Loading...
HomeMy WebLinkAbout0011 ELDRIDGE AVENUE - Health 11 Eldridge Avenue Hyannis P A = 292 270 r I 0 - _ 1 4 e TOWN OF BARNSTABLE LOCATION / GLi@ (� 1—� � SEWAGE VILLAGE fi` _ P_�iUPy ASSESSOR'S MAP& LOT L?9A:.270 _ INSTALLER'S.NAME&PHONE NO. SEPTIC:TANK CAPACITY �Xr• w�/ �© ���( LEACHING FACILITY: (type) �G1 � (size) /,T 15110.OF BEDROOMS ,BUILDER OR OWNER �P-,V^1 of PERMIT DATE: ° COMPLIANCE DATE:1 ;.;Separation Distance Between the: Maximum AMjusted Groundwater Table tdthe 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:facili,ty) Feet Furnished by f q fi k TOWN OF BARNSTABLE LOCATION �� l���G� � � _ SEWAGE # VILLAGE `��►-'a'o S ASSESSOR'S MAP & LOT �- INSTALLER'S NAME&PHONE NO. .5EPTIC TANK CAPACITY (()C)® !a.V'k, LEACHING FACILITY: (type) _ ° \ (size) f 003 i40.OF BEDROOMS BUILDER OR OWNER %cac c\fy 11 DATE: -7 i t Z Vl c" COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Feet Private Water Supply Well and Leaching Facility (If any wells exist �.j Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist ° Feet within 300 feet ofleaching . 7/i /q Furnished by -� �� i w 9� w W� tt,� � � N � `� O 6' �' r-- I 9 i I' � � TOWN OF BARNSTABLE LO^AT1ON II�^^) '��I I SEWAGE# VILLAGE ASSESSOR'S MAP&LOT o g r��O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �� LEACHING FACILITY: (type I I (size) Ci1� NO.OF BEDROOMS BUILDER OR OWNERcc tlCC �.I PERMIT DATE: 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 3—/2—?L 1 a r "�C11► � Tr s . C� Itl No. v q,ol. I FEE r COMMONWEALT14 OF MASSAC14USETTS �C�- ` f a Board of Health, Eaf n S rOcs,(3(,MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(-rUpgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location �� r �� Owner's Name e,rc�— Map/Parcel# Q 9a —. a)v Address Lot# too Telephone# Installer's Name A & B CANCO Designer's Name e �r ch Address 350 Main Street Address Telephone# W. Yarmouth, MA 02673 Telephone# d Type of Building ICE S Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures r /(/ //�-{� Design Flow(min.required) 'T`!D gpd Calculated design flow Design flow provided -7'J / god Plan: Date �0 -3O - 2 Number of sheets Revision Date ,/Ul� Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Per bn The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to o to pl a th system in operation until a Certificate of Complia ce has been issued by the Board of Health. Signed Date Inspections -..ara�..-`r�'ti�,,.r'J'Tr ti �f..."^,'...rr.i✓ti�Ly,J ` .. • iW}yi ry�^fza"-.*, k � ,,.-..,#y'`A,�•.,r`•rw\,y„ar1.F.,.r-�•-.a �-7 p hrv^"f'�+�w.+l��`t"..r+f`i'"y"-�•r'e ;' ^^a',f+J .u-t�{^....�..,ti.:-rI�-r"L-'�"*^,�y*rr'^'S y'y.r wF'r.� ( ) N J GV�-0/ FEE COMMONWEALTH OF MASSACHWAX-T-S Board of Health, t ' APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(`) Repair(-)"'Upgrade( Abandon( ) - ❑Complete System ❑Individual Components ti Location // r,716 j'/U CI t Owner's Name i Map/Parcel# Q 9a — Address Lot# (0 0 Telephone# Installer's Name Designer's Name Address Address Telephone# Telephone# Type of Building �� S •• Lot Size sq.ft. Dwelling-No.of Bedrooms [tI Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures / �s Design Flow(min.required) 9 Ct/Q gpd Calculated design flow Design flow provided C�.� / gpd Plan: Date Number of sheets Revision Date V C 4 Title Description of Soil(s) IJ� ('"t6✓1 r Soil Evaluator Form No. Name of Soil Evaluator L Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS ' d Y1 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. /7 Signed (�! i ft• .C_ l t Date ///j Inspections yt ,�� 3/O w No. eC U f) �"�_/q FEE ...� Board of Health, )&VAJ1 A6 k., MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired `,-Upgraded Abandoned g Y fY g P Y ( ) (mil ( ), P ( )Pg by: C i/�� A-)C < at 1 +CX'ciP has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. D 00 t!'If)161 , dated l 113 1 Zo L/ Approved Design Fl (gpd) Installer C\ i\ JJ Designer: Inspector: _ �rt Mom) Date: -2 �4 The issuance of this permit shall not be construed as a guarante that the system will function as designed. No. )o d q- O 1 FEE Board of Health, DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repaiir((c.,)�Upgrade( ) Abandon( ) an individual sewage disposal system r C at // / C 't, 4 V/t ��f,4.>i'�/S l as described in the application for Disposal System Construction Permit No.a vU 011 dated Provided: Construction shall be completed within three years of the date of thi��p mit. All Local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date J/1 /h t/ Board of Health 4zs - j � �' TOWN OF BARNSTABLE } LOCATION�l G�- �l�F SEWAGE # VILLAGE -IVAa ASSESSOR'S MAP & LOT 22�"-270 INSTALLER'S".NAME&PHONE NO. SEPTIC.TANK CAPACITYX� K��/ LEACHING FACELrN: (type).; (size) 1 s� NO..OF BEDROOMS BUILDER OR OWNER PERMTTDATE: FJj3hq OMPLIANCE DATE: �'"` AV Separation Distance Between the. Maximum Adjusted Groundwater able to the 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 ^] EXECUTIVE OFFICE OFTINN'IRONNENTAL AFFAIRS t. DEPARTMENT OF ENS-IRONNIENTAL PR•OTE E- ON . ONE WINTER STREET. BOSTON. MA O'-106 61?�'19N.4,CMG - R.° e� : REOVEO UILLIAM F'.WELD AUG � TRtDl'CC ` Gov=c -- 1998 se:rc TOWN OFBARNST �r9 ARGEO PALL CELLL'CCIH !TpEPT�LE DA\'ID B STR! Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE < I',ON FORM Co4issi, act Z PART A f� p— CERTIFICATION of Property Address; �>�.�\���e� -; �i�j1�iS 'Address of Owner: M Date of Inspection:l ` . .. :(If different) Name of Inspector: 4 / Leo 1 am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:�}-/7-v o►-rt-f,c Eir Y r'rf.7 01 we e i:i' / Mailing Address: Q /;cpx /. -— eLcJf-q Telephone Number: rSO 2�2 C=9-2— CERTIFICATIOti STATEMENT cerziI that I have personally inspected the sewage disposal syster: at this address and that the information reported be!oK Is true.' accurai and complete as of the time of inspec:oo-.. The Inspec;:on was performed base- on my training and experience In the proper function am r„amtenance o;on-site sewage disposa; systems. The system: ,,,X Passes _ Concitionaii% Passes Neecs Further Eva!uanon E`. the Local Approving Authority F a r' i na u Date: I Z Inspecto s S g t IH7' ,:re Svste^ Ins co• shall submit a copy of this inspection report to the Approving Authcrir, within them (30) days of completing this inspecnn. It the system is a shared Svstem o• has a des(gn flow of 10,000 gDd or greater, the Inspector and the systern owner shall subr' the repo: to the appropriate reg�or.al office of the Depznment of Environmental Protean-.- The orig:na! should be sent to the system c, and copies t'nt to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or U A] SYSTEM PASSES: - I have not found any information which indicates that the system violates any cf the failure criteria as define= in 310 CMR 13. Any failure criteria not evaluated are indicated below. COMMENTS: tiLV-\ �i/� `�lCi a:• C.�' a^ �!' .�; �: v-,t: �d.. '� �'.���\'Z..W�. t`-=��.'.��` '17 L:�lC���i� \\'..:� '?� _ 1. : ._..." �..}.t(�� �,��� I rV �q Cit'\ �i E� �j i�\.�'� �5 4�Y)/�,�':h.YL�-� W i 1.t �L.�'•(_\ 1��� IL{=F'�'�.1 �.r.9 �,ul U B] SYSTEM CONDITIONALLY PASSES: s One or more system components as described in the 'Conditional Pass' section need to be replaced or repairer. The system, t completion of the replacement or repair, as approved by.the Board of Health, will pass. Indicate yes, no. or not determined (Y, N. er NDt. Describe basis of determination in al instances. If'not determined', explain why nc The septic tank is metal, unless the owner or operator has provided tF:e system Inspector with a copy of a Certificate c Compliance (attached) indicating that the tank was installed within tw_nty (20) years prior to the date of the inspectio( the septic tank, whether or not metal• is cracked, structurally unsound, shows substantial infiltration or ex-filtration, Or failure_is imminent. The system will pass inspection if the existing se,-tic tank is replaced with a conforming septic tare as approved by the Board of Health. (re%"-sect page 1 of 10 CERTIFICATION (continued) - Property Addws: Owner: _. r- i T Tt ��' _� �'r� L. r• i .. 2n -Date of Inspection: Bj SYSTEM CONDITIONALLY PASSES (conttna�' Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) 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 pipes). The system will pass inspection if(with approval of the Board of Health): broken pipeisi are replaces obstruction is removed 77 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require furthe•evaluation by the Board of Health in order to determine if the system is failing to protect t. public health. safe-•and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or prn-% is within 50 feet of a surface water Cesspoo' or prvvy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM "'ILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES TH. THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ` The system has a septic tank and soil absorption system (SAS) and the 5AS is within 100 feet to a surface water supply tributan• to a surface w-a:er suppl}. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supr)'y 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 we'1, uniess a well water analysis for coliform bacteria and volatile organic compounds indicates the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal tc less than 5 ppm. Method used to determine distance (approximation not valid). 3) _.OTHER (revised 04/25/3-) ,age 2 of 10 SL.BSURFACE SEWAGE DISPOSALS YSTEM INSPECTION FOR-LA _ . . PART A _ CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ 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 bans 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 pondtng of effluent to the surface of the ground or surface waters due to an overloaded or clogge- SAS or cesspool. S,a:ic Mould level in the distnbition box above outlet Invert due to an overloaded or clogged SAS or cesspool Lieutd depth In cesspool is less than 6- below Invert or available volume is less than 1/2 day iiov. Reeuired pumping more than a times in the last year NOT due to clogged cr obstruc:ea pipe s . ~umber o-times pumped _. Anv portion o**the Soil Ansorption System, cesspool or pnv,)• is below the high groundwater elevation An,, por:on o:a cesspool or prn-�• Is within. 100 fee: of a sur,'ace water supcl or tributar' to a suriace water supply And por,,on of a cesspoo' or prn-�• Is within a Zone I of a public well. Am pc-lo- ci a cesspool or pmti• is within 50 feet of a private water suppi•, well Amy por,.or. o:a cesspool or privy Is less than 100 feet but greater than 50 fit from a private water sucoly well with no acceo:able Ovate- qualir analysts. If the well has been analyzes to be acce.:zbie. attach coo• of well water analysis for cciiiorm bacteria •:ola;ile organic Compcunds, ammonia nitrogen and nrtrz:' nitrogen. E] LARGE SYSTEM FAILS: You must indicate el:her -Yes- or -No- as to each of the following. The ielio-:-.g criteria app;% to :urge sys,ems in addition to the criteria above: The system serves a facilm with a design flow of 10,000 gpd or greater (Large Syster-: and the ss•sterr. 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 feat of a surface drinking water supply the system is within 200 feat of a tributary to a surface drinking water sup;: the system is looted in a nitrogen sensitive area (Interim We?lhp=a Prote_ or: 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 fell cemplia.ze with the groundwatec,treatment program - requirements.of 314 Cr.1R.5.00 and 6.00. Please consult the local regional office cf the De pa-,nent for.-further-iniormatioa:--- - - --- - SUBSURFACE SEWAGE DISPOSAL SYSTEM)NSPECTIO-N FORM PART B CHECKLIST Property Addeess: %: Owner: ��CACCiP i Date of Inspection: Check if the following have been done: You must indicate either"Yes or -No- as to each of the following: Yes N0 _ Pumping information was provided by the owner, occupant, or Board of Health. 1( _ None of the system components have been pumped for at least two µ•eeks and the system has been receiving normal c floe 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 ootained and e\amined. Note if they are not available with NIA. The iac:lr, or d%%elling .vas inspected for signs of sewage back-up. _ The systern does not receive non-sanitary or industrial waste flow. The site %%as inspected {or signs of breakout. _ All syste r. co^tponenu. excludine the Sod Aosorpuon System, have been Iccated on the site. --- 'r seGtic tank %%a_ 5 �• _ The seGt�c tank manholes Kere unco��ered, opened. and the interior of the � �n pece^ for condition of banies or tees. material o'cons;ruc'tion, dimensions, depth of liquid. deG:h cf sludge, death of scum. The size and location of the Soil Atsorpuon Svstem on the site has been determine ' based on. The fac,l.t% c%\ne• .anc occupants. of diReren; from owner, were provider w :h iniormaticn on the prope• maintenance of Sub-_c urface Disposal Svstem. Existing information. Ea Plan at 6.0 H. r, Determ-nec in the field !ii an. of the failure criteria related to Part C is a'. s- -c. approximation of distance i< unacce::abie (15.301:3i:bi? I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propert% Address: Owner:purwx',N t Date of Ihspection: -71-0 (f� FLOW CONDITIONS RESIDENTIAL: Design flow _g.o.d.•bedroom, for S.A S Number of bedrooms 0 Number o'current residents- Garbage g%r der (yes or no,:, Laundry co.—ected to system (yes or no! Seasonal use Ives or no-J-1i Water meter readings, if available (last two i2 year usage lgpdi: Sump Pump (ves or nor La<: da:e c- occupann' 4V 1 COMMERC tAL'INDL'STRIAL: Type of establ+shmen; Design fio„ ea!+onsida, Grease trap present tress or no_ Indusma! %'taste Holding Tani; oresen;. Ives or no :on-sartrtas. %,aste d.scnarged to the T:;ie S sys;ern ;ves or no_ eater meter readings if available Lzs:pare o: o C:P2-.c. OTHER: :De_cr+be last az;e of occuoanc. GENERAL INFORMATION PUMPING RECORDS an source of information t1i � - � iLs ia:iCi`V_ I System pumped as par, of +nspeG+on: Ives or no. fv If yes, volume pumped- Reason for pumping ; TYPE OF SYSTEM X_ Septic tankbaz=soil absorption system Single cesspool Overflow cesspool Pmy Shared system (yes or not (if yes, anach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other --- - APPROXIMATE AGE of all components, date installed (if known) and source of information: `{ 1 n,1)"�1/�5e1'A Sewage odors detected when arriving at the site. (yes or not (r•v1..G 04/25/91) Pap• S of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTESA INFORMATION (continued) Properly Address- ' Owner. Qi; Il�j Date of Inspection: 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 Ir-- Diameter Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK: I (locate on sue pla. Depth below. grade Material of construction:- _concre:t: _me:z _Fiberglass _Polyethvlene _othertexplain if tank is me:a). lis: age _. 1: age con;irmec c. Ce-..fica:e o: Compliance _('res.-No Dimensions Sludge depth Distance from top o: s!uage to boron o` ou:;e. !ee o• ba-;e Scum thickness-_S " Distance from top of scum to top o" outle: tee cr bake L-: i Distance from bosom o-scum to bo-o-•: o;o,Cie: tee c• bz*i.e How- dimensions Here determines Comments trecommendation for pumping. condition o; ir.:e: and outlet te=s or baffles, depth of liquid [eve! in relation to outlet invert, structural integrity, evidence of leakage. e:c.i �iTrv� •.`,-i if i,u T� ;t� ij .T-Y',CA GREASE TRAP: T (locate on site plan! Depth below grade: Material of construction: _concrete _me:z Fiberglass _Polyethylene _other(explair: Dimensions: - Scum thickness: & Distance from top of scum to top of outlet te- or baffle. - - Distance from bottom of scum to bottom of c_:!et tee or bah•ie: Date of last pumping: Comments: -- (recommendation for pumping.-condition of . :" and outlet tees or baffles. depth ofliquid level in relation-to-ou:!e:-invert--structural integrity, evidence of leakage, etc.: o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA 'PART C SYSTEM INFdRMATION (continued) Propert% Address: Owner. Date of Inspection: TIGHT OR HOLDI'vG 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. / Capacm• gallons Design floe galionssda. / Alarm level A:arm ,n %korking orde• _ Yes. _ No / Date of previous pumping j Comments (condition of isle, tee. condition o- a!a�rr and float switches. etc., DISTRIBUTION BOX:_ (loca;e on site p an De::h o; Iiauid le%e•. aoo.e out1e: in%e" Comments ,note r leve! and d,s:ribut,on ,s eaua' evidence of solids carr,•over, evidence of leakage into or out of boa, etc.) PUMP CHAMBER:_ (locate on site plan. Pumps in working order: (Yes or No' Alarms in working order (Yes or two Comments: (note condition of pump chamber, condition e' pumps and appurtenances, etc.) B i — SUBSURFACE SEWAGE D15POSAL SYSTEM INSPECTION FORm PART C SYSTEM INFORMATION (continued) Property Addr-ss: dr-IdgR Owner: � j4 Cf`!NI Date of Inspection: 7 SOIL ABSORPTION SYSTEM (SA5): fj (locate on s)teplan, ifpossible. exca. -,ion not required. but may be approximated by non-intrusive methods; If not determined to be present, explain: Type: leaching pus. number._ leaching chambers, number_ leaching galleries, number: leaching trenches. number length: leaching fields, number, d,^tensions overflow cesspool, number Alternative system name of Tecnnotog.- Comments mote condition of soli. s!gr.s of hydraulic failure. lever of pondmg. condition of eg -Uon, etc. r I C i I WC, C a _ CESSPOOLS: I� doczte on site plan. Numbe, and confegura:,o- Deoth-top of liquid to inlet Inver, Depth of solids lave-- Depth of scum layer Dimensions of cesspool Materials of constructor. Indication of groundwate- inflov,• (cesspool must oe pumpec as ,an o7 inspection} Comments: (note condition of soil, signs of hydraulic failure level of ponding. condition of vegetation, etc - PRIVY: v' (locate on sue plan) Materials of construction: Dimensions: Depth of solids: Comments _ _. .... (note condition of soil, signs of hydraulic failure, level of pondmg, conci;icn of vegetation, etc:- .. (r.vis.G 04/25/57) _ Yaq• 8 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM I40RMATION (continuedi Property ddress: ,IEk&V—,&gO Date of In3peRion: 7(z SKETCH OF SEWAGE DISPOSAL SYSTEM. include ties to at least two permanent reTerences landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) t tl .A �n VC, ; ( f Q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertv ddress• Owner: (I Date of Inspection: l- ! Depth to Groundwater +Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions. Check %+ah loca! Board o• nea!t^ Check FE,1A naps Check pumping records Check local excavato,s installers t.se L SCS Data a ' r, Describe in voi, q%%-� %-.orCp no-n m.; es:a61!!-ed the �-iigh Groundwater Elevation. (Must b- :or-,pleted: _ Ur �`C0-1) S� 'CtJZ (t C v l0Z,( fc�( j��,f�� Pago 10 of. 10 r _ - 6 i - Commonwealth of Massachusetts 6!.Z. .�l)L Executive Office of Environmental Affairs John Grad D.E.P. Title V Septic Inspector Department of P.O. Box 2119 .Environmental Protection Teaticket, MA 02536 WHIM F.weld (508) 564-6813 ev"Mor TrudyXe .y,EC t tru SncrelF-A Datrld B.Strhs Ccmmisatonet SUBSURFACE SEWAGE DISPOSALAYSTEM INSPECTION FORMPART 'Pere), CERTIFICATION t �� p, 1� Property Address: �� �������� - � an��S Address of Owner: '4 Date of Inspection: 3��Z\p . (If different) vs, 6' Name of Inspector: su Company.Name, Address and Telephone Number: 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: des — Conditionally Passes Needs Further valuation 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 floe 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 me system owner and copies sen: to tier buler, if applicable and the appro,ing au*.•.ority. INSPECTION SUMMARY: Checl�A B, C, or D: Aj SYSTEM PAS S: 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 components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, 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 VAnter Street a Boston,Massachusetts 02106 a FAX(611)SW1049 a Telephone(617)M-SS00 Printed on Recycled Paper 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): 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 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 SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Ine jbsien) nd> a ?eUU( tdnh anui suli ibtorpilon systen' dt'id I$ Kiilui5 ivv fcci IG a 561'.0-:c tC z surface water supply. The s\sten has 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 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 free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPm. 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 contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 r 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 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: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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: 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 wells 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 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: t-4"UMping information was requested of the owner, occupant, and Board of Health. L-Nvne 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. '!�\M71built 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. _L_>e system does not receive non-sanitary or industrial waste flow ►.Tfne site was inspected for signs of breakout. L-Ml system components, excluding the Soil Absorption System, have been located on the site. _,,,T�e 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--he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. �'Fe " C'�•— il»,4 .. r,in�n,< ;f diffprPn! (rnm mvnPrt were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 Y J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C \ SYSTEM INFORMATION Property Addr Owner: Date of Inspection: J FLOW CONDITIONS RESIDENTIAL: Design flow: allons Number of bedrooms: Number of current residents: Garbage grinder (yes or no)C)[.'� Laundry connected to system (yes or no)\--WS Seasonal use (yes or no):_V(,,S Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL:(� 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 or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RORDS and source of information: System pumped as part of inspection: (yes or o) S If yes, volume p,imped gallons '0-\ mom Reason for pumping: ctY,,X ye'd nu TYPE OF STEM V Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: `I�u Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: Owner: C ov _k\` Date of Inspection: SEPTIC TANK:1e___ (locate on site plan) ff Depth below grade: Loll Material of construction: 1,_-cUncrete_metal _FRP other(explain) Dimensions: Sludge depths t Distance from top of�'IuVge to bottom of outlet tee or baffle: 01 1 t Scum thickness: Distance from top of scum to top of outlet tee or baffle: Cott Distance from bottom of scum to bottom of outlet tee or baffle: »�( Comments: (recommendation for pumping, condition of inlet and outlet tees or les, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ki a -(� sera . J GREASE TRAP:S � (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Scum tnickne». Distance from.top of scum to top of outlet tee or baffle: Distance from bottom ro crt,m. t� 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, etc.) (revised 8/!5/95) 6 7 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ' �A d �6�6 Date of Insp ion: S1%-2A , , TIGHT OR HOLDING TANK:jC\\(.-4= (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:2i (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if levei and distnbutiur, i>eyuai, evidence of solid, car)o,er, evidence of leakage into or out of box, etc.) PUMP CHAMBER:--1�4\4 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C 1. SYSTEM INFORMATION (continued) Property Address:. 1 EN(�(�d(�Q Owner: QC 4\j el\.\ O Date of Inspection: 31 lZ��lo SOIL ABSORPTION SYSTEM (SAS):L-- (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: _ n ' leaching pits, number:�v� V 0.'\Oc1 N �� vGux-� \�k leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comm nts: (note condition of soil, signs of hydraulic ailur lev I nding, condition o vegetation,etc.) onur\ Qi- - CESSPOOLS: _D\(:� (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 groundv.a;c-. inflow (cesspool must 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: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �� �1��(�a�--� Owner:.— Date of 1 ion:�� 3\�Z\q6 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' - 0 q 4 DEPTH TO GROUNDWATER Depth to groundwater:_�feet method of determination or approximation: SCrS M Q�PS �t—CX1 (revised 8/15/95) 9 v I ��� ion ASSESSORS MAP : 2,`�2 TEST HOLE LOGS NOTES: '� 'HY N/ sf 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH ,,,,,c�� se PARCEL : ��C? VL+ R,S� ('C�� HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF �� I�k � SOIL EVAL ATOR . _ BOARD OF HEALTH REGULATIONS. " FLOOD ZONE:: I� 4 WITNESS ,)�, � . o REFERENCE: BI .. 11�g DATE: 2) . THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES PERCOLATION ON`�TE: � MAN � SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO s SALE C 5 �� INSTALLATION.` L- a��N � / � c,q " Owe ¢ !� TH- I eL'.3j,?5"' TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION , V ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE �� to a 4 LOA Il - ry/ DETERMINATION. � nos S ( 1 p,,ZS 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS t d $ '` "'� . ` t LA-K 3 ( SPECIFIED OTHERWISE) a p LOCATION MAP(N-, , 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A 2R,E GARBAGE DISPOSAL. 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) �IVM' MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON G A BASE OF 6"OF CRUSHED STONE.�/ s a y 135 —r� Ex�srr c, P►r vM(-t o o° 6w op,%v'e a 8 No twmw PR4yj w t rD'o PRo�aSa c— L. D zf _ S E-P T I C S Y T E M DESIGN �t�Nv w��t, >7� w to . 4D I + _ r9-No ll t 1- ram Mn& y Ga-li�wli!OF- ;64W C4o.o' FLOW ESTIMATE "Or It`' ._.... ..,� ,�.. ...... .._. 4,BEDROOMS AT I t 0 GAL/DAY/BEDROOM - ���GAL/DAY IWI I a SEPTIC TANK ` 0_ GAUDAY x 2 DAYS • bt_GAL I I USE 1 GALLON SEPTIC SOIL ABSORPTION SYSTEM 8)CIS77A] �� 500 6kLt,0 J F,e.A 66,,g-c tj L` u+�J 065 t ! SIDE AR EA: (33•S) f-6175)ZDx7- x D, 7Y ; r37, 6q EOTTOM AREA: 33,5' x 13' K 4, ?N : 3S2 V7 M 1 21 - SEPTIC SYSTEM SECT TON C i DNS �,9SSv�M , r, ' w&',4 yl'e��, ..,,. 9100, vp D-BOX ice. � tw;7 rr� GALj.0 37, ,3' E�r5 .c1 SEPT I C TANK � l+�✓ resS „�..,.. �33•S�LX I Wx 22 O) '-"--�' gq- 7 g's r V1\A OF k4S. Dh REN �� : S I TE AND SEWAGE PLAN Y10 LOCATION : �FGIST �� 41VI1"ARO''a 3' PREPARED FOR : C4-Alte> 0 DARREN M. MEYER, R.S. SCALE: a 43 VINE STREET DATE a W a' g �u- � � DUXBURY MA 02332 frztJ Z Fwk� (,�N `/ y DATE HEALTH AGENT (781) 585-0293 W Z