HomeMy WebLinkAbout0065 HAWSER BEND - Health 65 HAWSER BEND ROAD, CENTERVILLE
A=192-088
No. 42101/3 ORA
ESSELTE
10'/m
d O O
(,�
0
2000
BORTOLOTTI CONSTRUCTION, INC.45 INDUSTRY ROAD, MARSTONS MILLS, MA 0508-771-9399 508-428-8926 FAX: 508-4289399y ;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: w 6 ce—
Date Of Inspection d 1,W!V1oy Inspector's Name: o t
Owner's Name aid"Address: iVa Ile
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 IIAe Proper Function and Maintenance of On-Site Sewage Dis-
posal Systems:Th system:
Passes
Conditionally Passes
Needs Fur Ev ualiot By(lie Local Approving Authority
Failure -
Inspector's Signature Date: // Z00
The System Inspector shall submit a copy of this Inspection Report to 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 the6 '.-r;if applicable and'the Approving Authority.
a ARY:
A) SYST � �PASSES:
I have not found any Information which indicates that the System violates any of the fail-
ure criteria as defined in 310 CMR 15.303. 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 of exfil-
tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank
is Replaced with a conforming Septic Tank as Approved by the Board Of Health.
Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due.to
broken or obstructed 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):
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�j I =,I rat
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 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):
Broken.pipe(s)are replaced
Obstruction is removed.
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 it'
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 THAT THE'SY,STEM IS FUNCTION-
ING'IN A MANNEWTHAT PROTECTS THE PUBLIC HEALTH_AND SAFETY AND THE
F._. . . ENVIRONMENT: .
The system hash Septic Tank and Soil Absorption System and is within 100 Feet to a Surface
Water Supply or Tributary to a Surface Water Supply.71?
The System has'a Septic Tank and Soil Absorption System and is with a Zone I 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.
Y
The System has a,Septic Tank and Soil Absorption System and is less than 100 Feet but 50
�r .
;P Feet or more'from a Private Water Supply Well,unless a Well Water Analysis for colif -m
bacteria and volatile organic compounds indicates that the Well is from pollution from
'the facility and the presence of ammonia-uhrogen.and nitrate-nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
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 gro'uild'or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level ii►.tile distribution box above outlet`invertAue to an overloaded or clog-
ged SAS or.cesspool:
Liquid depth in cesspool is less than G"-below itiver't or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year 1 j flue to clogged or obstructed
pipe(s). Number of times pumped
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i
SUBSURFACE.-SEWAGE DISPOSAL;SYSTEM,INS P>'CTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
s' i"
Aqy portion of a cesspool or privy is within 100 Feet of a surface water supply or tributarN 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. If the well has been analyzed
to be acceptable,attach copy of well water analysis for colif•orm 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 more of the following
conditions exist:
The'system is within 400.Feet of a surface'.drinking water,supply i
' The'iystem is within 200 Feet of a.h•ibutary,to;a^surface drinking;water--supply
The system is located in a nitrogen sensitive area Interim Wellhead„Protection Area
(I WPA)or a mapped Zone.11.of a,public water supply well
The owner or operator of any such system sliall 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 Of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
v 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.
✓ The system does not receive nou-sanitary or industrial waste flow.
_Z. The site was inspected for signs of breakout.
„•;. t ,i. All system components,.excluding.th•e.Soil Absorption System,have been located on site.
Mile septic tank manholes were uncovered,opened,and.the anterior,of the septic tank was in-
spected for;conditioii of baffles,or.tees,-material of,construction,dimensions,depth of liquid,
�✓ depth of sludge,,depth of scum. ,
h:e size and location of the Soil Absorption System oil the site has been determined based on
1.existing information or approximated by non-intrusive methods.
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SUBSURFACE SEWAGE DISPOSAL'SYST M INSPECTION FORM
PART B
CIIECKLIST(continued)
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System.
X
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: -33(-') gallons Number of Bedrooms: ..3 Number of Current Residents:
Garbage Grinder: A.)o Laundry Connected To System: Seasonal Use:
Water Meter Readings,if available:
Last Date of Occupancy: C Z 2n o
COMMERCIAL/INDUSTRIAL•
Type of Establishment:t. # ` `
--Design Flow: _ gallons/day'Grease Trap Preseiit:
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discliarged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER' ,(Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS any source of information:�t0� 'j--��p/►
System Pumped as part of inspection: It,10 If yes,volume pumped: gallons
Reason for Pumping:
T7septic
OF SYSTEM:
Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy _
Shared System(if yes,attach previous inspection records,if.any).-
Other(explain):
APPROXIMATE,AGE of all components,date installed(if known)and.sou>`ce of°infiormatio�i: E*
Sewage odors detected when arriving at the site:- A)C)
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SUBSURFACE SEWAGE DISPOSAL.SVS`ITEM;INSPECTION FORM
PART C
{ F GENERAL INFORMATION (continued)
SEPTIC TAN K:x:Y- t/
Depth below grade: Material of Construction: ✓concrete metal FRP Other
(explain)Dimensions: X G'X 5_ _Sludge Depth: / Scum Thickness: 8 ��
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 tee or baffles,depth of liquid level
in elation to outle in rt,structural integrity,evidence of leakage,etc.)_ 4
ZZW/C C24a44 ao"
GREASE TRAP: /V U
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain):
Dimensions: Scuiu Thickness: _
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping;condition of inlet and outleke' or baffles,depth of liquid level
_ .in-relatio►i.to outlet invert,structural uitegi ity,evidence of'leakage,etc:)
TIGHT OR HOLDING TANK: A/p
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 liquid level above outlet invert: �U
Comments: (note if level and distribution is a ual,evidence of solids carryover,evidence of leaks a into or
out of box,etc.) az
PUMP CHAMBER:
Comments: (note condition of pump chamber,condition of pumps:mid appurtenances;etc.)
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r _
. S.UBSURFACE SEWAGE DISI'OSAL�SYS'I,EM_.INSI'F.("1'ION FORM
PART C
SYSTEM INFORMATION (con(inued)
SOIL ABS09RPTION 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:
Comments: (note couidtion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)_
DO
CESSPOOLS:
Number and configuration:. Depth-top of liquid to inlet invert:,/
Depth of solids layer: Depth of scum layer: Dimension's of Cesspool:
Materials of construction: ludication of groundwater:
Inflow(cesspool,must be puinped,as part of inspection)
Comments: (note�condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation,
etc.)
Y
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SUBSURFACE SEWAGE DISPOSAL-SYSTF,M INSPE(?'l'ION FORM
PART C
SYSTEM INFORMATION (cuotinued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references,landmarks or benchmarks.
Locate all wells within 100 Feet.
It
4-4
V
rv.
DEPTH TO GROUNDWATER: /
Depth to groundwater: l9 Feet
Method of Determination or App Milli,tion: /¢ ✓1li('� '��/"O�!e J. �C .�—
�
eu ew a r
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No. Fee /y
THE CO MONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISI 4 TOWN OF BARNSTABLE., MASSACHUSETTS
01pp4ration for Migogal *pgtem Construction i3erntit
Application is hereby made for a Permit to Construct( )or Repair( /an On-site Sewage Disposal System at:
Location Address or Lot N�o.� Own e;s Name, ddress end Tel.No.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
r�r'lvGo��G®s�s�
Type of Building:
Dwelling. No.of Bedrooms Garbage Grinder(J';W
Other Type of Building KnP�ee No. of Persons Showers( Cafeteria( )
Other Fixtures
Design Flow /l gallons per day. Calculated daily flow .;-30 gallons.
Plan Date tf/Z 7 7 7 Number of sheets Revision Date
Title
Description of Soil i LP.�IQ�/
Nature of Repairs or Alterations(Answer whe applicable) �l JfJO / lie J 7`
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by is pV H th.
Signed Date
Application Approved by
Application Disapproved for the following reasons
Permit No. ! � G Date Issued "'��=
THE COMMONWEALTH OF MASSA USETTS 9Z`Og
PUBLIC HEALTH DIVISION.- BARNSTABLE,k MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO C RTIFY,that#ic On-site Sewage Disposal System installed( )or repaired/replaced(`�)on
by Or d�0 / O/1✓�` for A",1..41c l4y y-/h
as 6 /`fA�t/ �/ C�y1)4e1"41// has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated��.A. '
Use of this system is conditioned on compliance with the provisions set forth be1UWq-
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.-
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Q No. fGj Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mie;pool *pgtem (Congtructiou Permit
Permission is hereby granted to to kl_A9 L� l GDh<5
to construct( )repair( V)an On-site Sewage System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with.Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date: 'r'' Approve�y
Z
No. �"' ' Fee f 6
THE C6AMONWEALTH OF MASSACHUSETTS w
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprtcation for XD !6pogar *p6tem Con!5tructtou 3dermit
Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at:
Location Address or Lot No. o Owne 's Name, ddress 4nd Tel.No.
Gay Brrii%!e AI'W b�'ffawsP✓(��. r
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
r foG�of`i Cva..s�`
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder(40 1
Other Type of Building f2�9/Q Plee No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 1/l gallons per day. Calculated daily flow 3.30) gallons.
Plan Date L112 7 7 7 Number of sheets / Revision Date
Title
Description of Soil ?�-e
Nature of Repairs or Alterations(Answer wheq applicable)
B sy� y t�l'rduti �
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by is o He`th.
Signed a Date �✓�
Application Approved by
s t
Application Disapproved for the following reasons '
,,/ ViV
Permit;No. 7�'r���' ;��p Date Issued
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1 G6RTIFY TkAT TNt: FOUNDATION '5WO%U J �-4� RCFcRE�.lGic
W SZ G ct.1 C"kAPLY'S WITH T WG S I DE U►-lE L O T Z�}
A►IJ� SIET$ACiG REsautRemawTS OF TI-IC— �AGa L I Z 7
-TOW IJ G11= Iv S T L
DATA 7 Ct. �.ti ATER. Wee 1�►JG.
REGISfC-3Za.D 1G.�.►-tom St�ZVcYoRS
T141S. Pt-A" IS '40T BASED V►J AN USTEQVILt.Fs o l4ia►SS.
t1JS11ZaJ�KEtJTQVY THE '.OFCsTS SNcuw
APPLI CA"T. pp_ Y E.
�,C-7n r, nr= Tr- PM%►JC l...oT l_tNw✓S
CERTIFICATION OF SKETCH AND,APPLICATION FOR A DISPOSAL
WOH1 S CONS'11tUCTION PE110111' (1V1'1'11OUT DESIGNED PLANS)
►, �1�de,-�" ,/. Ae 166 hereby certify that the application for disposal works
construction permit signed by me dated ���s�l�� , concerning the
property located at 6S ��S�r��r�C�rp� meets all of the
Following criteria:
There are no wetlands within 300 rest of the proposed septic system
JThere nre no private wells within 150 feet or the proposed septic system
Y The observed groundwater table is 14 reel or greater below the bottom or the teaching facility
(� There is no increase in flow nnd/or change in use proposed
There are no variances requested or needed.
SIGN
ED: _ DATE: 7 l
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
IAttach a sketch plan or the proposed system. Also irthe licensed installer posesses a certified plot plan,
this plan should be submiltcdl.
`` TOWN OF BARNSTABLE /
LOCATION t� jf��-fewt �� SEWAGE# 9��`6
VILLAGE 6 eWle—l' ✓�/ ASSESSOR'S MAP & LOT42Z16 011
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1D4e 9Re
LEACHING FACILrrY: (type) lOO, 9"Pel 'OK4, iT(size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE:_ � 5.;�COMPLIANCE DATE: ''��^ �
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �7� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
3S
' as
0
13
ASSESSORS MAP NQ,..; . ,
PARCELQ. =' =
Commonwealth of Massachusetts
Executive Office of Environmental Affairs IRECEN ED
Department of FEB 2 9 1995
• Environmental Protection
HF�TM oeF�,:
William F.Weld 1�UVN OF BARNSTRL,L E
Coremor
Trudy Coxe
SeerMary,PcOEA
David B.Struhs
Commlafoner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: &Slo-�dress of Owner:
Date of Inspection: Z— (-1— °I (� (If different)
Name of Inspector: VV\p i2 I N
Company Na'm/e,, Address and Tell phh/o�ne J umber:
P
CERTIFICATION STATEMENT oc
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:
_ Passes
L—Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: �- Date:
The System Inspector shall submit a copy of�this inspection report to the Approving Authority 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.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system coEnnents need to be replaced or repaired. The system, upon completion of the replacement or�r,/passes inspection. ` M P� IK44 JIndicate yes, no, o�determined (YY, N, or ND). Describe basis of determination in all instances. If"mot determined", explain why not)
The septic tank is metal, 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 conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)2112-5500
Printed on Recycled Paper
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
E CERTIFICATION (continued)
Property Address: IIVr""i
Owner:
Date of Inspection: ---
B] SYSTEM CON DITIONALLY'PASSES (continued)
_ 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
_ The system required pumpipg more than four times a year due to bpken or obstructed pipe(s). The system will pass
inspection if(with approval'gf the Board of Health):
broken pipe(s) are replaced
obstruction is removed
i
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HI;KLTH:
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. X,
1): SYSTEM WILL PASS UNLESS BOARD OF HEALTH 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 wafer
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 THAT
THE SYSTEM IS FUNCTION ING:IN A MANNER THAT PROTECT TH€ PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The systen•, ha, a septic tank and soil absorption system and is within a`Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 504eet 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
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppml
D] SYSTEM FAILS:
I 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 eontacted.to determine what will be necessary to correct
the failure.
Backup of wage into facility or system c9mponent due to an overloaded or iflogged SAS or cesspool.
cIP � � l
Discharge or pon ing of effluent to the surface df the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
^q
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D]SYSTEM FAILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day'"flow.
Required-Pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped /✓'
Any portion of the,Soil Absorption System, cesspool or privy is below tl a high groundwater elevation.
An onion of a cess o I or privy is within 100 feet of a surface�4 ter supply or tributary to a surface water supply.
_ Y P P�4_ P Y �Iic
PP Y rYAny portion of a cesspool or"privy is within a Zone I of ypu well.
f.
Any portion of a cesspool or pri4%is within 50 fee(of a private water supply well.
Any portion of a cesspool or privy is let 'in 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If t, wtiell has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
f� •�
E) LARGE SYSTEM FAILS:
The following criteria apply'to large systems in addition to the A,--'ria above:
The design flow of system is 10,000 gpd or greater (Large System) an the system is a significant threat to public health and safety
and the environment because one or more of the following conditions a ist:
die 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 s ly
f
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.60. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
�e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property A r /'ess: l0 7 � �'-7�2r c�/► ?�/v'�'� A.
Owner: C'
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
C--?qo__ne 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 ag part of this inspection.
��As built plans have been obtained and examined. Note if they are not available with N/A.
�e•facility or dwelling was inspected for signs of sewage back-up.
_system does not receive non-sanitary or industrial waste flow
e- tie site was inspected for signs of breakout.
�l system components, excluding the Soil Absorption System, have been located on the site.
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.
size and location of the Soil Absorption System on the site has been determined based on existing information or
Approximated by non-intrusive methods.
_The facility o%tiner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM+ INFORMATION
Property Add s: (.0
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: � gallons
Number of bedrooms:
Number of current residents:r
Garbage grinder (yes or no): Al
Laundry connected to syste (yes or no):�
Seasonal use (yes or no):Al -
Water meter readings, if available:
Last date of occupa �/`�'✓
COMMERCIAUINDUSTRI
Type of establishment:
Design flow:_gallons✓day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes orna)-�
Water meter readings, if available:
Last date of occupancy.
OTHER: ( nbe)
to of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
rn
System pumped as part of inspection: (yes or no) -2�0
If yes, volume pumped lOy gallons '�
Reason for pumping:
TYPE_OF STEM
Septic tan oil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (�S (-( ec,,,&-�
Owner:
Date of Inspection:
SEPTIC TANK: C/
(locate on site plan)
Depth below grader
Material of construction: concrete _metal _FRP _other(explain)
Dimensions:
Sludge depth: /S
Distance from top of sludge to bottom of outlet tee or baffle:li _
Scum thickness: l - /S//
Distance from top of scum to top of outlet tee or baffle: %�
Distance from bottom of scum to bottom of outlet tee or baffle:.-
Comments:
(recommendation for pumping, condition of inkaj and outlet tees or baffles, dep h of liquid ' atiionn to outlet i v rt, tructural
integrity, evidence of leaaka etc.)
s
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete etal FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet t affle:
Distance from bottom ni stem t- bo of outlet tee or baffle
Comments:
(recom en io-rf or pumping, condition of inlet and outlet tees or baffles, depth of liquid level in re on to outlet invert, structural
integrity, evidence of leakage. etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION (continued)
Property Address: (0 (-t a.cJITa�
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
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: w4�
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution. is equal, vidence o so.ld� ca/'.)ov r, evidence of akage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no) __.--- --
Comments:
(note condition of pump chamber, ,condit-ion of pumps an urtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(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, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments:(note c ndition of soil, signs of y raulic f 'lure, level of pon ing, co ditio of vegetation,etc.) �.
CESSPOOLS: _
(locate on site plan)
Number and configura
Depth-top of liquid to inlet in -"-
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: �..
Indication of groundwater:
inflow (cesspoo,l-racist be pumped as part of inspection)
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: '` f
Comments: (note condition of soil, signs-of"hydraulic failure, level of po condition of vegetation,.etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addr� (o-G ff�a-� �.y —�- -� ��'
Owner:
Date of Inspectio
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
b t'1
lr
_D j 36
DEPTH TO GROUNDWATER
Depth to groundwater: feet c -
method of determination or approximation: U S G S R 7 -1 Kti`r
(revised 8/15/95) 9
No....... _.... Fizla..13..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA H
OF....... ................... .�..:...'::..... - ".......----------
Applirtttaon -for Ui,ipustt1 Works Pustrurtion rruift
Application is hereby`made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at: ✓
..... �sER--.. .4E ............................................., � �... ---------------------••••-�...-........... --.
jLocation-Address or Lot No.
. 17---------------- -------•------ ,?1 t- `v(° !¢f ----- ------------------
,,rr�� Owner Address
a t ------• `y�%
Installer Address .�
d T of Bui ing Size Loty.. 3.....Sq. feet
U Dwelling—No. of Bedrooms.............. ..........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building - No. of ersotts____________________________ Showers — Cafeteri
G, YP g == P ( ) ( )
Q' Other fixtures 1,71-Ac�14__________________ ___
Ri Septic Tank—Li uld capacity -gallons per person per (lay. Total daily ow...............;_0.0_-__---_-..-.--.gallons.
Dest n Flow........................ L.�
W q 1 v�----- g g_ Total L, h.................... Total le lin t ------�--- ._.,
gallons Length ___ - Width-._�._ Diameter---------------- Depth--
x Disposal Trench—No- ____________________ Widtll_.-.•p+- -- __ _ � --• � � ' � g �i-��,�' -��sq. ft.
Seepage Pit No..... G�' ll�iameptYti ._.__ �r �-=a` --------Sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results _ Performed bY.......................................................................... Date--------------------------- -----------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...._-__.-----.--.------
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
------------------------- -----•=-•----------------•--------•"-•-"----•-------------------------"--.....................-....................•-•--------- -.
0 Description of Soil---------------------------------------- ------•-----------•----•-•-------------•---•---------------------------------•----- - -----------• --------------------------
V ----------------------•--•--------------- .................. -----•�'rr. ..�- ----------------•--•---------------•----•--------------•-•----•-•--------------
------"------------------•-------------------------------------------------••----------•--•----------
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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h beep is d b th board of health.
Signe ..
q
- - --------- ----- - - --yea*��--------- - - --------- -------- --- ---------�-
ate
ApplicationApproved BY ------•------•------------------------------------------------- - --------- ------
Date
Application Disapproved for the f owing reasons------------------------------------- -------------------------------------------------------•--------------
-•-•••--•-•---------------------•----•-•-•••-----•--------------••--••-••••-••---•---•--------••-•-••-•---•-•-•••••••---•------------------------------------------------------------------------------
Date
PermitNo.-----�i� ---•---------••-------------------- Issued----------------- ................................
Datete
No.-_ ...: F�>� �.. ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA
_ , . of .... . ....: .............
Apotiration;-for Bitymial Works ttitrurtimtt Vrrutit
A lication is hereb made for a Permit to Construct pp hereby'made, �) or epair ( . ) an Individual Sewage Disposal
System at
..........................
Location_Address w, or Lot N . h'
..-
- W Owner
Address
._'�-----
o Instal er
U �T f Bui ing Size Lot feet
Address : Sq. ICI
Dwelling—No. of Bedrooms_--_ __________ ___Expansion Attic ( ) Garbage Grinder ( )
`4 r ?��; Other—Type of Building _______ ______ ... No. of persons .-_-___--________--. ___ hoovers ( ) Cafeteria ( )a ' a, yp g l S
Other fixtures __..
-- -------- - •.-_------- - -------------- •••--------•--•--•---
Design Flow................. : -_____ -gallons per person per Total dail w.__..._ x� 0_0 gallons.
W . : 1.P P PY
WSeptic T.:nk—Liquid capacity...__...___gallons' Length.__._ _____ Width__ -_...'� Diameter----- --------- Depth_-------------
Disposal Trench No ,. ___ __ Width_: --__ Total th __ Total le ing a sq. ft. ,
r Seepage Pit No --_ I lliam :.._ epth sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed b - '
- a Y IJate -------------------
Test Pit No. 1................minutes per inch Depth of 'Pest Pit-.------------ .. Depth to ground water------------------------
Test
t= Pit No. 2................minutes per inch `.Depth of Test Pit---------------------Depth to ground water`__.__...-__._--.-------.
--
r • O *. Description of Soil--------- •-------- •-------------•-•--------- __--------•---------•-•------•---------•-----
xS '
x ---- - - ---------- -----------------------..........................
,.
t U. Nature of Repairs or Alterations—Answer whe ---------------------------
--------------------------------------------
n applicable..-.-.................................
--_---.__-.. --_._--:_-._-__ _ ._.-_.
F ,.
---
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—Thevridersigned further agrees not to place the system in r'
' operation until a Certificate of Gornphance Iha4 fbee is d b• h board of health.
g
...,, ate.
Application-Approved BY----- ------. �I~-- --••---• ••-••-•. ------•• ------------ ---------- . .......... �"� ---------
Date
7
Application Disapproved for the llowing reasons_________________________
----------- ----------••-------------------------------- ------------- •-----
t
a
Permit No.........................................................
Issued........................................................Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE
OF...
irrtifiratr of Tlintphanrr
THI IS TO CE IF Th he Individual Sewage Disposal System constructed ) or Repaired ( " )
by,......- i .... ---- . --- � .�..I. . ---- ---•------
} n�4aller
has been installed in accordance with the provisions of:Article XI of Tl.1e•;State Sanitary Code as described in the
application for Disposal Works Construction Permit No_____________ _ _' dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. x'
DATE ' y? Inspector ------ -- --
T.HE COMMONWEALTH OF MASSACHUSETTS
BOARD F' HEA
No._.f .7 � 3
"------' FEE __.-•---•---•--.....--
i'n LIgi 'r #r ��att Vrr it
`. Permission ,is hereby,granted---- ...._-. --------
to Construct r Repair ( ) Indiv uaI Sewa Dispos System
at No.......
Street �g
as shown on the application for isposal Works Construction Permit No/---- -------- Dated---.
----- ----------------------------------------------- - ------------------------------
Board of Health
DATE-----------..................................
FORM 1, 155 HOSES & WARREN. INC... PUBLISHERS
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