 'G ``j`� /_G
U :Y plc -:_�------------------
w.
UNature of Repairs or Alterations—.Answer when applicable __, .,- - .. -.. ::-------------------------------------------- ---- _ _--__-_-
- =--=-------- ---------- -----------•-._...__._. -
r
,. I
Agreement
The undersigned,agrees io install the aforedescribed..Individual Sewage Disposal System in accordance with
the provisions of Article XI'of the State Sauit ii y Code— The undersigned further agrees not to place the system in 1
operation until a Certificate of.Compliance has been issued by the board of health.
Sign d_ - 2 <f r-- -' -- - `--- •� ----- ---• ---- -_5,� 1
u
Application Approved.By :--- / � � i �._;.. _ .U-!11 . �� -•---.
- ---
Date
Application.Disapproved for she following reasons: -•---- -•_... --------------------- --------------_--
-----•••-•- ---- -----•------------ -------------------- -------------•--- •------•------- --- ----- ---- --- - - --- ----- --- -----•----
'. Date
I
- Permit No.-........................................................... .. Issued---- - - -- --- --------•---- •--•--••-
- .. - - Date
• - - - - -- - - - .t -.. _._ _.,. _. _•—.--• - --',=� - • _ _jam -_.__a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t .......OF. : .'.. : . .��S%Ga.�t�'. ....... 1.
err#ifir #r of `llouaVliararr E .
THIS IS157 ART I% That the Individual Sewage Disposal System constructed ( 4T or Repaired ( )
by. f� :L= ; 1 - .
at -_- .-- ---- - 1..3 .:_1- 1> � M � _ 'J
� � 1
has been installed.in accordance with the..provisions of \rfi e�i1I of. Stxfe Sanitary Code a escribed in the
application for-Disposal,Works.Constrtiction Permit No.
7�
-•-�............ ---...-----
THE ISSUANCE OF THIS CERTIFICATE SHALL.NOT BE CONSTRUED AS A GUARANTEE THAT THE i
SYSTEM MCI UPICTIOP. SATISFACTORY
'DATF- - ((J.- `' Inspector- - - ------ •-----
THE. COMMONWEALTH OF MASSACHUSETTS
� 1
'BOARD ''OF HEALTH.
,C
No. -••-._U -••••• FEE.- -L.5...--
-
Dinv ,jttl, jarplV_41
a #raar#i�at r- mit
= .,
Permissio is hereby granted r-- --u- -- ---- ----- --. i
to Constr ct ) or Rep it ( ) a ndividVa1 ,Sew a e Disposal Sy,
at: No.. i ��7 (�cc�� "//Lt -- �_�-Ln/.1 [! s ,%C ( `L2✓� !.Le� ----
1 _ ,. t�sz_._.
as shown on the application for.Disposal Works Constrta ion Permit-. -_..-. Dated _.7� - .............. l
Hoard of/Il l h .....................
- / --�7---------- ---- j
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