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Home My WebLink About0355 WHITE OAK TRAIL - Health 355 WHITE OAK TRAIL, CENTERVILLE A= • iMNiYi�tW I 7 fix•.,.. •. [� n 00 00 BORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD, MARSTONS MILLS, MA 02648 or r 508-771-9399 508-428-8926 FAX: 508-428-9399 cv,r�a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address`. �J w�Gt�c� _ Date Of Inspection: s�3 3 . UU Inspector's Name: Owner's Nan e a dAddress: Li CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.The system l� Passes , Conditionally Passes Needs Furo va ion By the Local Approving Authority Failure.. _ Inspector's Signature Dale: The System Inspector shall submit a copy of this Inspection Report to the the Approving Authority°with 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 l3,uyir;'If applicable and the Approving Authority. . V 1r. .,kt.'1 p t "s 't INSPECTIONISUMMARY• A) SYSTE PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.3.03. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Appi lived 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 pipe(s)or due to a broken,set t.led or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board(►f Health): i1 � SUBSURFACE .SEWAGE.-'DISPOSAL•SYSTEM!,_4NSPE DUON.FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced 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): '7LL- Broken pipe(s)are replaced �.n Obstruction is removed: C)FURTHER EVUUATION.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 HELATH DETERMINES 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 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 APPROPRIATE)DETERMINES THATXHE SY;'FEM IS FUNCTION- ING IN A MANNER-THAT.-PROTECTS THE.PUBLIC MEALTH,AND SAFETY.AND THE ENVIRONMENT: :n The system has a Septic,Tank and Soil Absorption-System and is,,within 10,0 Feet to a Surface r Water Supply or Tributary to a Surface Water Supply The System has a Septic Tank and Soil Absorption System and is with a Zone 1.of a.Public Water Supply.Well. The System has a Septic'Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply'Well. The System has a Septic Tank and Soil Absorption System and 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 from pollution from the facility and,the presence of ammonia nitrogen and nitrate nitrogen is equal to or less 3 than 5.ppm• D)SYSTEM FAILS: 1 have determined that the System violates one or more of the following Failure Criteria as defined 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. Backup of sewage into facility or system component due to an overload 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. , .n. Static liquid level in the distribution box above outlet.invert due•to.an overloaded or clog- r,: Iged SAS or cesspool;,, „Y�� t.., Liquid deptt in cesspool.is less than G'below inver_taor,avalable•volume is'less thanl/2 day flow. x' Required pumping more than 4 times in the last year NO;1<;due to:clogged or obstructed pipe(s). Number of times pumped y e. — 2 — {;c i, SUBSURFACE'.SEWAGE-;DISPOSAL SYSTEM& INSPECTION 'FORM PART A, CERTIFICATION (continued) Any portion of.the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Asiy portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to ,F'a'surface water supply. ` Anypairtion of a cesspool or privy is within a Zone 1 of a Public Well. An':portion of.it 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 coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or snore of the following conditions exist: The system iswithin'400'Feet of'a surfacedrinking water supply The system is within.200 Feet ohs tributary to'a'sorf•ace drinkigg water.supply File 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6:00. Please consult the local regional office'd6he Department for further information. -t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART B CHECKLIST Check if the following have been done: pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast 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. /As-built plans have been obtained and examined. Note if they are not available with N/A. — The facility or dwelling was inspected for signs of sewage back-up. ✓')yhe system.does not receive non-sanitary or industrial waste flow.. The site was inspected for signs of breakout: �AII system components;excluding the Soil Absorption System,have been located on site. ✓The septic tank manholes were uncovered,opened,and the,interior of the septic tank was in- ' /specteil foi vonditidn of'baffle's or tees,material'of construction;dimensions,depth of liquid, ✓ depth of sludge,depth of scum. l,he size and location of the Soil Absorption System on the site has been determined based on 1;existing information or approximated by non-intrusive methods.' ;,.t r; _ 3 _ SUBSURFACE''SEWAGE"DISPOSAL',SYSTEM t INSPECTION FORM PART B CHECKLIST(continued) .;r 41,1e facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. :r s, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION__, FLOW CONDITIONS RESIDENTIAL: . Design Flow: allons Number of Bedrooms:__Number of Current Residents: _ Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readinis,ifAvailable: Last Date of Occupancy: ('OMMERCIALANDUSTRIAL• D� " Tyne of Establishment; Design Flory: gallons/day Grease Tra`p`Present:'(yes orno) Industrial Waste Holding'Tank Present: - Non-Sanitary Waste Discharged To The-Title V System: _ Water Meter Readings,If Available:- - - Last.Date of Occupancy_ OTHER: (,'Describe) Last Date o,f Occupancy: GENERAL INFORMATION PUMPING.RECORDS any source of information: System Pumped as part of inspection: 1f yes, volume pumped: gallons Reason for Pumping: TYPE F SYSTEM: ,,Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes;attach previous inspection records,if any)- Other(explain): PROXIMATE A E of 11'co o�i its,da a inst lied (if known)and source wf informationi;l ._... __...._._. —.r. � .-.7= J .�.. * -.. Lx}:17ry k �,.�..{!i 4i1}4:. .ei.'? Y 'i� i •i Se Age odors detected when arriving at the site: -4- t'SUBSURFACE SEWAGEDISPOSALVSYS'I'EW INSPECTION FORM TART C GENERAL INFORMATION (continued) /U SEPTIC I'AN,K .`' -�� Depth below grado o.e: Material of Construction: ✓ concrete metal FRP Other (explain) Dimensions: ` 1 Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,conditioin of inlet and outlet 1 s or baffles,depth o liq i I level in relation to on invert,structura integrity,evi nce of 1 age,etc. I( GREASE'TRAP .Depth Below Gr de: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top 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,etc.) ` TIGHT OR HOLDING TANK:_/ i� Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:. _ Depth of liquidl level above outlet invert: 77 iAll A Comments: (note Klevel and distribution is equal,evide of solids carryover,evide of leak a iuto or ouf of box,etc.) 7G PUMP CHAMBER: " Pump is in working order Comments+'(n.ote condition of pump chamber,condition,of pumps and appurtenances,etc)'' _ 5 _ 4T'ha�+�'i 5�,�li°F�cf r �o-}yti tii�•.s t ...±' .. SUBSURFACE SEWAGE,DISPOSAL.SYSTEM INSPEC1.10N-FORM PART s.C SYSTEM:INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan;if possible; excavation not required,but may be approximately by non-intrusive methods) if not determined to be present,explain: Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: .Leaching Gelds,number,dimensions: Overflow cesspool,number: �o-gnnents: (note conidtion of oil,signs of hydraulic fail a level of nding,condition,0 vegetation,etc .� I CESSPOOLS/� 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: InOow(cesspool must be pumped as part of inspection) Comments: (nofercoiidition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY: .Material of construction: Dimensions: Depth of Solids: Continents: (note condition of soil,signs of hyddraulic failure,level of.ponding,condition of vegetation, etc.) Y�'w� :.YP�Sk.Y"T._•._w. ` i�,rrt. ; I« k —_<.�.:.,;��.._d..,,�'- .__ _ __ t_�_�_^w...___..—:i�.. S.,,C,,4�� 'k f _ ''`� 1 .,_�—... a4 - 6 SCJIISURFACE" SEWAGE'DISPOSAL`SYS I'I�,M- INSPN CTION`FORM PART C SYSTEM INFOI1MA l6N (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. �Yuw.____ lit a DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of Determination or Appro imation: ,y o 4. _ 4SiS.S ♦ q it ' _ 7 _ /9� �'� #s�. ass" • '%� LOCATION / SEWAGE PERMIT NO. Y a I'L L ITM ce ,l -Pr / I INSTA LLER' l NAME i A_DDRESS rf� dti � 6UILDER OR OWNER DATE PERMIT ISSUED �"� � 3 .r DATE C 0 M P L I A N C E ISSUED q �; i� 3g � `'-fie y �G� ,� -� �a�� No....................... Fimic ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD. OF HEALTH ----.......I..............................OF............................................. Appliration for %VviiFal Workii Tomitrurtion thrmit Application is hereby made for a Permit to Construct ( ) or!Repair ( ) an Individual Sewage Disposal System at ................� . ... ..��Ac '�. .............. C ..---------- --------------........................--- L cation-ATddrre�ss or Lot No. ..............Vie✓.• !_d. :............--........... ......... ----------•----.............--- I. a ....................... 4 ...-'Installer `=_;i.a =..... Address._...._.... �. UType of Building Size Lot............................Sq. feet ,.. Dwelling—No. of Bedrooms...... ..................................Expansion Attic ( ) Garbage Grinder (14 0) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ........----••• -•-----•-•--••-•••.........--•--••.......-•---•••• W Design Flow........... �? ........................gallons per person per day. Total daily flow............. .. _3.v._......._:._..._gallons. WSeptic Tank—Liquid capacity]JW4allons Length................ Width.______........_ Diameter._...��Depth....._.......... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..................................................................... Date...........................-•---•----- ,� Test Pit No. ]................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground.water........................ P4 •------------------------------------------------ ••------------------------------------------------- -------.----•----------------•--- 0 Description of Soil........................................................................................................................................................................ W U ............................................•--------------•-••--••••---...---•••...----•-••••••-•-••••...•-••-•-•••-•••-••------••----••-------••••---••-............................................ W UNature of Repairs or Alterations Answer when applicable.........................................:`---:.---____-_---__---_____---_-__-__-_--_-------__. -•-------•-•--...----•----------------------------••-•---•-•--------------........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT1 L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance hasobeissued'by the board of health. Signed.. � — .. 9 �..�:(.. , tQ g ,pte Application Approved BY s °-�-•.................... ..........1 ' Date Application Disapproved for the following reasons---------------------•------••----•---------------------•----------------------------•---•-•-----••--...----_.... ---------------------•------------•-------•-----...-----------•-••--------------•-•------......----------••••-•••--••-•--•-•------•-•-•----•••••--•.................................................... Date PermitNo......................................................... Issued-...................................................... Date ti No. ....._...... Fmc.............................. THE COMMONWEALTH"OF MASSACHUSETTS BOARD OF ' HEALTH ................... ... . - ........._OF............... ...............-........ Appliratiou for Disposal Works Tnnstrurtinn rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at < l _a.alk ------------ -..........••-----•....................... �1 Location-Address or Lot No. .............. ......................... ••-----••---------------------........-----•. Address a .................. ............................. .._... ..-•--------......_.............--------- Installer Address UType of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms.......::..................................Expansion Attic ( ) Garbage Grinder ( � aOther—Type of Building ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures _---•--••-------------=------•---------•---•----------••---•--•-••-•--•••------- ._......__._... W Design Flow..........-. ....._..................gallons'per person per day. Total daily flow.................. ................gallons. WSeptic Tank—Liquid capacity.1.5-Wallons Length................ Width................ Diameter__ ,3-0-Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by__________________________________________________________________________ Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water_-__________-_____-_---. f� Test Pit No. 2............_...minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descriptionof Soil................................................................................................................... ........................................... ......... 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 the provisions of TITii� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beR issued by the board of health. Signed-- ` ............ Application Approved BY---------- •----- ................--------__•-_... ................ / -'== 011 Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------- ---------------------------•-----•--•----:..----...------------------._....------._...----•-------------------------.--..------------------------------------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date S THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... QlrrtifirFatr of ToutpliFanrr THINS 0 RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) / 5 b ( !�, �"'�r ' Y -•-••••-- --- -------------•-----------------....._.._....--•-----•--------........••---------.............------•---- �s^ I do aller r !� t- at.. ---------!-��Aul �__k........ -,' - ------------ has been installed in accordance with the provisions of TIT N 5 of The State SanitaryCode as described in the application for Disposal Works Construction Permit No<__�'e. -� -------I--- dated .............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................. ........... Inspector__.._.. .......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF..................................................................................... � No..... FEE.......___-•--.......... Disposal : O ks (gnnstr ion rrntit k Permission is hereby granted :._ _. -_wt-----•-- to Construct ( ) or. Repair ( ) an Individual Sewage Disposal System atNo........... - -�' is...4 ...............:..:....................................................... Street p as shown on the application for Disposal Works Construction Permit No____________________. Dated_,l __al_t� y oard of Health DATE - '----•-•-•---- FORM IZ55 HOBBS & WARREN. INC PUBLISHERS 5%wGLr-- FAMILY*- :5 BEORooM WO GARBAs 60WDEI2- DA1L�( Flow A Ito x 3 = .3306.Pp 5F-PTIG TASK = 330X150% s-495G.P- 0- y5c- 1000 GA%-. -� o15P05At_ PIT V6E 1 vo0 GAt.. c(I•`b `LO,C�-1 b • S%DG.WAI.L A2Ga * 15c 5si qq,L Q t 5o $.t= X 2.•jc s .37`7 G.Pc> 50TTOM AQEAs .. to 4F Sa S.F x I• o � �•o -TaT A>-. c�.5t GN * .¢2 5 G.P v. d ��,�! -{-T�• " �'• -ToTAt- DA I uY F%-C>W 33o C.P. PE2COLATION RATE + I''IN 2MIN o>`t_�55 � j �ou �l�.. 1 15 �•�.1 __-x DIST V T Q iM Uf M � C"g' SOK RJCtiARO ?� ALAN G A. w. AweA BAXTE� w �o • , `l /, I j Na 2'1-048 N . 1 T E aisraR d'' e A V— Ab �� ONAL EN TOP FWDS%00.0 L.qg. INV. 97.0 LA dMI 4 1000 IWV. SJPySo�r,. D1ST. INV. GAL. gG•8 „SGPTIL y t o0o INV. box g�'� TANK 3 Gay.. 4a LEIaG�I - PIT INV. INV. wllTu 9&'Z' 96.4 I' r 1/3/9•Ivi. SANDY WACWSD LL- 11 CEIZTIPIGD PLOT Pt_AIJ PR.OFILG Lo 4-tloN E4. CE4T �/ I LLe, l� 12 No SCALE C.A.L M ". 4 .. �p'-r� 1-13•52 �o �pr e, p�.A N, REF:EIZEN GE I CERTIFY 'THAT THE t-vvU'7ATtor,1 SNoVYN HEREo►.t GoMPL`{5 YJtTN Z HE S I oELIN E Off. -� AWO 56'TeYAGK 9LFw4QUt9-EMEN'f- oF -tNE -TOWN Ol= 1!�,Artr15TAfs,L& AND IS �Jdr _PEAK DQTE� 4-S•1S SCAL5 1 LOcp.'TED "WITNIW TN6 FLovD(�'LA.1N R>E- 6E2A-LO P M�&LTHY i ,' M.RI e1 e - BAxTEcze LAYS INC. R.EG I'�'T EiZ6U�1AN�S u 2Y 6YoeS I, Tu13 PLAN Ili NoT atm5r.p c►d AN G3TG=iZ.VILIJr • MA55• INS�(R,uM6N'1• SV2VG-`( THE DF�'SET$ tS ougL Llo-q t3 C- V A C•C�T d O r--T • q 1►J C L_c�-r �I I I�� A P P I.I G A N"f'