HomeMy WebLinkAbout0101 WATERSIDE DRIVE - Health 101 WATERSIDE DRIVE, CENTERVILLE
A = 227 170
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UPC 12534
No.2153L_OR `�srcw�
HASTINGS,MN
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 signature's 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: -j " �( Fill in please:
APPLICANT'S YOUR NAME/S: �/
BUSINESS YOUR HOME ADDRESS:
#max Wit: ,z apt, NIP,
P °l d ®� �O✓ a� 1.L-'�
w rnti G, w h d,
; TELEPHONE # Home Telephone Number
NAME OF CORPORATION:
NAME OF NEW BUSINESS TYPE OF BUSINESS c��J
IS THIS A HOME OCCUPATION? YES NO ��PZ ^ l�� (Assessing)
ADDRESS OF BUSINESS �� C� v --MFAP/PARCEL NUMBER
I
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 operat etrr�Gusines i E OCCUPATION
MUST COMPLY
FAILURE TO
1. BUILDING COMMISSI�'SE J� RULES AND REGU
LATIONS. FAIL
is that pertain to this a of business. MAY RESULT IN FINES.
This individual has of an e t requirements p type COMPLY M
any CO
thorized Sig tur *
COMMEN
i�LJ r
CLL�J
2. BOARD49 HEALTH This individual has been i h requirements that pertain to this type of business.
�,," Author ed ignature*
COMMENTS:
3. CONSUMER AFFAIR : LICENSING AU ORITY)
This individual ha be ; o licensing requirements that pertain to this type of business.
tur
COMMENTS:
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COMMONWEALTH OF MASSACHUSETTS -
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor commisslo
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART A
CERTIFICATION
Property Address: 101 WATERSIDE DR. CENTERVILLE MAP 227 PAR 170 H
Name of Owner DEBBIE POON
Address of Owner: 606 HUCKENS NECK RD.CENTERVILLE MA.02632 40
Date of Inspection: 2/17/99 �
Name of Inspector:(Please Print)JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: John Graci Title V Septic Inspection �` t
Mailing Address, P.O.Box 2119 TeaTicket,Ma.02636
Telephone Number: (608)564-6813
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The Inpection Is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further Elklytion By the Local Approving Authority performing at the time of the inspection.My Inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:3/3199
The System Inspector shall fubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2/17/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
hID The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,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.
NO Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
obstruction is removed
_ distribution box is levelled or replaced
DID The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_ broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2/17/99
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(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
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 ppm,Method used to determine distance n/a_(approximation not valid).
3) OTHER
n/a
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2/17/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped n/a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
I
revised 912/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2/17/99
Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was Inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
11 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2/17/99
FLOW CONDITIONS
RESIDENTIAL
Design flowJMQ g.p.d./bedroom
Number of bedrooms(design): 5 Number of bedrooms(actual):A
Total DESIGN flow: L%
Number of current residents:Il
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):-M
Seasonal use(yes or no):JLQ
Water meter readings,if available(last two year's usage(gpd): n&
Sump Pump(yes or no): NQ
Last date of occupancy: 1116199
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n&gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):JLQ
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:n&
Last date of occupancy: n&
OTHER: (Describe)
n&
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n&
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped nl& gallons
Reason for pumping: n&
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1984 .
Sewage odors detected when arriving at the site:(yes or no): NQ
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2/17/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: M
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n/A
Comments: (condition of joints,venting,evidence of leakage,etc.)
n&
SEPTIC TANK: X
(locate on site plan)
Depth below grade: V
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
n/A
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
n/A
Dimensions: L 8'G"H F'7"W 4'10"
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: ME
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle:-"
Distance from bottom of scum to bottom of outlet tee or baffle: Jr
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED
EVERY TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
n/A
Dimensions: n/A
Scum thickness: n/A
Distance from top of scum to top of outlet tee or baffle:ll/A
Distance from bottom of scum to bottom of outlet tee or baffle WA
Date of last pumping: n/A
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n/A
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2/17/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n(a
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nla
Dimensions: n(a
Capacity: nla gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:jiL& Alarm in working order:Yes—No—: NQ
Date of previous pumping: nia
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n1a
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DID NOT EXPOSE D-BOX IS WAS TO DEEP -8' DOWN
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nta
revised 9/2198 Page 8 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2/17/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Wa
Type:
leaching pits,number: nLa
leaching chambers,number: 6-FLOW DIFFUSERS COVER RAISED
leaching galleries,number: _nLa
leaching trenches,number,length: n(a
leaching fields,number,dimensions: nLa
overflow cesspool,number: n/a
Alternative system: nla
Name of Technology: _nfa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE FLOW DIFFUSERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY THEY WERE EMPTY AT THE TIME OF THE INSPECTION.
DID NOT INSPEc,a-Uf1 a(' n C)(M 0 \ v�L
CESSPOOLS: _
(locate on site plan)
Number and configuration: Wa
Depth-top of liquid to inlet invert: n/A
Depth of solids layer: n&
Depth of scum layer. n&
Dimensions of cesspool: n(a
Materials of construction: n&
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)Wa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n&
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n&
Depth of solids: DLit
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2/17/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
o 4
a
G �
AR 3
A6 3y
AC 33
0
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 WATERSIDE DR.CENTERVILLE MAP 227 PAR 170
Owner: DEBBIE POON
Date of Inspection:2117/99
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: WA
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 10 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
GROUNDWATER WAS DETERMINED BY USGS MAPS AND CHARTS AND VISUAL,BOTTOM OF FLOWS IS AT 8'
revised 9/2198 Page 11 of 11
Safe Earth Systems, Inc. 4 T
P.O. Box 1359CfIVf®
b Marstons Mills, MA 02648
508-477-2999 - 508-420-2803 r, DEC ,1�9 5
Address of Property: 101 Waterside Drive e
Centerville. MA 4`9
Owner's Name: Jim Poon
Date of Inspection: November 14. 1995
PART A CHECKLIST
x Pumping information was requested of the owner, occupant
and Board of Health.
x None of the system components have been pumped for at
least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have
not.been introduced into the system recently or as part of
this inspection
N/A As built plans have been obtained and examined.
Note if they are not available with N/A.
x The facility or dwelling was inspected for signs of sewage
back-up.
x The site was inspected for signs of breakout.
x All system components, excluding the SAS, have been
located on the site.
x The septic tank manholes were uncovered, opened, and the
interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth
of liquid, depth of sludge, depth of scum.
x The size and location of the SAS on the site has been
determined based on existing information or approximated
by non-intrusive methods.
x The facility owner (and occupants, if different from owner)
were provided with information on the proper maintenance
of SSDS.
1
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If Residential
4 Number of bedrooms
4 Number of current residents
No Garbage Grinder (yes/no)
Yes Laundry connected to system (yes/no)
No Seasonal use (yes/no)
If Non-residential N/A
Calculated flow
Water meter readings, if available:
Last date of occupancy
General Information
Pumping records and source of information:
No System pumped as part of inspection (yes/no)
If yes, volume pumped
Reason for pumping:
Type of system:
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes/no) (if yes, attach previous
inspection records if any.)
Other; Explain
Approximate age of all components. Date installed, if known. Source of
information: 11 Years
No Sewage odors detected when arriving at the site (yes/no).
2
SYSTEM INFORMATION continued
Septic Tank: x
(Locate on site plan)
Depth below grade: it
Material of construction : x concrete_ metal FRP_ other(explain)
Dimensions: 6' x 10' x 6'
.5" Sludge depth
4.5" Distance from top of sludge to bottom of outlet tee or baffle
1" Scum thickness
z„ Distance from top of scum to top of outlet tee or baffle
1499 Distance from bottom of scum to bottom of outlet tee or
baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of
liquid level in relation to outlet invert, structural integrity, evidence of leakage,
recommendations for repairs, etc.) condition of all components good. Recommend
pumping.
Distribution box: X
(locate on site plan)
o Depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage
into or out of box, recommendation for repairs, etc.) Level&sound. No recommendation.
Pump Chamber: N/A
(locate on site plan)
N/A Pumps in working order (yes/no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc.)
3
SYSTEM INFORMATION continued
Soil Absorption System (SAS): X
(locate on site plan, if possible; excavation not required, but may be approximated by
non-intrusive methods)
If not determined to be present, explain:
Type
Leaching pits and number Four f41 4'x 8' x 1" flow diffusers
Leaching chambers and number
Leaching galleries and number
Leaching trenches, number, length
Leaching fields, number, dimensions
Overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of
vegetation, recommendations for maintenance or repairs, etc.) : No sign of failure
CESSPOOLS (locate on site plan): N/A
Number and configuration
Depth-top of liquid to inlet invert
Depth of solid layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater
Inflow ( cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs or hydraulic failure, level ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction
Dimensions
Depth of Solids
Comments: N/A
(note condition of soil, signs of hydraulic failure, level of ponding, condition of
vegetation, recommendations for maintenance or repairs, etc.
4
SYSTEM INFORMATION continued
Sketch of Sewage Disposal System:
Include time to at least two permanent references, landm�Fks or
benchmarks.
Locate all wells wi 'n 100'
r
Depth to Groundwater
Depth to groundwater
Method of determination or approximation: site
pp n. Obtained from mite well
information
5
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of
determination in all instances. If"not determined", explain why not.
N Backup of sewage into facility?
N Discharge or ponding of effluent to the surface of the ground
or surface waters?
N Static liquid level in the distribution box above outlet invert?
N Liquid depth in cesspool <6 below invert or available
volume < 1/2 day flow?
N Required pumping 4 times or more in the last year?
Number of times pumped
N Septic tank is metal? cracked? structurally unsound?
substantial infiltration? substantial exfiltration? tank failure
imminent?
N Is any portion of the SAS, cesspool or privy: below the high
groundwater elevation?
N Within 50 feet or a surface water?
N Within 100 feet of a surface water supply or tributary to a
surface water supply?
N Within a Zone I of a public well?
N Within 50 feet of a bordering vegetated wetland or salt
marsh (cesspools and privies only, not the SAS)?
N Within 50 feet of a private water supply well?
N Less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis?
If the well has been analyzed to be acceptable, attach copy
of well water analysis for coliform bacteria, volatile organic
compounds, ammonia nitrogen and nitrate nitrogen.
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INFORM
ATION FORM
PART D
CERTIFICATION
Name of Inspector: Michael DiMaggio
Company Name: Safe Earth Systems
Company Address: 135 Rte. 130, Mashpee, MA 02649
Mailing Address: P.O. Box 1359, Marstons Mills, MA 02648
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal systems.
Check one:
_X_ I have not found any information which indicates that the
system fails to adequately protect public health or the environment as.
defined in 310 CMR 15.303. Any failure criteria not evaluated are as
stated in the Failure Criteria section of this form.
I have determined that the system fails to protect public
health and the environment as defined in 310 CMR 15.303. The basis for
this determination is provided in the Failure Criteria section of this form.
Inspector's Signature " _.
Date NOVEMBER 14, 1995
Original to systems owner
Copies to: Board of Health
Buyer (if applicable)
Approving Authority
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If Residential
4 Number of bedrooms
4 Number of current residents
No Garbage Grinder (yes/no)
Yes Laundry connected to system (yes/no)
No Seasonal use (yes/no)
If Non-residential N/A
Calculated flow
Water meter readings, if available:
Last date of occupancy
General Information
Pumping records and source of information:
No System pumped as part of inspection (yes/no)
If yes, volume pumped
Reason for pumping:
Type of system:
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes/no) (if yes, attach previous
inspection records if any.)
Other; Explain :
Approximate age of all components. Date installed, if known. Source of
information: 11 Years
No Sewage odors detected when arriving at the site (yes/no).
2
Fizz ...........
'THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................OF.,'°............................... ...............................................
Appliration for Bhipviial lVorkii Timitrurtion ".truth
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Sy em at:
............... . .................................. . ......................................
Location-Address fr Lot No.
............................................................... ................................. -------------------------------------------
'nJe _ r
. ............................ ...... %.................
------------------------------------- ........
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...........................................Expansion Attic Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons........_.__.........__.._.. Showers Cafeteria ( )
0 4tiri,, Wires ................................................................................................
2 .................
Design Flow......... ul............ ...... .gallons per person per day. Total daily flow._ .......................gallons.
W
Septic Tank—Liquid aci 711on Length................ Width..............._ Diameter__._......_..._. ---------
N0.1 Disposal Trench ................. Total Length....._.............. Total leaching area..ttBsq. ft.
....................r-
Seepage Pit No. lameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank ( )
aPercolation Test Results Performed by......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit................._.. Depth to ground water..._..............._.__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........._.........._...
..............................................................................................................................................................
0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W
U .........................................................................................................................................................................................................
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
............................................................................................................................................................. .........................................
Agreement:
The undersigned agrees to
I inS tall t aforedesc(leI\!ndividual Sewage Disposal System in accordance with
the provisions of TLIT11Z 5 of the State Sq�dp—The undersigne urther agrees not to yplace t e system in
operation until a Certificate of Comp * nc h n i e 01
Si .. . .........................
Da L. . ......
Application Approved ............... . . . .. ... .. . . ........... .... ....... ...... .. ............ ..
ate
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo.......................................................... Issued.......................................................
Date
y �.h
Fmm..51...01................
• THE COMMONWEALTH OF MASSACHUSETTS
• BOARD OF HEALTH
........................... ...............OF..............................
........-
ApplirFation for Disposal Works Tonstratrtion Vrrattit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
...... ... ...........
.. _...- ...................... '-- ............................... .... .......................................
--•-
Location-Address for Lot No.
O�
...................
Installer '
.. -- '*•' -•- ...................
Address
d Type•of Building Size Lot............................Sq. feet
U ' Dwelling—No. of Bedrooms-4
............................... .....Expansion Attic ( ) Garbage Grinder ( )
�� Other, Type of Building ................•_______.... No. of ersons........_.__............._.. Showers —
'"•; ; yPeey� g p ( ) Cafeteria ( )
4 (Oa res ---------••------------•-
W Design Flow______________________ __ __gallons per person per day. Total daily flow_tt4i.�.____._...................gallons.
WSeptic Tank—Liquid' c41 '. $�' Length................ Width................ Diameter____.__--_._..
x Disposal Trench—No. .................... Width-............_._._.. Total Length.................... Total leaching areal.-
Seepage
Pit No_____________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
`-, Percolation Test Results Performed by.......................................................................... Date......-----.............................
a
14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ...
•......
---------------------------------------------------------------------------------------------•------•••---•------------•-__---••--•--••••--•-------
0 Description of Soil...............................................................................................................................
x
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
...-------•-••-----••----------------------------•---------------------------------...._...-•-----••.....------•-•-
Agreement:
The undersigned agrees to install Akke aforede ribe Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State 1 ry de—The undersigne further agrees not to place he system in
operation until a Certificate of Co m an en u b t b o
S ed........... --
e
�^- � .
Application Approve . .---- --• -------- ,t .. ' -----•.
J Date
Application Disapproved for the following reasons---------------••---------------------------------------•------•-----------------•-•-----•---•---•-•---..._------
.................•-•................-•••-••-•--•-----•-•----•-------•-•-----•---•-•••---•-.._...-------•--------------••--••------•----•--------------•------•----------•-----------•-
------------------
Date
PermitNo.......................................................- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..............................................................
Trdifirtt#r of TontpliFam
THIS TO CE TItFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---------- -
b` �� ' taller
f�
at---•-------...--•---------''-� ---•--•.. . s�. . ----. _�._....... ----
has been installed in accordance with the provisions of TI........ .j of T1 e State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... ......._........ dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. -----•---•.............•-------' � j- Inspector `. !�
...................................................
THE COMMONWEALTH OF MASSACHUSETTS
1
• BOARD OF HEALTH
No. �. � _ ......................................
••• FEE.__ .............
e o
Permission is hereby granted = = �. ,� � � ` ...
at No......... ` �........ / ��
to Construct,(��.ori Zepair ( an Indiv„aylual e�ag Disposal ������"'--------------------------------------•-----.....-•---....
treet
as shown on the application for Disposal Works Construction Permit No..............:........ Dated..........................................
_._...._...' .___. ..................Y.._.
I: Board of Health
DATE �� .'�'= 1 r--• -- -
7
fg_ FORM 1255 A. M. SULKIN, INC., BOSTON
i i
/70.
OCAT N161 SEWAG PERMI NO.
VILLAGE
�1NSTA LLER'S NAME i ADDRESS
e U I L D E R OR OWNER
DATE PERMIT ISSUED -ZU
DAT E COMPLIANCE ISSUED
u
Y
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