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HomeMy WebLinkAbout0130 GREENWOOD AVENUE - Health � 130 Greenwood:=Avenue Hyannis P A = 288 145 s a j No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitation for Disposal *pstrm �"ttrtiott 3permit . Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X ❑Complete System ❑Individual Components Location Address or Lot No. J3 p CR40JUcJ0dC> AQ j5 Owner's Name,Address,and Tel.No. 519Z4" t S ice$, ✓RS0c-00 Assessor's Map/Parcel '� $ f (3o vot�- C M"Xl 6 Installer's Name,Address,and fel.No.50g�4-11-g$']1 Designer's Name,Address,and Tel.No. u.�.CapEc,�l�E �s� N/A Type of Building: e Dwelling No.of Bedrooms /" Lot Size 7 L(d sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /V W gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He S Date $ -aa -c e0 Application Approved by Date Application Disapproved b Date for the following reasons Permit No. Date Issued �IzZ�z�H No- �I Fee ^00 t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes 1 . PUBLIC HEALTH,DIVISION -TOWN-OF.BARNSTABLE, MASSACHUSETTS application for MispoSal *pStem o strUction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X ❑Complete System ❑Individual Components Location Address or Lot No. 13 0 �0 ,J�j j Owner's Name,Address,and Tel.No. 51Z4 ,c,t s tip, O A50(-Ca Assessor's Map/Parcel $ �� 1 Sa ` :;.-t3 _g (qjvo AUYJ Installer's Name,Address,and el.No. 5 0S.4-j-).-�$71 Designer's Name,Address,and Tel.No. �AnEt�lnc LCC— N1A � U S Type of Building: Dwelling No.of Bedrooms Lot Size 7 0 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A)ra-- gpd Design flow provided /V gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected:- . Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal . Si a Date -1 a -1�O 1�( Application Approved by Date Z Zo 1 Application Disapproved by Date for the following reasons Permit No. 2 CC, %4— 1 :?U Date Issued ;T?7170/j TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(X)by Ap E lR� at 1 Q '� 8V r4 S has been constructed in accordance with-the provisions of Title 5 and the for Disposal System Construction Permit No.201 tf" 13c� dated Installer�� EU7�gMp,*!<L­'�' Ue4 Designer #bedrooms Approved design flow gpd{� The issuance of this p"im't shall of be construed as a guarantee that the system wi'1yfu(r��ct�io )as designed Date ) Inspector �'"f"¢ �111.�s PJl/7 I l•(�{ --- p -------------------.-------- - - t! No. �� L _ �0 Fee �l THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon System located at ) 3(D ��f�E. (�,22�z15 A u F Y M)Iy/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 77 70 Approved by �— f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 5� v00 4t, TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: / 20 reek)Wooj "me, Owners Name: ✓i ` i r,ti n i `t FDJERC�� J ` 20 03 Owner's Address: 0 wee., o o _ ' � TOWN OF dAR ,STAPLE Date of Inspection: %/ eZ� ' �'u/ HEAL CH DEPT. Name of Inspector: ( lease print) /Y�✓'rl✓ � Company Name: //j 0 /f MAP Mailing Address: v PARCEL Telephone Number: .62)1' — LOT 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 Section 15.340 of Title 5(310 CMR 15.000). The system: t Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority l Fails Inspector's Signature: ) 71,71 Date:- // halt23' The system inspector shall sub 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 regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. 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. O d . Page 2 of 11 0 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 D r V-00 J �t✓ Owner, (�e I✓i l G o i Date of Inspection: D d Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy�esme I have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: :B.e em 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: d Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ? CERTIFICATION(continued) Property Address: J r-ee✓►ivotgvJ — ��N��� ip4rf Owner.• evvl I (,I,)i' Date of Inspection: // v i93 C.j her Evaluation is Required by the Board of Health: G/ 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 unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic 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: U Page 4 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A C-,--I-e CERTIFICATION(continued) Property Address: / •2 0 (Vo o d Ale, Owner: V1 I ch V1 It Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No/ _ acicup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 'scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool — _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool t iquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow _ �quired 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 SAS,cesspool or privy is below high ground water elevation. 1 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. y portion of a cesspool or privy is within a Zone 1 of a public well. _ y 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. [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.] //A(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as describ ed 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 1pd. You must indicate either"yes"or"no"to each of the following: ( e following criteria apply to large systems in addition to the criteria above) y no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. d Page 5 of I I a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B J ? CHECKLIST Property Address: / ✓ C-�eo/(�v�+,q'j Owner: 64✓`)i C Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Y /No t _ Pumping information was provided by the owner,occupant,or Board of Health 11�_ Were any of the system components lumped out in the previous two weeks the system received normal flows in the previous two week period 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 were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up 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 t"effies 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 proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y� _ Existing information.For example,a plan at the Board of Health _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)P 10 CMR 15.302(3)(b)j ,y Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: l D OW(OCICi 110e OD Owner: P117101 Date of Inspection: /A O FL W CONDMONS RESIDENTIAL Number of bedrooms(design):�t— Number of bedrooms(actual): DESIGN flow based on 310 CMR—l5.203(for example: 110 gpd x#of bedrooms): Number of current residents: U Does residence have a garbage grinder(yes or no) Is laundry on a separate sewage system or no):�[if yes separate inspection required] Laundry system inspected gyes or no);/L Seasonal use: (yes or no): Water meter readings,if avle(last 2 years usage(gam): Sump pump(yes or no):/U Last date of occupancy:--�� 4 COMMERCIAURMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and Basis of design flow(seatstpersons/scAetc.): 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): GE RAL INFORMATION Pumping Records Source of information: Was system puniped as part of the inspection(yes or no): � If yes,volume pumped:____gallons—How was quantity pumped determined? Reason for pumping: TYP 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) _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 components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): „ s Page 7 of l 1 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /-70 t�f :mil o Aie, Owner: (; v ti,4 Date of Inspection: / G BUILDING SEWER(locate on site plan) Depth below grade: c�j Materials of constriction:—cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ” �OocatVnsite plan) ) Depth below /9 Material of construction:—concrete -— 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: 'J Sludge depth: �6 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto frutlet tee or 1e. How were dimensions determined: /C Comments(on pumping recommendations,inlet and outlet t6 or baffle condition,structural integrity,liquid levels as J A;ated to outlet invert,'dence/,of leaf g`e/��etc.): // �/"- _ _ -1 rrl N". 4/�Tjf- �_- Cj-T- -vl(� -f-( ✓Y! GREASE TRAP/10 (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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): d Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o 6TI,,-evt woE-c) /Via— .,OT Owner: ✓1'1 10 jel- Date of Inspection: / D TIGHT or HOLDING TANK:/1//(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: xallons Design Flow. pHons/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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: y1 ery l a, Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into�9r out of box,etc.): ` -tM PUMP CHAMBER:ArrV(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.): d Page 9 of 11 Y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: J O n PV0 ec ':�74z3 Owner. Date of Inspection: / 0 0 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type eaching pits,number:, 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.): T All All-T- 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.): a 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.): d Page 10 of 11� OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �s o reeP wog � -- Owner: W'1/vl vt C Date of Inspection: 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. 3 3 2 63- 13 US G %/ d Pagel 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 L' &,P7ko,,J i9 e,— Owner: h o I G9✓x ' Date of Inspection: m 0 SITE EXAM Slope Surface water Check cellar Shallow wells ` Estimated depth to ground water feet 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.-ynthin 150 fat of SAS) Checked with local Board of Health-explain / O k/vi Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mustt how youptablisheo the hig group w/�ter a vation: / J 77— /S Ci ov �i ��ivkH !-cr l or c� n S��Pr�Ti o�► 31 I� S-�L I � COMMONWEALTH OF MASSACHUSETTS : Z F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION ,4t) TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /,?/1 feev► oo aEe- Owner's Name: Arl ' IV7 Oct A j Owner's Address: SZ " / vcl r Date of Inspection: 1 / Name of Inspector: lease print) / " /C41^4`1 P ke,11 Company Name:j&Jlt o —7"E Mailing Address: v Telephone Number: -o - - 774-4/ 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 /oS to Section 15.340 of Title 5(310 CMR 15.000). The system: y Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Ax Date: ��Zwo/ The system inspector shall submit 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 regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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 V conditions of use. f Page 2 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / 6-rP-2✓voo OU Owner: 6 e►�1 v1 r' Date of Inspection: / p Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: I have 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: B. �Syystem 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 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFI/CATION(continued) Property Address: (.' ✓eeoW00 U �ve 4 "Ind U3'� Gq Owner: —e�M Date of Inspection: C. /Further Evaluation is Required by the Board of Health: AConditions 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 unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic 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: Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 13 Greeowooc) Owner: �h'I Vi 4 Date of Inspection: t 0 3 b 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 ( Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ &/*"Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number �of times pumped y portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of 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 1 of a public well. -4/'jAny 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. [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.] i t/Ov(Yes/No)The system fails.I have determined that one or more of the above failure criteria 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) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone lI 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 m 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 accordai:ce-vvifh _.4. lie system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 0 (TreeV1 L1/00 6l(!e �fNraylrl/SDr:i^1, WV 0dG4 j Owner: 61 ,-✓t'11✓1 iuHi Date of Inspection: / 0 vZ Z t2, Check if the following have been done. You must indicate"yes"or"no''as to each of the following: Yes No Z— Pumping information was provided by the owner,occupant,or Board of Health ZWere any of the system components pumped out in the previous two weeks ,Z-_ Has the system received normal flows in the previous two week period 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 were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up V _ Was the site inspected for signs of breakout 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 Z Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no TExisting information. For example,a plan at the Board of Health. — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance Fs unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 13 (rneP»I.vdO 0 6�f% Owner: e- "1 ✓1 i Date of Inspection: O 3 0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): `+ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): k'0 Is laundry on a separate sewage system(yes or no):/1/0 [if yes separate inspection required] Laundry system inspected(yes or no): &0 Seasonal use: (yes or no): {✓0 Water meter readings,if available(last 2 years usage(gpd)): 191/ - III 0 QO d 0 00— I d 3l p©-C' Sump pump(yes or no): 100 Last date of occupancy: A� 11 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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 INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TY_MOF SYSTEM Septic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool —ivy _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 components,dat installed(if kgpwn and source of information: Were sewage odors detected when arriving at the site(yes or no):1VV i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 6,-/ee4 /4 6�'> Owner: ►M,h Date of Inspection: [0 3 a BUILDING SEWER(locate on site plan) i Depth below grade: c2-?/ Materials of construction:_cast iron _40 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 on site plan) Depth below grade: Material of construction:_concrete_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: Distance from top of sludge to bottom of outlet tee or baffle: Y`t Scum thickness: //Z Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions detein rmed: , g Comments(on pumping recommendations,inlet and o et tee or baffle condition, structural integrity, liquid levels as elated to outlet invert,eviden e o leakage etc.)): /_ / / _,/- 1.1v'1 iy U f / ✓1 /✓LI� c I GH�Y GNG ei _5 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(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 wocj e'-rv'2 Owner: Date of Inspection: i 0 TIGHT or HOLDING TANK:Z(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: gailons/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:Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:00,^rear Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of le#ge into or out of box,etc.): 1s /ems7. f=/��,� �o tycd1e,1.r -aqw, - 460 L-Pa ti-s PUMP CHAMBER: A/(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.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q (9—,ee16v G Ud�01 Owner: v"t i iG P?, Date of Inspection: /o d� o SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T'yU Q� 6X b % 12 l/ leaching pits,number: 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.): to - J 5 i ✓� CESSPOOLS: IV"(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: (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (9�r-el,?WooJ av-e, ©a6 44;�, Owner: t 1 N Date of Inspection: O 0 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. Bl- Ml `t f,10-4 p-JC CS-21 G I � ir F T r � i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /20 ✓.n Owner: C—emi'Ari t 11 Date of Inspection: /O 02 3 SITE EXAM Slope Surface water Check cellar Shallow wells r Estimated depth to ground watert;23/ feet 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) —2 Checked with local Board of Health-explain: r'd j,," ytlg f Checked with local excavators,installers=(attach documentation) Accessed USGS database-explain: Q Zvv� P You mu d be how you blished the high ground water elevation: /O 9- O? ?, tk/, • / v Pe- To F 0000 (9000 I 46:' 0000 /xr� 19 ; 0000 ohs n Z ,41� LS/ oelow Je 4,3• %�, d 0 ©0 c 1 ASSESSOR'S MAP NO. PARCEL LOCATION SEWAGE PERMIT NO. _ j3D 4n.4 P LZ VILLAGE 6 it G I N S T A ILER'S NAME i ADDRESS + • U I L D E R OR OWNER DATE PERMIT ISSUED /o-3-8G DATE COMPLIANCE ISSUED __ __ _� � . ~ , o � .. `�� ��. f �� r ,� I r _"�� � �� � �Y r/ hi � \ �., -� / !- r r i � ei �1 J � �����`_ ASSESSORS fv!Aw ItiU: PARCEL NO.- No.... g. .. �- F$..a .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF `HEALTH 119W7!l ..OF.. .......... Appliration for Disposal Works Tonstrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair *) an Individual Sewage Disposal System at: ......!30 r ...?JeS�S�,�.....�` gnh�1. .....-•------ --•........................•------•--------------- --------•--------.......---------......------. �.p Location-Address or Owner Add ess W ��� rco ----------------------------•------------ SO-_�Q�......S.'�rs-Q•..... W --... .. -- V Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms................................V---------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ---------------------------------------------------•-... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--__--------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by ••----••-------••--------•......----•-••--...-------•-•-•----------•- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..-._.-.-_---.-_..._.... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---------------------------------- ••--------------------- .--........ •----------- ---------------- ------------------.....------------- •-------------- ---------- 0 Description of Soil.........................................................................................................................-.............................................. W U ----.............-----••--------------------------........---------------•-------•--------••-•-----•---------- -------------------•-------------------------------•--------------...-•----......•--•-- W _ -•--•. iLd U Nat re of Repairs or Alterations—Answer when ap licable.-�Ns ---1SDD lc,��_ ____ je �j ---- ------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys em in accordance with the provisions of ii l'1.?. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed..... _.1Cct ! ............................... ...-------- Date Application Approved By.................................................. ..... ......... ........t®� Date Application Disapproved for the following reasons:... .- ------•-----------------------------------------------•------------------------------------------------- --------------••-----------------•-••---...------------------•---•-------...---------....--•--•-----...............--------------•--------------------------------------------------------- - Date PermitNo......................................................... Issued_....................................................... Date 4_; S.' 7► No........................ Fes$... t _—.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 1HEALTH . f)'��7J..................OF..�-t.rrti c� ,IQ_ Applira#ion for Dispaiial Works Tnnitrnrtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair .(�4, ) an Individual Sewage Disposal System at: l l �c� [;'r_e?.�.++nc� }ttlp , �• raitir.4:-, Location-Address 1 or Lot No. ..........._-'-'-'.............."---•--""-"-'---""""""..._.._...._..----'-•..._--_... .._......._......__...........-•-'-.._.......•-----------•'•-•--•--•-•--••---.._..._..--•...-•---- c ) P Owner ry _ $Add'resss n ►!'L�! a Installer Address Type of Building Size Lot__ Sq. feet V Dwelling No. of Bedrooms___.."......................................Ex Expansion Attic P4 Other—Type of Building ________________ No. of persons............................ Showers (Garbage Grinder ( ) — Cafeteria ( ) a' Other fixtures __________________________________ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter_------------- Depth................ Disposal Trench—No- -------------------- Width_-_.-____-_-__...... Total Length.................... Total leaching area------------.......sq. ft. Seepage Pit No----------------_--- Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft. z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by-------------............................................................. Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____-_--_-___-__-....___ 9 ._...-•-----•-•••---•---•-•-....._._.•------•••............................................................................................................. 0 Description of Soil......................................................................................................................................... %= x V .....--••-•-----------•••-•---•--•----------------•-••-•----••----•--•-----•.._.......•--.__....----•..._......._....._..---....-------•-'-•-•---•--..........----............_..----------•••-•---..•--- UW -------- - -------------------------------------------------»..........._.._...._.._........_-.....;rl kt^... ......r--�-....------..... .... Nature of Repairs or Alterations—Answer when applicable.................../..do ��I... ��I,'-� ..�G[� /n�-r�, 1 l3 �_`�c»►e. Cc i c�Cau iYPr7:. S .. ,. --e-4-------------------------- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sy in accordance with the provisions of A IT }of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed........f__k'., '-t ..,- ------------- c"14 . ------ -----------------•--- --------------------- Application Approved By..................•-......_........,�...._. :........" + -------��".-.6Da�4------•-- Date Application Disapproved for the following reasons:-- •......................- ...............................•---._............._....---•-.._.••......._..__....---•••-•.......__...._.....__..._._........_..----•----••-•----•-•.....••--••..........•-----••----•--......_..._------ Date PermitNo......................................................... Issued....................................................... Date eO THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........�. C'w'7 OF. !:::l�,rn� c.u�P_ ............................... ..r. ....................................................................... �Cr rif irtt#1e off�nrntrli�anr�e THIS IS TO CERTIFY, That the ndividual Sewage Dis osal System constructed ( ) or Repaired (�:) by------------------------------------------------------------------ �b� ---------_-----(2 'v►r�' 0 G 1�(,V, woa CA_ Installers , `/1'A r1 1— at -•-------•-----•--••------ - ------ 9 has been installed in accordance with the provisions of I r 1E j of T e State Sanitary C y 6 e�cribed in the 11/ application for Disposal Works Construction Permit No.. .f?..........1 ............... dated..--�_.-- ------ ---------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FPNCTJON SATISFACTORY. DATE.. .............. Inspector ..--:..__-"""-"--""•"-"-"-"-"""-"....--"-....."-"•-'...-"---•---'----••-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF -HEALTH r �6' Id �1 ......�.......... ..'.....................OF......!... 1 ....t'`14Z oft? N0......................... FEE........................ Bitilmoal Works TIMInstrurtion rrruVi Permission Is hereby granted.................Ph............................qh b� O to Construct ( or Repair an Individuo Sewage Disposal System atNo..............--1.S..r�..-........... --•"-"""""•-•- ............................... Sheet g as shown on the application for Disposal Works Construction Permit NoV__ gl¢Dated..... I----"- ...$.6-"_""""---. �v A/8 / Vaard of Health DATE.............." ...............-""""-"-•-"-"-"-........"-"""-"---•---•- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS