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HomeMy WebLinkAbout0123 SEVENTH AVENUE (HYANNIS) - Health 123:Seventh Avenue Hyannis P A = 245 054 v' i j f (E Y i it a a Commonwealth of Massachusetts a 5 -0 6Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 Seventh Ave 1`9 Property Address Paul Paresky Owner Owner's Name information is n required for West Hyannisport MA 6-19-17 every page. Citylrown State Zip Code Date of Inspection rj„f 6 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information /oZ�VV/�6/2,., �/� forms on the computer,use 1. Inspector: t only the tab key �t. to move your DOUGLAS A BROWN cursor-do not Name of Inspector ° use the return key. . D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 '�d0° Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-19-17 InspectoAl4bignature Date 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. ****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. t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 17 /RndY r — Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West Hy p annis ort MA 6-19-17 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System 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: At time of inspection system met all minimum passing requirements. This report can not predict the future performance under the same or increased use. This report is not to be used for bedroom count or design flow. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West Hy p annis ort MA 6-19-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) S ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y / ❑ N ❑ ND(Explain below): 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments µ„ 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is ort MA 6-19-17 West H annis required for Y P every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West HY P annis ort MA 6-19-17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Mt 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West HY P annis ort MA 6-19-17 every page. City/Town State Zip Code Date of Inspection C. Checklist 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 ❑ ® 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? ❑ ® 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 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 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: ® ❑ 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) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3pepeer Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West Hy P annis ort MA 6-19-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: According to permit system consists of a 1000 gallon septic tank d-box and 2 flow diffusers with 3 ft of stone. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: System not designed for use with garbage disposal. House has been vacant and only used seasonally and property has an irrigation system so water usage was minimum. Sump pump? ❑ Yes ❑ No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 123 Seventh Ave Property Address Paul Paresky Owner Owners Name information is required for West Hy p annis ort MA 6-19-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: seasonal Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. El Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West HY P annis ort MA 6-19-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 9-14-88 per permit Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 per permit Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Page 10 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1-b ANk- Owner: V 2 ' Date of Inspectio 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. oo 10 rage Y of i i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 6A°` rn', Owner. Q _ Date of Inspectio . SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,,excavation not required) If SAS not located explain why: Type leaching pits,number:_ jleaching chambers,number. M leaching galleries,number: U i i TT U S(�('S 2�j \(� 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.): p 11 Pn Q R d Nr��Tl,\0 T "I qc U I,e G-�I�n 7SSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number a�configuration: Depth—to inlet invert: Depth of Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(ye no): Comments(note condition of soil,signs o draulic failure,level of pon ' g,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note con3�hof il,signs of hydraulic failure,level of ponding,condition of etation,etc.): 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M a 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West HY P annis ort MA 6-19-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness light Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions.determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): If tank has not been pumped in the last 3 yrs I would recommend pumping at time of transfer and every 2-3 yrs there after for maintenance. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West HY P annis ort MA 6-19-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is ort MA 6-19-17 West H annis required for Y P every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0„ Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box was level with no signs of failure or solid carry over. There were no measurements to the d-box so it was viewed by camera from the outlet of tank. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West Hyannisport MA 6-19-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 2 flowdiffusers ❑ 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.): The Flowdiffusers were also viewed by camera. Scott Frank was able to get the camera from the outlet of tank through the d-box and then into the flow diffuser. The flowdiffuser was found to be in working condition at time of inspection. 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 ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West HY P annis ort MA 6-19-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM , 123 Seventh Ave y Property Address Paul Paresky Owner Owner's Name information is p required for y West H annis ort MA 6-19-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for west HY P annis ort MA 6-19-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar Shallow wells Estimated depth to high ground water: 5.5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record Y 9 If checked, date of design plan reviewed: 6-19-17 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 / I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 Seventh Ave Property Address Paul Paresky Owner Owner's Name information is required for West HY P annis ort MA 6-19-17 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 • � 'ter.. �_`Vt �_/ , �. 1 •. Fxs No.....t��...:� .a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .-.o.w..N..........OF..... .AVOQfe�.:�. �............................... 3 Applirtttion for Disposal Works Ton#rur#ion Fermi# Application is hereby made for a Permit to Construct ( ) or Repair (fin Individual Sewage Disposal ystesn atGG: A-f......... .sue .... ... ..� ..............................• .......... �i�c!:!! .1. ''-- •fi �.......................-...... ......• Locatio -Address br Lot No. .�.icl.M.`............._... ......... ... !R..........s ►�w: .................._............................... ........... Owner Address W ....... 1? ..(� '� ' ....Tac............................... ............ ........................................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms... .....Expansion Attic ( ) Garbage Grinder ( ) �., 'k Other—Type T e of Building .............. No. of ersons....._.......__............. Showers — Cafeteria Pit yP g •------------• P ( ) ( ) C4 Other fixtures ------------•--•.........................•.--- WW Design Flow.....5� ..............................gallons per person er day. Total daily flow......3.3 b-..............:.......gallons. WSeptic Tank—Liquid'capacityl"..gallons Length... ......... Width..:Z/....... Diameter................ Depth................ x Disposal Trench`—No...../............... Width.../ .......... Total Length... Total leaching area.............._.....sq. ft. 3 Seepage Pit No....::...:.......... Diameter.................... Depth below inlet....................Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) •-' Percolation Test Results Performed by............................................•-----••---------•............ Date...-...........:...-.-------------- aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ----•.....................................................................................••••--•-_......-•••-••-••-•--•-....._..................--------•... Descriptionof Soil...................................................•---..................................-------...-..--•---•-•--------------.----.--------••---•----------------•-••--- U - -----------•---------------------•*r-------.•----•--•-•---------..•.-.----- ----.-••--•----......_......-••-•-. ...... .t: U Nature of Repairs or Alterations—Answer when applicable....�IµS:Te4�f....kt! '4z�.....� P.....�5 %� ....I�.I ......1 e. ...........ems-... -.O�e.z i��kj4s ?f�.S.....1,u•• ----....S O.k e............................................................ Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I TAIS 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 teaL_f�do Signed ... ....i.Q:��.._.... Date Application Approved By--•... - - ---------=---------------------------- .....-------C�t- _,.7:1 5_.... Date Application Disapproved for the following reasons:................................................•-----••--..........._.......-----------......--••-•-------_... ............................•----......---...----------------------........................................-.......................................................................................... - Date Permit No.--••••-•-A-.Q- �� �.b.....----••---........ Issued---•----------------- ._................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � J(NF1J.........OF.......aS.1 �4w �.A��.�................................ (Crdif iratr of Toutplittnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......................... 9.. . .... J. ...... ? .G.---...........-----•-----•--.....-•-•----•------................---•------..................---........ ,5 70 - 6 K�v�...... Installer at............................... . . ........•----...•-•--•........._.... t .: ..yo l.T ---------------------.-------------------.--------------.------ ..----- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No............. ...... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r7j DATE......................... ..... . `.................................... Inspector......---------•-----------..._-:,. ............................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l`. 7 3 Applirat l n for Disposal Works Tonstrixrtion p.erutit 'x Application is hereby made for a Permit to Construct ( ) or Repair (L—)--arn Individual Sewage Disposal yytem at: ......•-••-� ..... ........ U C.................•.............. ----•------ Yc � 1.� A ............................... Locatio .Address •. or Lot No. itGu.l!11..`- ---------•---------------- S 14 w4' . Owner Address C Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms... .Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons Showers Cafeteria Other fixtures .-- W Design Flow.....��...........................gallons per person per day. Total daily flow......3 ..__ . gal WSeptic Tank Liquid capacity) ..gallons Length. ....... Width....Ll....... Diameter................ Depth................ x Disposal Trench-,—No._.../............... Width.../�........... Total Length...i?.. .. Total leaching area....................sq. ft. Seepage Pit No._.' __.:N......... 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........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------------------------•-••--------................•••••..................••••-•••..._........-••-•--••--••-•........•-•--------•-•-•........-•--••••••. 0 �. Description of Soil........................................................................................................................................................................ ,. -............................................................ ... .-..------•---...........--•---......_... U Nature of;Repalrs or Alterations—Answer when applicable_.�'�S'i;e ,-,_..k--- _.._.....�.V 1P7% ..T�9k 1 J ET ----------a- —QLe.1...VAPjl 1.FS�lr.S�--...t. l ,5Ce�1!` ..--........... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T U 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 d of heal Signed........ =-------- ----------•-.... .... . _ Date Application Approved By_..........76� u "' ....................................... -•--------- ._.�.�5_.... Date Application Disapproved for the following reasons:.........................•------•---•-------•-•-••-•---•-----...--------------------------................--•--• ......................••------•-•----•......----••-•-----------•----...........-------•-•--•----------••.--------•---••••••---------•-•-•••-------------------•-------------•-------------------•------- p� Date Permit No...........?. -._.��j..L..b. Date t' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �1!v�.........OF.......,S.a C�-.k� 1.A t�.0................................. Tertif iratr of Tontphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ........ .......... .....= .L:.o......:: _P.n4l........................................................................................................ S7b �h A V1 Installer at..............................•.........................................----•----•--------. ..�OLY ------------•-------------------------------------------•--.-----.---••-------- has been installed in accordance with the provisions of TITII, j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No............. ...... dated_................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... . . '.. ........................................ Inspector........................... THE COMMONWEALTH OF MASSACHUSETTS - - BOARD OF HEALTH` No.. Disposal Works Tonotrurtion autit ? Permission is hereby granted..........C -1 1v...� w_w ._ 'f?1.l - -•------------------------------• ........... to Construct ( ).or Repair (Q_an Individual Sewage Disposal System at No..---•---•------.---•-_-4 7(. --•---......T.........PSG VC- '� r �_ <<�>,^� .................. - -•Street ' G, as shown on the application for Disposal Works Construction Permit No:__�l PP P D8._S(_O._ Dated............................................ l ...................................................... /f(. Board of Health DATE........................ ............. I� TOWN OF BARNSTABLE LOCATION !9-70 SEWAGE # VILLAGE =FA.0 2� lJo�-�' ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 0-9'0 LEACHING FACILITY:(type) `DeeUSSCPS (size) -� NO. OF BEDROOMS PRIVATE WELL O PUBLIC WA BUILDER OR OWNER DATE PERMIT ISSUED: lot DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �/ `: 1 • � r �1 ff P 1 G 1 I%-N- LA O No... ." r, Fl�s..... 5._..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -. .. ... .........OF..�.. . W - 3 Appliration for Disposal Works Tonstrurtion rrrmit Application is.hereby-made for-a Permit to Construct ( ) or Repair (L-)-do Individual Sewage Disposal ystem at: ----- �? .�.h ...1 -v-C------------------_....._.. .....----- Y�� -y?a:t �e _ ........................................... Locatio -Address or,Lot No. ........_s...2 :JltSl......SJI�C- `�._ -- -- ._.......... ............................................:............ •-O Addwner - ress a tu'! ' � - - Y .l~�?.5.............................................................. -------------- •••••-_...- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms....3....................................Expansion Attic ( ) Garbage Grinder ( ) Other—,Type of Building .... No. of persons............................ Showers — a YP g ----------------------- -•--- .... ( ) Cafeteria ( ) Other fixtures -------••------............................................ Design Flow.....��__-_-__ ---------gallons per person per day. Total daily flow......3�b........:......:.......gallons. . WSeptic Tank-Liquid capacity-/kW..gallons Length.. :......... Width.... . ..... Diameter................ Depth................ x Disposal Trench No,_../............. Width..'4 ..........Total Length..., ...... Total leaching area....................sq. ft. Seepage Pit No.... A--------- Diameter............. ...... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results .Performed by...............................................=.......................... Date...................................... Test,Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GZq Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water.............-.......... a' ---------------••-------...........-----.......-•----................-•-----....-------•--.......................................................... ,O Description of Soil........................................................................................................................................................................ W .7 --- •-- ' i `------•--------------------------•----------....---------- .. _.._ _... --....---------:..._•-•-•----•----- ffolhiw U Nature of Repairs or Alterations Answer when applicable..: `lrt�S �._l!S!Y ...... a� ..60c........... Fi-Qt-_aa iUAF1� tu �`tczham---------------------------- ------ --------•--•--...... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance.with ' ,the provisions of iI ij, 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 t r�heal Signed.----- � .......... Date Application Approved By-----••-•-. t.- -----•--------------------------------- ...--•----- '�- Date Application Disapproved for the following reasons:................................................................................................................. ------------------------------------••••••••.........••---••••••--•••-••----•-•--•------•••-••-•••-•---•••-•--••......••-•...---_.. Date Permit No.......... �.Q... Issued............................................... Date -�. a - rw;.r�..,,,,s,..r�.t.--�.v ''r,`•_.Ws;. .-.-...P� ._a... . ,+5.e-...-axrn..._-. Fps... . ...._ THE COMMONWEALTH OF MASSACHUSETTS }"_,BOARD OF HEALTH Appliratiun for Disposal Works Tontrur#ion Prruti# Application is hereby made for a Permit to Construct ( ) or Repair (L--)—an Individual Sewage Disposal System at: - h w uL1 t t Location-Address °or Lot No. .•--••---•---•••'S 1$ �Q a Owner Address'••'1' = 's� ........ - ............14 w_-!a'.}S_____________________________________________________________ Installer Address Type of Building Size Lot.................... .....Sq. feet �-. Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures 1' 9 Septic Tank'—Li uid ca acit / .. allons P Length ........ Width............. Diameter ....... 1� ti Design Flow_...Cam...........................gallons per person per day. Total daily flow----- 3_.....---......._.........._._.. Ions. s W P q P Y g , g �. ,�� Depth--•-----•--••-- x Disposal Trench—No...../............. Width...Z�_........_ Total Length..-s�'t-_....._ Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.......:............ Depth below inlet.................... Total leaching area..................sq. ft. I . Z Other Distribution box ( ) Dosing tank (• ) aPercolation Test Results Performed bY----------................................................................ Date.... ----- t Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.....................--. �`4 Test Pit No..2...............minutes per inch Depth of Test Pit-.:.---.-.--...... Depth to ground water...::.---.........--_ 0 Description of Soil..........................................................................•---------------------•--------------------•------------------•---------------........__------ . [.................................................................... ...`------------------ -------------------------- -•--------------•-------- U Nature.of Repairs or Alterations—Answer when applicable.. ......J.. --. �'r %4.7sp -----------------------•--..........------ Agreement: The undersigned agrees to .install the afoi-edescribed Individual Sewage Disposal System in accordance with the provisions of TIT!Z- 5 of the State Sanitary Code— The undersigned f&ther agrees not to place the system in operation until a Certificate of Compliance has been issued by'the board of health. Date Application Approved BY ---•--__-._----•-------------••---•- -g �. _Date Application Disapproved for the following reasons:................................................................................................................. ......................................................-....................= -------------•--------...-----------•--•-•--••-•--•------------. ........................................................... Date PermitNo..........3a:---5--1--0•-----------••-_._.. Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD -�-�OF HEALTH TJ....✓V .........OF....... r�t! -` .!A. , '................................. Tnr#ifiratr of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired06 ( ) bY-------------------------�• ..._1. !!`!V) .---••...............................................•---•----------................--•-----.....------- Ins aller has been installed in accordance with the provisions of TITL: 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.---.-------- ...... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................... - t{L/ S \ -----•-•-•---=---�---------------•------....-•---: Inspector.....:..-----•--��-------•�................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . �..........OF..... .. .leJ t ..�&� ........... � No.. .._�a✓..��..__ .... FEE../:S.-•--•- Disposal Works Tonu#rnr#ion firrutit Permission is hereby granted..........�6A ft--�n4� 7............................. --------------------------•----.......--- to Construct ( ) or Repair (A,—)—an Individual Sewage Disposal System = .,041 Street G as shown on the application for Disposal Works Construction Permit No.-- Dated.......................................... ............-...................� _-70---------...---...................................... ey /�/'I Board of Health DATE------------------------! C-1--��-7....---------------------•-- 1..r0i A lACkje o 76 12e;21 ACC max,5 (,J d _ o m MORMG.E. INSPECTTOW PL" c ' m W _ 134-' _ ADDRESS 325 .'S TdY fJ.Tu Alf C-, o af(Y/rom at ,A,12tJ 5 j'.4 E+L.E c EL On SCALF- t",.20 ' DATE-- "?if ''v 1 .7 99 c LOTZi 57Q - 572 LUG DEED MD PLM RfFEWN(X �? A - 10,720 5-F .> 1�Ate+-iSTA[3t. pegtatry of Deeds 'P Deed Book. `�6¢? page ZG Plan Book -44 Page '2'5 hd Certilf�catlan Es hereby mode to: r W P. 2 5T Y. MOMT4SAG F. M 43TE R, PJC. the permeoent structures are apProed'twfely w 1U 110.t23 located on 1he.grnund as■hown and they m. Ur "fir either_conrormed to the mv%oc c.raQuiroments r •G of the local Zmttng ordinances h effect of r W l!1 the tIMN ofaa cstrtrellon or as ekernpt.trvm h' O Q entarosrient action under M.GJ_, Chapter 40A. m r > Section 7, uhlesv otherwise noted- f 1tt (1{ Certilfcatlon Is horeby made that the struchre Z Z 71 �• {� shown on this.plan Is ant located within a p r 4Q `! SpeclaL Rood Hazard Area as delineated on the f the}nap or y ' Comrnunity Pond No: 9'30f3Q1-0008A EI(ecthe Data. _ Juv? 2, 1992 rs qm By the U.S. Department a(!lousing A Urban Development, Federat Insurance Adenfnfgtrnlian. NOTE. This Inspection vas prepared fn aacerduree with the tedmW standards for rA Mortgage Loan Impectlaps as adapted by the Q Commonwealth of tlassaclsrsstts. and ure tar u� S Wm any other purpose is prohblted, f2 CURD" NEPONSET VALLEY m � SURVEY ASSOC., INC. Cn m - ,�L` LO 95 MTE STREET m _ c� QUINCY. M►SSACHU EFTS 02169 m CS) 4,1-1 TR"H!DNE: (617) 472-41767 Ili f� •n -i 117 f9 I� CS) N00 Lf o co m o C r ¢ co n { F., m .4n� Y° COMMONWEALTH OF MASSACHUSETTS �Z q„ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ��p _. _�.IF - OCT 2 7 �t104 TOWN OF L. 1 rtr a HEALE LTH uc.r'�. LT'fTLE.>5___ yy_ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION CD Property Address:J Z J�• Owner's Name: , ; r Owner's Address: ttia . Date of Inspection: Q Name of Inspector: 1 se pr'nt) ` I Company Name: �n �— Mailing Address: r� 02601 Telephone Number: — CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: C I L-1 I U L 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 flow 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: 2�4 e.- Owner: Date of Inspection. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System 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: �1 { I Q System Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced or repaired.Th stem,upon completion of the replacement or repair,as approved by the Board of Health,will p Answer yes,no or not rmined(Y,N,ND)in the for the following statements. If"not determi "please explain. The septic tank is metal and er 20 years old*or the septic tank(whether metal or t)is structurally unsound,exhibits substantial infiltratio r exfiltration or tank failure is imminent. Syst will pass inspection if the existing tank is replaced with a complying tic tank as approved by the Board of alth. *A metal septic tank will pass inspection if it i cturally sound,not leaking a if a Certificate of Compliance indicating that the tank is less than 20 years old is ilable. ND explain: Observation of sewage backup or break out or high stati ater level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven dis ' tion x.System will pass inspection if(with- approval of Board of Health): broken pipe(s) replaced obstruction ' emoved distribut" box is leveled or replaced ND explain: The system required p ping more than 4 times a year due to broken or obstructed pipe .The system will pass inspection if(with ap val of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: JeV1A�\ Pk9 Owner. Date of Inspectio . D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup 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 J Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ J 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 _ Any 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. _ J Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.] /V 0 (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. Large Systems: To be idered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate er"yes"or"no"to each of the following: (The following criteria a to large systems in addition to the criteria above) yes no _ the system is within 400 feet o urface drinking water supply the system is within 200 feet of a tributary surface drink' ater supply the system is located in a nitrogen sensitive area a ellhead Protection Area—I WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any quest' in Section E the system is considered a si ' scant threat,or answered "yes"in Section D above the lar stem has failed.The owner or operator of any large system—considered a significant threat under Sect' or failed under Section D shall upgrade the system in accordance 310 CMR 15.304.The system o r should contact the appropriate regional office of the Department. 4 A G5G J W 1 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY_ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: S J A\)2. Owner. Q Date of Inspectio : AG, l Further Evaluation is Required by the Board of Health: nditi ons exist which require further evaluation by the Board of Health in order to determine if the system is failing t rotect public health, safety or the environment. 1. System *11 pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)th the system is n functioning in a manner which will protect public health,safety and the environ ent: _ Cesspool o rivy is within 50 feet of a surface water _ Cesspool or p 'vy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Boa of Health(and Public Water Suppy' r,if any)determines that the system is functioning in a manner th protects the public health,safe and environment: _ The system has a septic tank and s '1 absorption system(S )and the SAS is within 100 feet of a surface water supply or tributary to a s e water supply. The system has a septic tank and SAS an the SAS ' within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and th AS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS an he SA is less than 100 feet but 50 feet or more from a private water supply well" Method used t etermine ' tance "This system passes if the well water alysis,performed at DEP certified laboratory,for coliform bacteria and volatile organic compo ds indicates that the well free from pollution from that facility and the presence of ammonia nitrogen d nitrate nitrogen is equal to less than 5 ppm,provided that no other failure criteria are triggered.A py of the analysis must be attache o this form. 3. Other: 3 s Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: i'n S Je Ave Owner: Date of Inspecti : 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 _ IM 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? ►�Q 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? t _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition f the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? T _ Was the facility owner(and occupants if different from owner)provided with information on the proper a intenance 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 _ 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 unacceptable)[310 CMR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INNFORMATION Property Address: Owner: v Date of Inspecti : FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 C 15.203(for example: 110 gpd x#of bedrooms): �3 Number of current residents: L Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): h0[if yes separate inspection required] Laundry system inspected(yes or no): [e Seasonal use:(yes or no):ti.0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): /I-O 1 Last date of occupancy: MMERCIAL/INDUSTRIAL Type o blishment: Design flow(b n 310 CMR 15.203): and Basis of design flow(se rsons/sgft'etc.). Grease trap present(yes or no):_ Industrial waste holding tank present(yes o Non-sE!F arged to the Title 5 s o Wateavailable* Last dOTH GENERAL INFORMATION Pumping Records Source of information: Nwf\tf- Was system pumped as part of the inspection(yes or no): ,�,� If yes,volume pumped: all ns--How was quanttry pumprddete7��n� '/ Reason for pumping:_M r,�I'�y-\�Plc,Y�cQ �2C C`)n=f n T E 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: 1 to A/- rS. Were sewage odors detected when arriving at the site(yes or no):`Qb 6 ' Page 7 of l I , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Q Date of Inspect n• BUILDING SEWER(locate on site plan) Ic r� Depth below grade: v Materials of construction: cast iron ,L40 PVC_other(explain): Distance from private water supply well or suction line: Y-\ Comments(on conditio of jo' ts,venting,evidence of leak-ape tc.): SEPTIC TANK:_(locate on site plan) 1� Depth below grade: 44 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 r,o):_(attach a copy of certificate) B � Dimensions: 1p Sludge depth: ?, Distance from top of sl#dge to bottom of outlet tee or baffle: Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: 'G Distance from bottom of scum to bottom of outlet n�®rbaTe:How were dimensions determined: C Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): h ed e�e� ASE TRAP:_(locate on site plan) Depth below gra Material of construction:— oncrete_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 e: Date of last pumping: Comments(on pumping recommendati ,inlet and outlet tee or baffle condition, ural integrity,liquid levels as related to outlet invert,evide o leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ave, Owner: e- Date of Inspecti :GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth be e:terial of cons n: concrete metal fiberglass polyethylene other(explain): 77 Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in wo • order(yes or no): Date of last pumping: Comments(condi ' alarm and float switches,etc.): -- DISTRIBUTION BOX: (if present must be opened)(locate on site plan) I Depth of liquid level above outlet invert:C Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out o box,etc. P CHAMBER: (locate on site plan) Pumps in working or s or no): Alarms in working order(yes or Comments(note condition of pump cham ndition of pumps and nffiies,etc.): 8 rage v of i i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: kill) �. �v Owner. \-J Date of InspectioiV. CZA SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,.excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: M leaching galleries,number: F\U i 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.): U Ii SSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number a configuration: Depth—top o ' uid to inlet invert: Depth of solids lay Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(ye no): Comments(note condition of soil,signs o draulic failure,level of pon g,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note cond' ' n of soil,signs of hydraulic failure,level of ponding,condition of etation,etc.): 9 Page 10 of l 1 ' s y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• JON Owner: V e Date of Inspectio : 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. O Q 1� 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 fih v� Owner• Date of Inspectio . SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water �y� ►'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) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: m i W _ 2A 2—one- �j• Z Yr must describe how you establi ed the high ground ater vation:tp v © o C= t= i� l J 11 Toi✓. F✓iJOPATlotil e� ST EL. i o , 4' DiA SCE C' 40 PVC: PIPE 4 CIA. �,C.�ED 40 F,,"- F pE 4 C'iA. SCA EL i MiPJ. 5LOPS.. 7 -F� _ y — E- '/R' : ►�i�. 5LC> e SEE -- — " �I Jl I � I i 8' IodO GAL. PRECAST SEPTIC TAB ST. EC)V, SCaLG '/d = O - 3 .3 iy 5.7 LcT 5-7 d I I , rj 15 Ic i W ? f EXIST I�.1C ,` p�Ii DECK. CJ L 5]O L 57Z F F. G�I�ELI.I►.IG 10 4 6. �- --- - - - Z Icp 7 8 I 0 *a I ' OLD CESS�L i 134 r I 4.4 9..5 i. .Z j LvT 5&8 511„ E PL; L LEGEND o.OD existing elevation front yard setback = 2-4D proposed elevation side = I O — — = existing elevation rear —o—o—= proposed elevation flood zone Ate -. ' = test hole water sopply , , --o- = Utility pole - . pl'a"n refer..ence PL..sK. sa, wn z3 -Z Pu ` f i're hydrain zon�i ng di stni ct g water service �A a' SSCD PAP-ceL-54 PA-7E. '- 61 izISs Ed of �1I-ALTH' : J- r,-i J6 EXC A�fA"f(,'2 : E_A G L P c.:• j F�A'-TCkS EnJC1►JEEQ - ECGir.�E>_ 2-! j IAgE5 A,F:FLICA._T1%1,J t P 7C C_& AFFLICA,QT 5N;AWtJ F. Mz CLAMS. El- . 11. i - � PV C: F IF 2 LAYE!^C of 3/_ PEA..'TOIJE, i TW W t, 11.R. F-L . w L 1 t l Tr-- EL S E rJ E AT ui-kc rl 1 i U `�'l'SEbI . EAc�F LL 1.1 I I 4 'x ii5 P REC AST Lc7 1J�i�={ L��RS .jai E� ':,e� L i ----- —T-- - - - -.. - F_L . L I QESIGIN DATA I�i.Cn Percolation Rate: < Zt� i,J • / t►JC-M- (aarhacle Disposal___�j Design flow: 3 bedrooms x. I I oals/dau/bdrrn aa Septic' Tank: 330 gals/da} x �:C 4,�a1 a:?ls/dav l ,Z Use: ( I i I l7C G A L P�'I-C A 5Y ; '" G 7 A NJ V__---— --- ---- Distribution Bor.: C +7) z l_e.achinc; ! a i 1 1t, : 0- 1 1 EC�F�4?i PL."%full; Fr GENERA NOTES it w3 �.. _ - i � ; L fi.:=it?iAtltri I1 Sr!led,,11, 4., '�'`�` or equal (G. 1/E. .,'1 ' s•- 1 J�vttsti. w 4s _ _.___.. __ 1/4' : 1 ' slope before septic tank. 31U i;htn 15.04 (5) } 2. Ail stone must be washed an4 fre4 Irom iron, fines , and dust in 1 T The minimum depth of cover material over the stone shall be 12 310 CMR 15. 11 (7,11 ) 1 � 3. The grade above and adjacent to the leaching f ac i 1 i ty sha 1 1 s 1 o, �� least 21 to prevent accumulation of surface water. �. 4. Topsoil , peat, and other imperviou, materials shall he removed all areas, beneath the leaching fa:: ili'y and for a distance of 2 all directions therefrom when the leaching facility is above n a i ground; 10' when below natural ground. 310 CMR 15.02 ( 17) ---- ll! 5. The distribution box outlet pipe shall be level for 2 feet. 6. Manhole covers for septic tanks shall not he more than 12" belo finished grade. 310 CMR 15.06 (12) 7. o L D C E S5 rO0 L I S TO B� D i S C o>,1��1✓1��-C D, ���M P AC k F I L LE t7. 10 3 t I J l 1 r • f ENGINEERING 4A Bayberry Square, 1645 Routt Centerville, Massachusetts 0; ASSOCIATES consulting ar>d design engineers - civil and ' 1 TOLERANCE(, REVISIONS A J �E ; � l�C� F 3TE+ I YF_FAIZ IN t 1C 6Tt \NVffD N( QAr# RN ueanvu S M e G LA M +� 570 :SE� t�JT ptdF G11TE : aI 1a J S8 Ed of �4P.ALTI-i E_X�AViA : E A G L V- G` E..�,lG1►,1El=2 = E►..IGE��Et'�i�� �CtAT�S ' Ap�Lk�O."f1C+.J ►.iG• F 7oZ8 APFLICAQT o SHAWJ J f'• McGLAME. TOP. F0JJP0T1o�! 1 E*UST EL. G` El . E 1.0 O r 4"DtA�SCOEG' 40E-,C PIPe _ — - 4•' C1A. SC�1�p 40 Fv� Fipt:- 4' DI A. SCrieC 4,i FV F Pe 2 t_AYeR or3i� PEASTO►-IE - LOAM a 1 g" : 1 HI1 J. SLOPE. '7 Q '/*�i':1 MI�J SLCPE i t 1 /4 E M 1�,1. S LCJP� 7 T _-. I 1 r o f 3/4 ' I �L t„!/Uc hI E*� lJ f --` - SEE JOT S Unit✓ ALL AROL IP EL. �•O - L� 3 ` Cc ",�r t SG -5 I.It F�.7Oa-W-W tse_ w •*^ ' _ -T "' c',VA-,/E:L 4-C — 1 ! 1 T 51 L7,4 !FA V ' -�� �' �L.�.� B E al E AT t•� t�_.AG t�I I LL- ` 1.1 ' I �' ! a1 MEYD UM SAID i TEC�r~l _ IC t�i� • _._8. (o _ -�..�,, _--- _ _- _ -____ _ _ _ .-+-•+-_ �ELT1' SArI'D P 1000 GAL. PRECAST SEP(IC i•Al►�i� V-r-CA5T 015T 501k CZ; 4 "8r FKE:GA.ST Lc:;>1•JVl :JATER Z•o - jABLE " -L_ --- ----- ----- EL . L�)E-?"AIL / Plzof=-ILE EL . o.0 - SCALE 114 1 O„ a 1 DESIGN DATA Percolation Rate: e- Z t-4 it-i . / Ilk 1`4 Garbage Disposal.--tJ o i Design Flow: .3 _bedrooms x 1I0 gals/day/bdrm = 33G_ gals/day 3 .3 ! Septic Tank:- 33O gals/day x IUD`_ = 4o15: Ygals/day 5.7 LC7T `�'7 d 13•Z. Use: C I� 1000 6AL -PQECA,ST ---- 1 0 i st r i but i on Box: Z' - Z' � �' PR E.c.A`31"_D P-1 - 1 1 I E (n Leaching I: do i i i ty: 0- PV -CA-sT VFL.OIJC 1 Ff d-cX% +,J 3!of s-ro fE. ,..+.. 4 !' .1�'�rf'�Xt 3 ' r'�, y ;'� Z' r(.. .:r. ;ri• r, { "'"` 'S ..�'! t� - . atom >� r- Dais, a1+ - i 10. to _+' - ��- I u i 373�! Y Z 5 r13 a� ''' w ! GE NERAL NOTES II' 1 . Sews: 1'liliItli 4" ilia. Schedule 4�? PVC or equal 1/Is : t ' slope. g to (~1� _. __ Li5 - --- -- ( ' 1/4":1 ' slope before septic tank. 310 LMR 15.04 (5) 2. A11 stone must be washed and free 'f rom iron, fines , and dust in place. I t t _� Z the minimum depth of cover material over the stone shall be 12 inches. 13 � E x i S� 11..IG I O 8 �. ��=�1 E_� :t� � I---- 3 t 0 CMR 15. i t (7,11 ) W -, 4 3. The grade above and adjacent to the leaching facility shall slope at E_c71 s c �7z DECK, 3 �peCOH aS ..� ,�1c.' 1z �� least ?I to prevent accumulation of surface water. c rP -570 - ELLII.JG ! ✓ LLB 4. Topsoi I , peat, and other impervious materials steal I be removed from �I 1 I all areas. beneath the leaching facility and for a distance of 25' in all (directions therefrom when the leaching facility is above natural ground; 10' when below natural around. 310 CMR 15.02 ( 17) w I � I � 5. The distribution box outlet pipe shall be level for 2 feet. 6.4i------ - � � 1e•9 �_ G I`�J 6. Manhole covers for septic tanks shall not be more than 12" below LL1 finished grade. 310 CMR 15.06 (12) t' � tG;4 t7�'i�lt=wfi�' I I j 7 : � 7. OLD GESSroOL IS Tc e" DESCC�I���CJ�ED, PtJMP�t� I ! oI`c cEss � �tiAt 1~ F I L LED. a 13.4' G - I I 10. 4.4 9.S LoT j 17, -, FL � 2 LEGEND " ENGINEERING 4A Bayberry Square, 1645 Route 26 x Centerville, Massachusetts 02632 0.00 = existing elevation front vard setback = 7-4D ,` /'16SOCIATES `� ` (508) 740-2882 ©.Oo = proposed elevation side _ _I 0 `� rt `� (;insulting and design engineers - civil and stT mural — = existing elevation rear 1 O —o _ proposed elevation flood ood zone iARINWONS {+� = test hole water supply `©,, �f _ _ _ ,5E..LJAIGE 5 -STET FF-FAIZ "d o- = utility pole plan ref erence PL.EX 34 � 2.3 ..� '` fBCW"t P. Hc6LAt4F- rm ko oAtF - - = fire hydrant zoning district �g __ � 5?O SEVErJ }T+4 AN/F . 1 z F- MA. — #`15 -- = water service ASSE-550P.5 M A P F-4Cp PAQGE.L S 4 f .-___ FRA(TfOf�Al URA1v*A, Fp.J P .(A�F ��_1 I P JoB 8�-.13Z - ----- - --- w� fHK'D � DATF � t ��p_J DR Axi'.G AO z TRACED `i APY U s I A/AV EPE ACE