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0042 GREENBRIER LANE - Health
42 GREENBRIER LANE, HYANNIS A = 268 078.015 a o o TOWN OF BARNSTABLE LOCATION U o`� Of('e,,) 1pf 1 r SEWAGE# ,9QJ J5--as`7 VILLAGE y ,Nl S ASSESSOR'S MAP&PARCEL;; 7 �— 2Gg•-o7g DiS INSTALLER'S NAME&PHONE NO: IGS SEPTIC TANK CAPACITYx15? +� LEACHING FACILITY.(type) (size) J f3 X: IF 1 NO.OF BEDROOMS OWNER Ff�Ut))G PERMIT DATE: "7—�(� J _ COMPLIANCE DATE: Separation Distance Between the: c F pe(-( Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1 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 iJ B ?:3' bU r- 21 1 - 34 'G No. _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for MispoBal 6pstrm ConstCurtion j3Prmit 0 Application for a Permit to Construct( ) Repair(0 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. a�.r.�+e r eyf %A/ Own Is Name,Address,and Tel.No. Assessor's Map/Parcel aC; �- - Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. r:rj/Gi iff✓.s.y am Sj 1{ ..7fc r y Ile Type of Building:. Dwelling No.of Bedrooms 3 \\ Lot Size i©,y(X) sq.ft. Garbage Grinder Other Type of Building /e`i 0C,01r,K) No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '3>0 gpd Design flow provided 7 gpd Plan Date 7 Irv° Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 25" C9 (.,r.��c.�.,v 46AO/X�C(s Description of Soil Nature of Repairs or Alterations(Answer when applicable) A.;t w o toe* CV-3 �;C70 c.l 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 Certificate of Compliance has been issued by this Board of Health. Signed' Date -7 " � 0 Application Approved by Date s Application Disapproved by Date for the following reasons Permit No. tL� DL.77 Date Issued wt-_..i. $'""�'_„Y.y ,k* .r �. ��.ti��wt�.,,.; ,+:`•-/t.. .,nit "'`t""^�t`-` -♦ a < r +. .r.. No. k. _ FeeTHE.COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTHPIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS"-, Yes 01pptication for 19t108af *pstetit (Constructionerlltit Application for a Permit to Construct( ) Repair(0 Upgrade( ) Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. N2 Grr►.b r►r% L. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1UA/yawa rs A#`�//4 SG g Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Vbt5jci A i Tnz S -�ct7-7/$�1 N ��r,�r►.v�, t�ail�. Type of Building: Dwelling No.of Bedrooms 3 Lot Size /t70)0 sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) \' E Other Fixtures ,t Design Flow(min.required) `3'30 gpd Design flow provided 70/$, 7 gpd Plan Date 7 a/3 1Q§ Number of sheets Revision Date Title . Size of Septic Tank /f K� �,�a� Type of S.A.S. 2 SC)o yr llnm t-lAr��ts e�6 r�f (a 1 Description of Soil /ON TCT Nature of Repairs or Alterations(Answer when applicable) 4 New �&2K ow 2 SC>O G c:416A) 11-ArtAkAr°rs t tl~in ► 5!to�P 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 Certificate of Compliance has been issued by this Board of Health. Signed' I Date 7 7 U —lF3 ApplicationApprovedby C'� Date `r7. (J -- /1 — Application Disapproved by // Date for the following reasons Permit No. 0 1 Date Issued ;�o THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Qtertificate of Compliance THIS IST.O--CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( AT' Upgraded( ) Abandoned( by ,,, 1 r . A le at aI 2 G+r r prJ ln,r„v d-rJ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No..2 W dated Installer A A > > i C&, r3 'L ra0 Designer �a�����,,�<������ S #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will nc oMMa'ssrii ed Date Inspector -= -. --------------------.- - --- -------------------- '----------- No. t Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(L< Upgrade( ) Abandon( ) System located at bf 2 ✓p orJ t;,./ 4,r'aiv e, XI.v&,mru r S and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 permit. Date ! .� t f Approved by �f Town of Barnstable P# Department of Regulatory Services 1m Public Health Division Hate 01 i639 w,� ZOO Main Street;H 1,Hyannis MA 016 prED MA'S� y Q Date Scheduled / ! Time / Fee Pd�I m Qa -e =�� �Jl 0 Soil Suitability Assessment for SeuMe 1 *!?sal Performed By: Pe;t-ei /t'ie Er1�-ee 5 E- �.ryz Witnessed By: LOCATION& GENERAL rNTORMATION location.Address tyz /! __h b�;Q r `N Owner's Name SrAlt-o 77HyQCnTna`t�,r Address., tyj r'tQ{'11�tr S p J V ILK CT' B G ?17 Assessor's Map/Parcel: Z 6 O 7�•• (f f 1 Engineer's Name L n y I/��pe� NEW CONSTRUCTION REPAIR �_. Telephone`# S41� 7' 77-S34 I.znd Use's vi�J 4 , Slopes(%) ! - Surface Stones_�YJ Distances from: Open Water Body:o-" Z�Z ft 'Possible'Wet Area N 1i e. ft Drinking Water Well l ft Drainage Way ft Property Line U A r. ft Other ft .CTI TCH:(Street name,dimensions of lot,:exact locations of test'holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) 63(1�Lk)aS Depth to Bcdrock. Depth to Groundwater. Standing Water in Holef�)tJ n e Weeping from Pit Fade d u Estimated Seasonal High Groundwater- t 3 Z— DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used, . Depth Observed'standing in obs:hole:. _ ____ in. Depth it)soil Mottles: Depth to'weeping from side of obs,hole: in. Groundwater Adjustment Index.Well# Reading Date: Index Well level a�r A($factor_� Adj.Groutidwnterlevel, PERCOLATION TEST Date . Thne Observation Hole# 0,1 L'-Q C�je at t�„ __ _ _ �Q 9 Depth of Pere. '' _cc �71in a b" Start Pre-soak Time Q Z. fM,,e ! 11C,'► timd(9'1•6") End Pre-soak S5;, iS AL rf- Cc- 5 11J fi tt 'LL�r, Rate Min:/Inch. AC Z.— / Site;Suitability Assessment: Site'Passed / Site Failed: Additional Testing Needed(Y/N) Original: Public Health.Division Observation I-Iole Data To Be Completed on Back - -- ---- 0*1f percolation test is to'he'conducted within.100' of wetland,you must first notify the Barnstable Conservation Division atleastone(1) week prior to beginning. Q:\S EPTiCTERCPORM.DOC i DEEP OBSERVATION HOLE LOG Dole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. on i ten ravel Ld`((L 25 _ .13 1z C Cfta'se SUVA 2=5"9 C. DEIEP OBSERVATION HOLE LOG Hole# `Z Depth from Soil Horizon ' Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,:Boulders. onsi en % ravel f 30. P L ,5 fa`PR-sfF 6 —ryz— DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure;.Stones,Boulders. Consistency. G ve �._. _ —....._ DEEP OBSERVATION HOLE LOG Hole l# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in) (USDA) (Munseli) Mottling (Structure,Stones,Boulders. onsi ten n Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes ,,( Within IOO yearflood boundz y No.! Yes . Depth of Naturally occurring Pervious Material Does at least four feet of naturally occurring pervious:material exist in all areas observed"throughout the area proposed for the soil absorption system?: yj�= :> If not,what is the depth of naturally occurring pervious material? Certification .L,' ��Ik�`I have passed the soil evaluator examination approved by the rt that on ( ) I certify Department of Environmental Protection and that the above analysis was performed by me consistent with the required trainin expertise and experience described in 10 CMR 15.017. C Date Signature Q:�.SEI'T[LIPBRCEORM:DOC ' Town of Barnstable �oFz�to ywP wti� Regulatory Services Richard V. Scali, Interim Director � BARNS7ABLE, 9 MASS. m a - Ppblic Health Division pO i639. `0 'DrFD ,ta Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 509-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form n,� Date:7_ Sewage Permit# �d��r����ssessor's Map\Parcel y ? Designer: tnn�Q,-1 ts, s�C • Installer: _ J 1 nJL_ Address: 12 w, C�ss�-'e (d Rcl Address: On `7-20 1 f3 �; issued was a permit to install a t � (date) installer} septic system at C� s �J(`1<of L rJ based on a design drawn by (address) el_e t Ev►�inex�,"n�; War bu /4 C , dated �/5 / (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes'such as lateral relocation of the distribution box and/or septic tank_p Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (Le. greater than 10' lateral. relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructe nce with the terms of the I\A approval letters (if applicable) %OF PETER WE T. crvai� � Installer's Signature) NO.331ag /STER (Designer's Signature) (Affix Designer tamp Here) PLEASE RETURIN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANNCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QAScpti6Dcsigncr Certification Form Rev 3-14-13.doc LO CATION S E PERMIT�NO. VILLAGE Z6,,r—jo,-,16f (��/Z02)3plm, LqA)r. LA INSTALLER'S NAME i ODRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��- _77 cl i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) We Propene Address: 6r11 N hr/{ r 1,44 Owner. 1- h v 17 Date of Inspection: y- 7- 9,0 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) S��e1-7 122o� „ �3y d 20 2 / 7, 3 y �' '3 3 Ta uiU�r 3 v" (revised 04/25/57) Page 9 of 10 C,l���o� Z(o� /® ?r"/o 5 f o�� cr n z G no (b 4 p � N v� G i � I �� .9 \4(�yI 810Ck- / CO oe/ 09F/ L7 �i por U L5�e4 �Jpskej Wha ,b / 'geVl ��j V 7i (r 8 7 N i Qa��J �Z 9 r' PB 337-PG 20 EXISTING SEPTIC TANK EXISTING LEACH I (TO REMAIN) TO BE PUMPED, FIL TOP OF TANK, EL.=100.20t SAND & ABANDONE INV.(OUT)=98.85f 99.71 IN Ob 5b' rc 100.00 BENCHMA RK 7,100,67 COR./BULKHEAD EL.=101.42 LQ i :SHED I 99.90 0,000±S.F. � x , 100.48 0180 O 100.40 100,51 .>SU/v!{ (A101.;ROOM` 00._._9._.. 00 W k' ;� 9 { O N DECK w j o 0 N o %`i%EXISTING i m zt o r.- , f 100.29 ;'%"HOUSE(#42); 0100.74,. r z/ x 10/T.O.F.=101.4t -,1 N l 100.381+ .2.•ol f + at WALK 0 :yI 100.92 Q ' IOp 1.00.44�';'.• :•. :. 100.13 99.23 Q 100.00 „ N 05'36'59" E ._,... . ._.... -1�0 98.64 98.95 edge of pavement PK SET 99.50 G REENBRI ER LANE OWNER OF RECORD FAVILLA, SANTO & CHRISTINA 148 MATHER STREET WILTON, CT 06897 T I ; 3 Q'-Ja A DECK f __. ' /- EXISTING,,r,,',;-;;... :,/,'HOUSE 42 T.0.F.=104.4f f � _ 9' l I Iv 282399, 1 SEPTIC LAYOUT ®®®® ® E' ®®®It ®®® ® E®®® 33„ N z ®�®®®® ® ®®®® 102" 4" KNOCKOUT 20" DI A. COVER 4" KNOCKOUT 0 / 4" KNOCKOUT 58" 4" KNOCKOUT 500 GALLON CAPACITY, H-10 LOADING CHAMBERS N.T.S. PROPOSED SEPTIC SYSTEM UPGRADE PLAN 42 GREENBRIER LANE, HYANNIS, MA Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 ngineering by: SCALE DRAWN JOB. NO. ngineering Works, Inc. N.T.S. P.T.M. 188-18 2 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. 508) 477-5313 7/13/18 P.T.M. 2 Of 2 5� Date Physical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) Storage Information - location of storage, how long is storage for? If none, note that. /U Disposal Information -where and who? If none, note that. Applicant Signature - understand what is listed and noted Staff Initial any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and xplain it Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE:-� Fill in please: F+vil!I iId••Aa - APPLICANT'S YOUR NAME/S: IZ,n •4. aLjC:)nTC�/� tii Q• '"•RI„ `'' �f��Y'��'" Jt,," YOUR HOME ADDRESS: .� '✓L V :,, BUSINESS 1;i'til$�fcr $jrr nrLhli 'f f.'i,< LJAJ 4 11 IS I� 7N"' d`'' TELEPHONE # Home elephone Number ,..1 ',. a ,•J' ®n:a rrs71,'.1, ,t>�N„ , _ l f f itJ C� ✓l/1 NAME OF CORPORATION: � A( r �� NAME OF NEW BUSINESS TYPE OF BUSINESS O rT(�, IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS67��G ��` ,, Al,v Wim '�f PARCEL NUMB (Assessing) � / When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you-may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your uslness'in this town. 1. BUILDING COM ER'S OFFICE This individ l h s e n info o ny rmit re uirerrients that pertain to this type of busineti-ES AST COMPLY WITH HOME OCCL.` AND REGULATIONS: FAILLI' �u I, ed Signa e** COMELY MAY RESULT IN FINES. COMMENT l iOq �/YI Qll 2. BOARD OF FLTH U This individual has en inforqied of he permit;xQquifyents that pertain to this type of business. 1 Authorized Si ature** > WRIKALL COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: acifm5L & bly-( L, (/A 1[61V6- l M Pao JZCj_-t4EA- T BUSINESS LOCATION: e-12 icar .- 2.v I��Sj„�,v v�s 4.,,40 2 A-f INVENTORY MAILING ADDRESS: S A ,%A r✓ TOTAL AMOUNT: TELEPHONE NUMBER: e ?L � 4�� CONTACT PERSON: (iGth EMERGENCY CONTACT TELEPHONE NUMBER: 4y911 A ,QjA 16 2 MSDS ON SITE? TYPE OF BUSINESS: i T // INFORMATION / RECOMMENDATI S: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals(Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables er products not listed which you feel Floor&furniture strippers may c or hazardous(please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials l - COMMONWEALTH OF MAS SACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIROiikti Uf,4E A rlpgR�D,T]-ZCTION Y V �t z NO y 7. �� 1z: no C2, LOP Di u ,---- TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: �reeo blv✓' 1--IV' s -Ah f Owners Name: ,,, Owner's Address: ?""roe Date of Inspection: Name of Inspector: (please print) Company Name: Eyvl a - 7-eC 6- Mailing Address: o p � Ode G cF,2 Telephone Number: v _ 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to S ' n 15.340 of Title 5(310 CMR 15.000). The system: ses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 4 - Date - d- -ar The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 regio g nal office of the authority. DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approvin Notes and Comments- ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: v Date of Inspection: Q p Inspection Summary Check A,B,C,D or E/ALWAYS complete all of Section D A.�Ihave asses: not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 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. ND explain: I T:tlu C incnnntinn Rnrm 41 ci,)nnn 2 - i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �4p) Owner: Date of Inspection: D g D C. Furt er 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 public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 b that the system is not functioning in a manner which will protect public health,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 unles s the Board of. Health(and Public Water Supplier, ' system pp r,><f an determi m is fun Y) nes that Y functioning in a manner that protects the public health,safety and environment: the The system has aseptic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: T; to S fncnontinn pn�m A/i;iinnn 3 " Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) I` Property Address• /eo N 6/1 p,/ Z 6)02 f of h old /lj 6 Owner: �� / ' Date of Inspection: 0 9 r D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No )ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Di ha or ponding of effluent to the surface of the ground or surface waters due to an overloaded or �ged SAS or cesspool _✓✓✓✓✓✓ Static liquid leve l el in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓— kiquid depth in cesspool is less than 6"below invert or available volume is less than%z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number Hof times pumped ✓_ t /Any portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ater supply. ,Any portion of a cesspool or privy is within a Zone 1 of a public well. portion of y p a cesspool or privy is within 50 feet of a '�'Y private water supply well. v 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facilityand the presence of am monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure crit eria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Xthe e system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped ne II of a public water supply well If you have answered"yes"to•any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title inenoi.tinn Gn�m All ai')nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORAM PART B C/HECKLIST Property Address: pl /"P�Vt 1, Owner: /" G yi ti h o/�/ Date of Inspection: /O / 9 01— Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No/ ✓Pumping information was provided by the owner,occupant,or Board of Health LA Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? r/Have large volumes of water been introduced to the system recently or as part of this inspection'? Were as built plans of the system obtained and examined? If they y were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back u '? g P — T Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the maintenance of subsurface sewage disposal systems? proper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: - Yes no / /c/Existing information.For example,a plan at the Board of Health. v— Determined in the field(if any of the failure criteria relate is unacceptable) [310 CMR 15.302(3 d to Part C is at issue approximation of distance Title C fncnontinn'17-lii ciinnn 5 I Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATI�O/N Property Address: "WFLO Owner: a vi Date of Inspection: DITIONS RESIDENTIAL Number of bedrooms(design):-3— Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �a Number of current residents: Does residence have a garbage grinder(yes or no)://0 Is laundry on a separate sewage system es or no):� [if yes separate inspection required] Laundry system inspected(yes or no):/K Seasonal use:(yes or no): f Water meter readings,if available(las 2 years usage(gpd)): Sump Pump(yes or no): X/o Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgf%etc.): 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/use: OTHER(describe): GENERAL I ORMATION Pumping Records / / � f-e� Source of information: /1/ K--ly V c. /, Wass stem —partp �� ✓ y pumped as of the ins ection es or no): /(/O If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: / ✓ TYPE OF SYSTEM eW f _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) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank —Attach a copy of the DEP approval Other(describe): Approximate age of all component date installed(if on: wn nd source of information: (434 - 0 _ Were sewage odors detected when arriving at the site(yes or no):/fo Titla C Inenortinn 1±nrm!./1 5/7nnn 6 ' r Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /'P Pvl ki e►- 4 Owner: Date of Inspection: 0 /9 e. BUILDING SEWER(locate on�site plan) Depth below grade:�_ Materials of construction: ast iron _--4'0"PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:—"(-locate o site plan) Depth below grade: Material of construction: oncrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: Sludge depth: off—' Distance from top o sludge to bottom of outlet tee or baffle: a? Scum thickness: /-QSf / 1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom tlet tee or affle: How were dimensions determined: �to/ Comments(on pumping recommendations,inlet and outlet fee or baffle condition;structural integrity,liquid levels as re l d to outlet invert,eviden a of leakage,etc.): 44 fAi! 4-j P"e, T41hli an d in O c i o oN�i/ion . GREASE TRAP:/-L11(1ocate 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): I Title G fncnnrtinn Cnrm Aii ai1nnn - 7 I Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6'1-eeo l/ v- � Owner• F—at✓i Date.of I.nspection: TIGHT or HOLDING TANK: tank must be pumped 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 present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (i✓ f present must be opened)(locate on site plan) Depth of liquid level above outlet invert:JQ9/'r"-1 A �— Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage in r 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 pumps and appurtenances,etc.): Title G fncnertinn r—m A/1;r)nnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �rOPJA h/r;,r e Owner: Date of Inspection: 0 /q 05 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Tyeeachin _ lg pits,number: /-e leaching chambers,number: / leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,� etc.): 0// . p / � v'•C l✓� Gruel /vle 11211 --G G' CESSPOOLS: (cesspool must be pumped as part of inspection)(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(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:IL(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.): f Titlo S 4/1 Z/7nnn 9 1 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: —(()',' J11,ek- Owner: PovjA / Date of Inspection: / a j SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. 14 U J, t( o 40/ �3- a3 ' y 3;L ay Tiflis C Incnanfinn r—m.<il aii-nnn 10 • Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property tyAddress: oL G/wei 6a te✓ Z— v av►n �/ /�� ©a� 6'Id Owner: Favl Date of Inspection: SITE EXAM Slope j U. Surface water �( Check cellar Shallow wells 1�0 �v Estimated depth to groundwater fleet to w C Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed-site(abutting property/observation hole within 150 feet of SAS) ecked with local Board of Health-explain: /ZI-1�JS Checked with local excavators,installers-(attach documentation) F Accessed USGS database-explain: You must de cribe how ou a tablished the)high ground water el/@vation_:/ /`o W✓r !i✓`� 1/ c, Y� �wl 1• [�f a7'tpv! JJ ` - o h ( t9 10 n b N 0010 s ,� 41' Title lncnartinn Anrm 4/1 VIAnn 11 COMMONWEALTH OF MASSACHUSETTS !y EXECUTIVE OFFICE OF ENVIRONMENTAL A F41 S DEPARTMENT OF ENVIRONMENTAL PREGQ N ONE WINTER STREET. BOSTON. NIA 02108 61 7-292-�ry0`U 9 1 9�rHa NSr9 998 Fpl BlF N ILL1As! F. WELD > TRUDY"COXE Governor Secretar\ ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Go�crnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: �11 /y�qs,„;� Address of Owner: Date of Inspection: 6�7�g� (If different) Name of Inspector: JUl-r y� �� _ I am a DEP approved system insp for ursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: h kY,Z. o Se,[r� Mailing Address: nA Telephone Number: 02 R _�5:q CERTIFICATION STATEMENT I cenrfy 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: Zsses — Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: C - � � Date: 1-7—�' ` 1g The Svstem Inspector all 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 repon 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: AI 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. 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 (10) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (r•vca•d 04/25/97) - Pag• 1 of 10 DEP on the World Wide Web, http:/Avww.magnet.state.ma.us/dep r• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART CERTIFICATION (continued) Property Address: LJZ tTrP1h �i'I1yf+'0H'e QHner: \. P/eaA? C/'S Date of Inspection: y- 7 _ 9$ B) SYSTEM CONDITIONALLY PASSES tcontinued) 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 C) FURTHER-EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 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 priory 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet 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 (approximation.not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: "?I (yrllr� /jyJ-lr �s�H� ��jdiH/y�f �'Jpy� Owner: CY4 1 Ctrs Date of Inspection: /� O 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 cfggged SAS or cesspool. Static liquid level to the distribution box above outlet invert due to an overloaded or clogged SAS or cessFurDl. 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 watwr 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. Anv 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 copv of well wam( analysis for cohiorm 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 significaea 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 Zane 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 treatmwnt program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. tr•vised 04%25/97) ?ago 3 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:- yZ Gr{d h LJv l.lr 4,, ,e W� yt�htii s t�avl Owner `/!Gv,Ci s � f)�j�{ / Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: K 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 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 non-sanitary or industrial waste flow. y _ The site was inspected for signs of breakout. All system components, a iag 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. / The size and location of the Soil Absorption System on the site has been determined based on: 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 Pan C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) Ir.vi..d 04i:5/97) r.y• 4 ut 1U , . t - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71- 61.--44 J rl-e r 4H h.e � /7ys�hvriS poY� Owner: �/�Gth Ci S .6/! y J•-( / J Date of Inspection::) _ 7— 90 FLOW CONDITIONS RESIDENTIAL: Design flow: 170 e.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Allo c Garbage gri:.der (yes or no):—!/v Laundry cor•nected to system (yes or no): � Seasonal use ryes or nol: v `�� $y Ste' Cgb "g7 /D� O �� Water meter readings, if available (last two (2) year usage (gpd): S � � Sump Pump (yes or no):—Aj6p Last date of occupancy: COMMERCI.4UINDUSTRIAL: Type of establishment: Design floe+•: >;allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: Ives or no)_ Non-sanitary Kaste discharged-to the Title i system: (yes or no)_ \Water meter readings, if available Last date of occupancy: OTHER: iDe�cribe; Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source f information: System pumped as part of nspecti n: (yes or no)_ If yes, volume pumped: gallons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)An (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ��Ib hi�SrJoy Owner: {��-h C/5. E Pay Date of Insp ction:_ ! . 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 hr•c Diameter Comments: (condition of joints, venting, evidena of leak/age, etc.) 71 l/nr� SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: e metal _Fiberglass _Polyethylene _other(explain If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: 4, Distance from top of sludge to bottom of outlet tee or baffle: �U Scum thickness: / Distance from top of scum to top of outlet tee or baffle: ,y Distance from bottom of scum to bottom of outlet tee or baffle: 21 How dimensions were determined: ru Ie 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.) S-� � ar..k ,rrl,�:. �' awa mu.7"/tf" vG ' t i, v u fit? GREASE TRAP: (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 04/25/97) Page 6 of 10 4 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 G rr ,)j�-%1 r' � /1�141 AIA7 /)p 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 floes: gallons/da\ Alarm level. Alarm to working order_ Yes, _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan! Depth of liquid level above outlet invert: O Comments: (note if level and distribution is equal, evidence �o(yf.solids carryover, evidences 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 pumps and appurtenances, etc.) (revised 04/25/97) Pag• 7 of 10 6 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I- SYSTEM INFORMATION (continued) y2Property Address: r�rrl/-eri� Owner: `/ 01-1 c/S G /,}ovi{ U Ae Date of Inspection: Q —�� 9U' 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:_AY leaching chambers, number:__ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation, etc.), // , / (442 i- 10 :�� rJ> � '✓D " .TO ceye.,- /1a 4a <c// /H .leACLa� 2 a, oge""S y P G[/oy %- Sir' /S cv r yb 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 pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ F (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 04/25/97) Page 8 of 10 J` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � (fr-e-e N�7hr/ . r �A-'� We Owner: `/-ii N Gv 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) ELI d 76, i 2 Ta tvir er .3 (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) r � Properly Address: yL Cr.e e H Owner: )r;-L4Hc/y Oe) Date of Inspection: y-� Depth to Groundwater ?. Feet 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 Check with local Board of health Check FEMA Maps Check pumping records C/ Check local excavators, installers y Use USCS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) y�'U h y(/` �u R / l ��, •f— I�H9,H1-eik� ��If!^P arm bi,//v 70 L yYvct •-,vr �Govt� cd 1 y roN Nvr lws7*'!� (zovlsad 04/25/97) Pago 10 of 10 I� LOCATION.,g2 S E PERMIT�NO. VILLAGE /S Zoe- ,,nn'' IM (),6J�t� ZAA) t� o ZI INSTA LLER'S NAME i DDRESS ) � IUILDEIt OR OWNER Q fl-6IM 0- DATE PERMIT ISSUEDD DATE COMPLIANCE ISSUED ;-6�_77 r r .. No.---------- ! Fmc.. ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD F H_! A ------------- Appit"ration for Miposal Workii Towlrur$iott rnmit Application is hereby made for a Permit to Construct (. or Repair ( ) an Individual Sewage Disposal Syst at � Wit? -- U Location• ress or Lot No. Owner ress a •................... �,y-� /..... . ... ..-------- ' Installer Address �y� Q Type of Building Size Lot.&_ _��.5�-------Sq. feet Dwelling—No. of Bedrooms................_..................Expansion Attic (/ Garbage Grinder p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures --------------- --------------- . W Design Flow............................................gallons per person per day. Total daily flow_______,53.&....................gallons. WSeptic Tank—Liquid capaciJU460_gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width_____. ....... Total Length............j__._ Total leaching area............ __sq. ft. Seepage Pit No---------/....... Diameter-__/62........ Depth below inlet..... .......... Total leaching area.. q. ft. Z Other Distribution box,.(CS Dosing to ) ~' Percolation Test Results Performed by....... ,i��i._�_----- __ ,4% !_____________ Date...... y� Test Pit No. 1____-0.._..minutes per inch Depth of Test Pit____________________ Depth to ground water----- QQ. Gi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................... a -------- -------- ........................................................ Description of Soil---------------------•--•------------..... 24-1m.T e? v ............................................................. _------ �------tip--I-. .rr ,u W ----------------------------------------------teat.......... UNature of Repairs or Alterations—Answer when applicable._______________________________________________________________________________________________ ---•---------------•----....-----------------------------------------------------------------------------------.._...--•---------------------------------------------------------------••--•-•••.-•---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:i LL 5 of the State Sanitary Code— he undersigned fu- er agrees not to place the system in operation until a Certificate of Compliance has bee s by t and of 1 alth. ned- ----- d - --------------- ---•��Da.t.. /11;1 at Application Approved BY....`-..... --,r- -------- - --•-- -- �------------------- Date Application Disapproved for the following reasons---------------------------------•--------------------........................................................ .................................•-----------------------------------------------•--.._......---------------•-•----------------------------------------------•------------•---•------------------------- ate Permit No......................................................... Issued........1� 2�- -? Date No........... FEs... .............. THE COMMONWEALTH OF MASSACHUSETTS 'r " yF:( ,..BOARD F HEA1 TH ------------- L ' + ........OF....... . #'l "� 1 ..... ApVftrafiou for Dhipiial Workii Tonutr trtiou Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Systey at:i, �v Location- ress or Lot No. L.:T ✓ � ��r r ss Installer Address Type of Building Size Lot__/4 40 ------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (A Garbage Grinder (s Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P I Other fixtures ......-----•--- ----------------- ------ ------------------------- W Design Flow...............................�.,y.r!'::.__:_.gallons per person per day. Total daily flow------- ._._..............._gallons. WSeptic Tank—Liquid capaci gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .............. Width.._� _:..._.... Total Length........ f--- Total leaching'area._.. , ,Sq. ft. Seepage Pit No......... Diameter ../V ._. Depth below inlet..... ..... Total leaching area-.� h�.sq. ft.' Z Other Distribution box. Dosing to ) '-' Percolation Test Results " Performed by....... .... ... ' _._. r �..__....__.. Date... ° minutes er inch Depth of Test Pit.................... Depth to ground water_-__-Test Pit No. 1._..., .__-- P P p gi• . . >� . rX4 Test Pit No. 2................minutes per inch -Depth of Test'Pit.................... Depth to ground water........................ 1 O Description of Soil................ Z..__ s . U vl��O_w--------------------------------------------------------- W ----------------------------------------------- ` 1 ------ VNature 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'TT a p 5 of the State Sanitary Code— he undersigned fu• er agrees not to place the system in operation until a Certificate of Compliance has bee oll by th,b. and of h lth. Date Application Approved B ~" .�.. ••-••-..... " PP PP y---- --•-- ... Date Application Disapproved for the following reasons------------------------=------------------------------------------------------------------------•-••••••...__.. ----- ----------------•-----•------------------------------------- ----------- ----------------------------------------------------------------------------------------------- Date PermitNo.......................................................... Issued--.....--=•-••••-••-•-......•--•••-••----•---••-•-•--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEAL H � 3tie, , .... O F...... 1'�: .... .. ................ . ... Trtifiratr of Tl mViiFaatrr s...... THIS IS TQRTIFY, That the idual Sewage Disposal System constructed ( or<=Repaired ( ) by ! �•i / Installer x at . ......-...... _ / 7�L .� Fay 4--- ......-..-r... has been installed in accordance with the provisions of T9��I-tj of he State Sanitary C e as described 'n the application for Disposal,.Works Construction Permit No._ _____________ dated-.:.___ "' ✓ `..:� -_-_____-- THE ISSUANCES OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE 'SYSTEM WILL. fUNCTION SATISFACTORY. DATE_......• � � tor. _. ............................ ns ec .... THE COMMONWEALTH OF MASSACHUSETTS ,.... BOARD OF>,17HEALTH Ak w 7� � '1' f?'e .....O F...... r, ................................. -- No.......... .......g./ l... FEE....................... igal kil w mid ......isgranted............... to Construct.,(1worpair'( ) /I vidu ewage Dy osal S st atNo........................... Street p as shown on the application for Disposal Works Construction Perm' o_______________4ated--_--��'"-...�l......... DATE.........-�-h---'"-•-�-�"-��---�-................................ Board of Health , x FORM 1255 HOBBS & WARREN. INC., PUBLISHERS .r -