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HomeMy WebLinkAbout0100 CAPTAIN ELLIS LANE - Health 100 CAPTAIN ELLIS LANE, HYANNIS A= i I TOWN.OF BARNSTABLE LOCATION !®�. .A/1.l SEWAGE # r -769 VILLAGE /-/-I 0? 'a ASSESSOR'S MAP & LOT A'6- INSTALLER'S NAME&PHONE NO. t � - SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Cn%,r- 4V'1 n+-i;f h'A U i " (size) .Z',I NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: , D. Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t T5 o, w.Lj - ---- i TOWN OF'B^A,RNSTABLE `-LOCATION I©o Cad t• C`16 LA, mot* lot SEWAGE # VILLAGE 4 ;S ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I80o LEACHING FACILITY: (type) (size) NO.OF BEDROOMS d' BUILDER OR OWNER PERMTTDATE: Io' I�'��� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of I.Sxhing facility) 117) (�f � Feet Furnished by Ut _� O Q � J No. X � Fee a THE COMMONWEALTH OF MASSA HUSETTS Entered in computer: 'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ` ZippYication for �Digoe;al *pgtem Construction Vermtt Application fora Permit to Construct( )Repair( )Upgrade(VI Abandon( ) ❑Complete System individual Components It Location Address or Lot No./ c1gai'l y �s Owner's Name,Address and Tel.No.�o Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. IhIO Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow `Z 30 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ;4?cr ST 6 vw Type of S.A.S. Description of Soil Wes '✓ Nature of Repairs or Alterations(Answer when applicable) 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 ue y i Sig ed Date Application Approved by Date Application Disapproved for the ollowing reasons IV Permit No. Date Issued � — �n TOWN OF BARNSTABLE LOCATION 1��� ;%' � SEWAGE # - C VILLAG ASSESSOR'S MAP & LOT - INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ``�" - a�;_n�/ t` ' f i',?t�r` (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: - COMPLIANCE DATE: 12 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ' on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I -- f n �2- 17 - a �i rt t> No. Fee THE COMMONWEALTH OF MASSA HUSETTS Entered in computer: Yes PUB�IC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS 01'plication for .Miopoml bpztem Con.5truction Permit Application for a Permit to Construct( )R6pair( )Upgrade(�4Abandon El Complete System Z4;lvidual Components Location Address or Lot No./00 07,677",4 PL_ Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. _57 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No. of Persons —Showers( ) Cafeteria( Other Fixtures -30 Design Flow 'Z gallons per day. Calculated daily flow 3 qC1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ;:F�,S1 v OCr-, '70 Type of S.A.S. /-r/,' CeIACf7 _ Description of Soil yVL4_e -5 Nature of Repairs I or Alterations(Answer when applicably gW dl,�� 156K 64�12(-i'r �Q L-7ee--i arj L'-7q, VCC­2 17,6/V"', 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 Paen-i5§u-e-d7Fv`This 'a Signed. Date Application Approved by f! Date Application Disapproved for the following�reasons Permit No,- Date Issued ------------- THE COMMONWEALTH OF MASSACHUSETTS f I 9, - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired Upgraded Abandoned by &�2- -e-A 0 E -5 E_0-Y( L. at on r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.g4r-�J0' dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date r? Inspector -------------- ------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Imiop I ozat *pztem Construction Permit Permission is hereby granted to Construct Repair( 6,<Upprade Abandon System located at tO 6A(7( I q I 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. Provided:Construction must be completed within three years of the date of this Pei it. Date: Approved b 'd t. } r. , p _t 11119t97 as l NOTICE: This Form Is To Be Used For-the Repair Of Failed Septic Systems Only: =# ;CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby sertify that the application for disposal works r construction permit signed by me dated f —� , concerning the S, property l/ located'at 100 G <<w�'�� ��S /� meets all of the �— following criteria: l�✓ There are no wetlands located within 100 feet of the proposed leaching facility (� There are no private wells within 150 feet of the proposed septic system -There is no increase in now and/or change in use proposed j-There are no variances requested or needed. j o �f the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the i proposed leaching facility will am be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. _. _.. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Elevation(according to Health Division well map) go,SIGN b DATE: ED: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER . 9 [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I i q:health lblder.cart i • � tb �� T . John Graci D.E.P. Title V Septic Inspector 564-6813 - - - SUBSURFACE SEWAGE_DISPOSAL SYSTEM INSPECTION F 2 Address of property- 00 CCtPI.C(its LA- Rj vv l5 -owner's name guSFr - __ - ALI e— Date of Inspection __ 0 19 PART A � - - CHECKLIST Check_ if.-the_ following have been done: S V - _iL Pumping information was requested of. the owner,. occupant, and Board of -- I Health. 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. ✓ 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 T site was inspected for signs of breakout. .� All system components, excluding the SAS, have been located on the site. The . septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on exist: ng information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. i _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.-B - --- -----r------ ----SYSTEM--INFORMATION - -FLOW CONDITIONS If residential _ number of bedrooms _number- of current—residents- Am' garbage grinder, yes or no - laundry connected to system, yes or no Apo seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: E �14� Last date of occupancy GENERAL INFORMATION Pumping records and source of information: Heit AA �L"-I eJ System pumped as part of inspection, yes or no if yes, volume pumped �3w Reason for pumping: lF�' �►��'VI a,�c� Ty of system Septic tank distrib P / ution box/soil 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. Source of information: ( r. .Ab_ Sewage odors detected when arriving at the site, yes or no { 9 SUBSURFACE_ SEWAGE DISPOSAL SYSTEM INSPECTION FORM r ` PART B ', ------- - - -_ —_— --- SYSTEM INFORMATION continued SEPTIC TANK: - (locate on site plan) depth -below grade:-- material of construction:._ t/ .concrete metal _FRP other(explain) - ---------- -- - -- -- - - -- _ dimensions: 6`` H !i 7` / lag - $� sludge depth i ' distance from top of sludge to bottom of outlet tee or baffle &'r scum thickness S" distance from top -of scum to top of outlet tee or baffle 3 ` 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. ) ; DISTRIBUTION BOX: (locate on site plan) 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. ) PUMP CHAMBER: 1� (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, '' recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -- - -- - --_--- -- - PART B `SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, --if possible; excavation not required, but may be approximated byznon-intrusive methods) If not determined to be present, explain: Type leaching- pits and number - _� to (06 oregoi P 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, cond�tyon�f vegetation, recomm ndations for maintenance or repairs, etc. ) s CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater - - inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction IL4/ dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) f -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: - include ties to at- least two permanent references landmarks-or benchmarks locate all wells within 100' _ a AA 6 � a B A4 Y 31 DEPTH TO GROUNDWATER �43 depth to groundwater method of determination or approximation: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ - �..---- - ---- ----- -:=- ---- PART C - - FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of . determination in all instances. - If "not determined", e:-.plain why not) Backup of sewage into facility? �U Discharge -or -ponding--of effluent- to-the- surface of the ground or - surface waters? 1�+ 0 Static liquid level_ in the distribution box above outlet invert? Liquid depth in cesspool <6" -below invert or available volume< 1/2 day flow? ./V Required pumping 4 times or more in the last year? number of times pumped _AZ_ Septic tank is metal? cracked? structurally unsound?' substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? A,1 within a zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? /V within 50 feet of a private water supply well? 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 analy: for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. t 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM D - CERTIFICATION Name of Inspector - - JOHN-GRACI Company Name _ Title V_Inspector - Company Address P.O. Box 2119 ' - - Teaticket, MA 02536 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 manitenance of on-site sewage disposal systems. Che k one: 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 f . a Date __ Original to system owner Copies to: Buyer (if applicable) Approving authority TOWN OF BOARD OF HEALTH SUBSURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D - CERTIFICATI-ON TYPE OR PRINT CLEARLY- - PROPERTY INSPECTED 4 - STREET ADDRESS � _ ASSESSORS MAP, -BLOCK AND PARCEL # LT : i� OWNER' s NAME &f0A0► �I PART D - CERTIFICATION - NAME OF INSPECTOR COMPANY NAME TiitleIInspector - Box 211 COMPANY ADDRESS Teaticket,-MA 02536 Street Town or City State LIP COMPANY TELEPHONE ( 1 - FAX ( 1 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 maintenanc e of on- site sewage disposal systems. Chec one: 2System PASSED The inspection which I have conducted has 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. System FAILED* The inspection which I_ have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspect n form . Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 .1 partd.doc t 1 ,EVE Town of Barnstable s uv,WAB . Department of Health, Safety, and Environmental Services MASS. Public Health Division P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health December 21, 1998 Mr. George Lopes 27 Warren Street, Raynham, MA 02767 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 100 Captain Ellis Lane., Hyannis was inspected on November 30, 1998, by Michael DeDecko, Jr. a Massachusetts licensed septic inspector. The inspection of our septic stem showed that your stem has failed under the P Y P Y Y Y guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged soil absorption system. You are ordered to bringthe septic stem into compliance within two 2 ears of the P Y P ( ) Y date of discovery. Therefore, the construction of replacement septic system component(s) must be completed on or before November 30, 2000. First, you must hire licensed Town of Barnstable septic system installer to submit a sketch diagram of proposed replacement septic system component(s) to the Town of Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5. In the meantime, you shell ensure that no raw sewage discharged onto the surface of the ground or into any surface waters. You must maintain the system by hiring a licensed septage hauler to pump the septic system whenever it is necessary. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Z� as McKean, C.H.O. Agent of the Board of Health Town of Barnstable BARNSTABL& : Department of Health, Safety, and Environmental Services r Public Health Division EDN1D�p 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health TO: Georf Lv 27 DATE:}9ee—• 'ULi `99�' ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at k6 C ,)6 J was inspected onQl e,,&ri- 36,E r�i- 8 , by A,,Aa4 a—UE o a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: b - �� 1 o� P ` -� � �� C d ! You are ordered to bring.the septic system into compliance within two (2) years of the date of discovery. Therefore, the construction of replacement septic system component(s) must be completed on or before Mje4 tow- ,3v, 2 coo First, you must hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of proposed replacement septic system component(s) to the Town of Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5. In the meantime, you shall ensure that no raw sewage discharges onto the surface of the ground or into any surface waters. You must maintain the system by hiring a licensed septage hauler to pump the septic system whenever it is necessary. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health q\ha1th\dbfi1a\tit1u,.d TOWN OF BARNSTABLE LOCATION `0�� �Q�N4t� ���o� SEWAGE # VILLAGE ASSESSOR'S MAP& LOT S O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY c>t,:>Q yN- LEACHING FACILITY: (type) \ (size) k C 00�-1*1 NO.OF BEDROOMS BUILDER OR OWNER �OS 4F1=DATE: \ b COMPLIANCE DATE: Separation Distance Between the: rrll Maximum Adjusted Groundwater Table 3 V 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 �-Q�� � N'� � � � ,t c� s � � .� � � r � W N � N � c� �- � s .� e /.ot Q COMMONWEALTH OF MASSACHUSETTS DES' a.19gs EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 WILLIAM F.WELD TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Lt. Governor V Commissioner P� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM to — �S PART A �v�- ,�� CERTIFICATION ' s 5S C ec+ �,pts Property Address: %GG7 �TA l�% ��t - ���w °i'y` Address of Owner: _ Date of Inspection: //1.�p { (If different) �� WgYLYL'e_ty S l Name of Inspector: 6 � L� `���� tt►��► I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) 4 Company Name: r _ '� L- c C�2�((0 Mailing Address: C- Telephone Number: ,= ]1 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: _ Passes _ Conditionally Passes Needs Further E o e ocal Approving Authority Fails Inspector's Signature: Date: rt( 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 SUNCNIARY: Check A, B, C, or D: A] SYSTEM PASSES: _ LID - 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. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: - _ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of•Health, will pass. Indicate yes, no, or not determined (Y, N. or ND). Describe basis of determination in all instances. If"not determined explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (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 exfrltration, 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 04/25/97) P2ge I of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl 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 DETERN1ILN- ES THAT THE SYSTEM IS NOT FUNCTIONTNG I\ A MANNER WIUCH WILL PROTECT THE PUBLIC HEALTH AM) SAFETY A_\"D 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 (ANT) PLBLIC WATER SUPPLIER, IF APPROPRIATE) DETER ]ENES THAT THE SYSTEM IS FLTCTIOti ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH A.\I) SAFETY AND THE EINVIRON`,�IENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to 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 (appro)imation not valid). 3) OTHER (revised 04/25/97) P2ge 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A C' CERTIFICATION (continued) Property Address: 0 V L.tOTQ u,►S Owner: Date of Inspection: D] SYSTEM FAILS: ` You must indicate either "Yes" or "No" as to each of the following: 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 contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 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 the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria. volatile organic compounds. ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The 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 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ` c- `, S Owner: Date of Inspection: so Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at 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 pan 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 non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. l —The size and location of the Soil Absorption System on the site has been determined based on: 1�(\ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revised 04125/97) Page 4 of 10 � 'tt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 100 L9��ild i111,s Owner: Date of Inspection:a &Sf 4 FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom for S.A.S. Number of bedrooms: 8fb Number of current residents: a Garbage grinder (yes or no):V Laundry connected to system (yes or no): Seasonal use (yes or no):�S Water meter readings, if available (last two (2) year usage (gpd): IJ Sump Pump (yes or no):� Last date of occupancy: C O NIlNlEER C I AL/INDUSTRIAL: Type of establishment: Design flow: eallons/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 or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL IN'FOR.MATION PUMPING RECORDS and source of information: t System pumped as part of inspecti n: (yes or no)_ If yes, volume pumped: eallons Reason for pumping: TYPE OF SYSTEM _ Septic tan /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. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source,of information: r� Sewage odors detected when arriving at the site: (yes or no) (revised 04125/97) Page 5 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /P,� SYSTEM INFORMATION (continued) Property Address:160 CAP ELt►5 Owner: Date of Inspection: i t t vls BUILDING SEWER: \ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site pla r( Depth below grade:a,6 Material of construction: (concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: (003 C w'"l Sludge depth:_ (i Distance from top of sludi:e to bottom of outlet tee or baffle:_ Scum thickness: f( a Distance from top of scum to top of outlet tee or baffle: it Distance from bottom of scum to bottom of outlet tee or baffle:_ How dimensions were determined: hl�Qe,.fll�►�o Comments: (recommendation for pumping, condition of inlet and outlet lees or baffles. depth of liquid level in relation to outlet inveia. structural integrity, evidence of leakage. etc.) �-' 0.0 GREASE TRAP:T t (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee.or baffle: Date of last pumping: Comments: (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.) (revised 04125/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in workinv order _ Yes: _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches. etc.) J' )ISTRIBUTION BOX: (locate on site plan) 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, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pum/andappurienances, etc.) (revised 04/25/97) P2ge 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (V® Cq-Uw Sk1.k S Owner: Date of Inspection: © SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation of required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: lp/C� leaching chambers, number:_ leaching galleries, number: leaching trenches. number.length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (n to condition of soil. si ns of hydraulic ailure, level of pondin , condition of vegetation tc.) / l CESSPOOLS:._&AU (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: \(�G C!;k-qT,"j Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 163 Z (revised 064/2S197) Page 9 of 10 . t r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C SYSTEM INFORMATION (continued) Property Address: [t3 C0 ITN "e-1 �S Owner: Date of Inspection: t Wl� Depth to Groundwater �3OFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions t Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers Use USGS Data w w Describe to your own words how you established the High Groundwater Elevation. (Liust be completed) sa (revised 04/25/97) Page 10 of 10 4 100 37 �9 LO,Cl-AT ION SEWAGE PERMIT NO. 4071 A/41s dw VILLAGE INSTA LLER'S NAME & ADDRESS ly oelx-a Af og 5 7>*— U U I'L D E R OR OWNER DATE PERMIT ISSUED � w,,,� DATE COMPLIANCE ISSUED Iwo 0 to o o r n No.. ?Z_.. Fps. -.... THE COMMONWEALTH OF MASSACHUSETTS 7;� BOARD HEALT ........OF......... - . -- -- Applirutiun -fur Ui puutt1 park Tote trurtiun Vrrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal PP Y ( ) P ( ) a P System at: °- - ................ ........ .y ------------------------------------------...----------------------._....--------- (� L-ocaV-on Address or Loto. ---------------------------- `/ (s Address O-ner ---___...--•---16A—-._�_i.. -W-,---------------- -•-----------•-•-•- Installer Address UType of Buildin Size Lot..... `° ----Sq. feet Dwelling/ No. of Bedrooms-____�----------------------------Expansion A_ttic Ala Garbage Grinder Other—T a ype of Building ___ 0'1 £______ No. of persons....... Showers O — Cafeteria ( ) dOther xtures --------------------------------- ---------------------------------- -------- -----------------•-•-------------------------------------------- W Design Flow____�4�___________________________gallons per person per day. Total daily flow__._._ �s_._....._._...-_.___gallons. WSeptic TaZe—Liquid capacity1_Me__gallons Length________'_____ Width_..... Diameter________________ Depth--_-________.... x Disposal Trench—No_ ____________________ Width_________:__________ Total Length.................... Total leaching area---------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet---------------_.... Total 1 aching area.._..______-______sq. ft. z Other Distribution box ( ) Dosing tank ( ) B " "`�� 76 ~" 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__-_---___ O Description f�Soil r® �_4 l r nd =_' �- x , - -------- x ------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ .............................................--------------------------------------------------------------------------------------------------------- •----------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h een issued by the board o�f.hheealth. Signed �"� --------- �_ ---------------------------• ' Date // Application Approved BY-------- - -------- i Date Application Disapproved for the following reasons:............_.................... ______________________________________________________________________________ _...-•-•-•---•--•-••-•-----------------------•-------•----------•---.-_.._-•-----------------••--------------------•-----•---------------------------------•-•---•--•--------------------•------------- Date PermitNo......................................................... Issued........................................................ Date No..........Y�?Z ............... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H1tE_AL_r1Lj ....... .......OF......... ........... Appliration -for Uhqpoiial W,arks. Towitrurtion Vrrnift "Application is hereby made for a Permit to.Construct (tom) orRepair an Individual Sewage Disposal System at: L'OT ------------ - /. -...........I.......................... ...................................... .................................................................................... .0 L flon-Add 4 C o a Address or Lot No. ............1.4 ............... . ..... --------------------------------------------- ---- ­/­A�Y_.,-------------------------------------------------------------------------Jer I Address ...�."_5,. ................ ................ ............................. Installer Address Type of BuildinW- Size Lot..... I- --------- ....Sq. feet Dwellingi—***'No. of Bedrooms ...__.._....-__-_--__-.-_-Expansion Attic NO, Garbage Grinder (40 ------- No. of persons_..._._______________ Showers (I Cafeteria V- --------------------- P4 Other—Type of Building ---A-- PL4Other fixtures -------------------------------------------------- -------------------------------------------------------------------------------------------------- Design Flow, -6)----------------------------- gallons per person per day. Total daily flow------- ---________.,.__.._._gallons. 9 Septic Tank-ke T e --- jAW_Liquid capacity_ .gallons Length..._..._....... Width-.?:........ Diameter-..------------- Depth---------------- Disposal Trench No. .................... Width-_-_-._..--_--_._._- Total Length--_-__--__-----.---- Total leaching area.............. -----sq. ft. Seepage Pit No..................... Diameter________---__--_---- Depth inlet_._...___....._..... Total I aching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( )below/, — el-2-2 - — )--q Percolation Test Results Performed by-------................................................................... Date---------------------------------------- 0-1 Test Pit No. I-_------------minutes per inch. Depth of Test Pit-.__-___--___---_--- Depth to ground water.--------------------_- rXq Test Pit No. 2................minutes per inch Depth of Test Pit.....___........__.. Depth to ground water_..__._.___ ---------------------------- water ::------ ----------- — . - --------V-------------------- ---- Description Soil- - - - - ------ ....... A ---------------- U --­---- --------- or ------------I---------------­------ --------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------_------- ------------------------------------------------------------ ................. --------------------------------------------------------------*---------------------------------------------------------------------------*-----------------------------*------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h een issued by the board of health. Signed.. ... .... ... ......................... -------- i�. . .............................,,Pate Application Approved By-------- ...... Date Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- ..................................----------------------------------- .................---------------------------------------------------------------------------------------------------------------- Date PermitNo--------------------------------------------------------- Issued-------------------------------........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .. ... ... ....*...OF........ ..... ................ ir Qxrtif iratr of mQUImphatta HIS JS TO CERTIE1,V, That the Individual Sewage Disposal System constructed Repaired by..:7T L-d —.................... ------- ....................................... 4 - -- --- ---------- ---------------------- ----------------- I 6aller of Z- - ------ -------- ------- at----—-- ---- rZ�7--- _eV, ---------Z, ............. has been installed in accordance with the provisions of J�(j fe'_�'T)of Ti'le State Sanitary Code as described in the 4 dated'_-/a. ............ application for Disposal Works Construction Permit No.-.Z_­"-.-A1_1__7---- - THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... ..... ........ Inspector----- ...................... --------------------------------------- ......�;..........I................ I THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALTH ..............­OF.....4W. ......................................... .................... No......E....f............. FEE....A-1/1........... ui_nvofia— .�b r kq C rtrurtion Vamit Permission is hereby g'anted-- ------- -- ----------- �--------- --- - ----------- to Constr_ t r Repz d idu..a.J lZVSe..v.a..g..e..D....i.s.p..o..s .I y-s--t-em- at No._ . - - - 7 all St as shown on the application for Disposal Works Constk/lcti.o.n P t t No___ ,,�a t e d---- .......................... 7C Board of Health DATE..../0................................................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS %i co .1 1 v t3 �, vu 4y 41" -It V, tY i fI 3.a1P, -W t­7 'k t; _�•i� 4, 77;,�477r*­ 7 7 ;A- vJ'M•A: A_,Nw S. 14,Z­!�4T,.- '-'4. .If A�X Y_ �7' 1IM4 Ir,�i. 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