HomeMy WebLinkAbout0147 WINDSHORE DRIVE - Health 147 WINDSHOREDR., HYANNIS
A 1
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No. ZDI Fee 00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppfication for Disposal 6pstrin Construction j3ermit
Application for a Permit to Construct( ) Repair 0� Upgrade( ) Abandon( ) ❑Complete System Ondividual Components
Location Address or Lot No. �'���j' jpryL oriLp_ Owner's Name,Address,and Tel.No. Y13,3 vO y6--Q
Assessor's Map/Parcel l 1 Vet'1 lei( 6/� ae/ ,
pa AAA1
Am 0168S
Installer's Name,Address, Tel.No. 50-6. ��_ �ga(o Designer's Name,Address,and Tel.No. Qom""
r4otdtti,026 'W ��/�C. ///4
hv� &?s Yls W Q. S�
Type of Building:
Dwelling No.of Bedrooms �� Lot Size O'33 AcmS sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A/it 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 Environmenta n n to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt
Si Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued t
No. Lit/ I '1 T Fee V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4plication for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System XIndividual Components
Location Address or Lot No. I c,!/7 lc)jf)dShp Owner's Name,Address,and Tel.No. 3 y�-
S
r� �/ �� �r3. 3
Assessor's Map/Parcel — tr(,rtCn 6,Q,� N kc 104W 0 tbr,,d3e(m .
Installer's Name,Address,A Tel.No. Spa- l 0-3 Designer's Name,Address,and Tel.No.
d -36r75 %/s F
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size O'3 3 A&Z -- sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) Nit gpd Design flow provided gpd
Plan Date Number of sheets f Revision Date
Title
Size of Septic nTank Type of S.A.S.
Description of Soil
I
Nature of Repairs or Alterations(Answer when applicable) - } on
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 Environ_m,,en�t'all"Codes`and no to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health..•'"
Si Date
Application Approved by _ _ Date ZZ
Application Disapproved by Date
for the following reasons
Permit No.��( �( � I Date Issued 1Z l 7A) 1
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by ( �(��G�l f r ��,n5��'� Y_ �Cy z Lc�C
at.
l�II �
�1- 1 �tN S n P l)t—• (-l-tr(.ti'1i1r S has been cons"*nn with the provisions of Title 5 and the for Disposal System Construction Permit No d
Installer �2r 1p�ULI [ LL,j)Sf fC l i c Designer 011 }-
#bedrooms 3 Approved design flow / gpd
The issuance of this permit shall not bt con trued.as a guarantee that the system will fa c'tion,as.designed. t ti ip,
10
Date Inspector f'1� �(fj �, av Y` l
yam. V
-------------------------------------------------------------------=-------------------------------- ---------=- ------------------
c,J
No. — Fee ��
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( )
System located at / (4 (�;n�Sh��(P �r'�t E, �— V l_t 0 n t 5
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 1 7_ /17-D1 14 Approved by
Cornmonuvealth of Massachusetts
W Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 147 Windshore Dr �j Y
Property Address..
Mike Bliven
Owner Owner's Name
information is
required
for Hyannis - — Ma- 02601- 11/20/14
_
page. City/Town State Zip'Code Date of Inspection
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 forms A. General Information
` .
on the computer,
use only the tab
. DI U
key to move your 1 Inspector:
cursor-do not use the return Michael DiBuono
K
key. t` Name of Inspector
DiBuono Sewer and Drain
Company Name
8 Johns path .
Company Address
S Yarmouth MA 02664
City/Town State Zip Code
508-364-9587 S113522
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. I 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 Evaluatian-by"the Local Approving Authority
Inspector's Signature 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.
I
****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.
iti I q I
t5ins•3113 Title 5 Official Inspe tiInnyem-
:Subsurface Sewage Disposa Sst Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
147 Windshore Dr
Property Address
Mike Bliven
Owner Owner's Name
information is
required for every Hyannis Ma 02601 11/20/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ 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):
Dbox needs replacing
❑ 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
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 147 Windshore Dr
Property Address
Mike Bliven
Owner Owner's Name
information is required for every Hyannis Ma 02601 11/20/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cost.)
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 15,000 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
qi. W Title 5 Official Inspection Form .
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
147 Windshore Dr
Property Address
Mike Bliven
Owner Owner's Name
information is required for every Hyannis Ma 02601 11/20/14
_
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is made up of a 1,000 gallon concrete septic tank. A Distribution box and a 1000 gallon
leach pit. The system is in good working condition however the distribution box is rotten and neE Js
replacement.
Number of current residents: 2
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 ears usage 2012 26,000
9 ( Y 9 (gPd)) 2013 28,000
Detail:
79 gallons Per day for the last two years
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
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 Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
cw •'' 147 Windshore Dr
H
Property Address —
Mike Bliven
Owner Owner's Name --------
information is
required for every Hyannis Ma 02601 11/20/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
30 plus years
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 18 "s
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.):
No evidence of leaking at building sewer or tank
Septic Tank (locate on site plan):
Depth below grade: 1 ft
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
El 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 Gallon
Sludge depth:
3"s
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments
wM 147 Windshore Dr
Property Address
Mike Bliven
Owner Owner's Name
information is
required for every Hyannis Ma 02601 11/20/14 page. City/Town 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.):
Pumped on a regular basis
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
147 Windshore Dr
Property Address
Mike Bliven
Owner Owner's Name
information is
required for every Hyannis Ma 02601 11/20/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ 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.):
No signs of hydrualic failure
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
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Foy
o
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 147 Windshore Dr
Property Address
Mike Bliven
Owner Owner's Name
information is
required for every Hyannis Ma 02601 11/20/14
page. City/Town 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
Ll �
/1 - � � 6 --- 1 22 �
Z Z� -
3
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
147 Windshore Dr _
Property Address
Mike Bliven
Owner Owner's Name
information is required for every Hyannis Ma 02601 11/20/14
page. Cityrrown 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
C
Y
CO.N .NION\NE:aLTH'OF.�LaSSACHt'SETTS
EXECUTIVE OFFICE OF E\vIRONI�4ENTaI AFF.�,If;
1 DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE nT\TER STREET. BOSTO\ \L-% 02106 1617i 292-S5oo ,
TRUDY COX=
Secretar:
ARGEO PALL CELLLCCI `DAVID B STP,LHs
Commiss:c-.e:
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .. ,
PART A F
( ( � �J( CERTIFICATION
Propeki Address: 1 y—\ Vj 1 K \�t/ t• Name of Owner
f. � ��\� Address of Owner: w
Date of Inspection; l // , a.U7 \GST`; 3"
Name of Inspector:fPleasrri •C h a c�C %t=)EL�U 1Mll��a-*-�t �tt 3�� >
.1 am a DEP approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15�.00d)
Company Name: Fk
Mailing Address: ?,,Z2 g L�V 4- f�q5 1- p L—E J�'r9 oLC�t`I
..Telephone Number: �Q —C /L,� • `moo_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate
and complete as of the time of inspection. The inspection wai performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the kcal Approving Authority
jF ils ,,�
Inspector's Signature
Date: r
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
m q uc Q
3 1999
w�voF�,sr
revised 9/2/98 ,A Page Iof11
0 Pnmed on R"k-d Paper
P
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
w 'PART A
' CERTIFICATION (continued) _
Address: ¢ rw._•�I'r/'� ,
'roPe*tY
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, o/ D:
`.'A " �SYSTEIVI PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMIR 15.303.exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:,
One or more system components as described in the.,',,,,Conditional Pass".,s.ection need to be replaced or repaired.. The system,upon
completion of the replacement or repair• as approved by the Board of Health_ will pass.
Indicate yes, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If 'not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy"of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the,date of the inspection; or
the septic tank;whether or not metal,•is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.i>The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
f . ;. t..,..+
broken pipe(s)_are replaced r
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four.times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
q - 4
r
revised 9/2/98 � :_ �''Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
"PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to de ermine if the system is failing to protect the
public health, safety and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANC WITH 310 CMR 15.303(1)(b)THAT-THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
NY
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND P LIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC LTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption stem (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 soil absorpti system and the SAS is within a Zone 1 of a public water supply well.
_ The system has a septic tank and soil absorpt• n system and the SAS is within 50 feet of a private wateritupply well.
_ The system has a septic tank end soil ebsor ion system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well wa r analysis for eoliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that fecilit and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine istance (approximation not valid).
3) OTHER
wi
•Y r'e s'•�1_"•
revised 9/2 98 Page3or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
CERTIFICATION (contirwed)
property Address:
Owner:
Date of Inspection:
,D.,,:....SYSTEM FAILS: f, ...
You must indicate either "Yes" or -No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 3 CMR 15.303. The basis for this
-determination is identified below. The Board of Health should be contacted to determine w at will be necessary to corre_t the failure..
No
Backup of sewage into facility or system component due to an overloaded or ogged SAS or cesspool.
T Discharge or ponding of effluent to the surface of the ground or surface w ers due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an o erloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available vol me is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(si. t
Number of times pumped_.
_ Any portion of the Soil Absorption System, cesspool or priv is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100~feet ofY surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I f a public well.
Any portion of a cesspool or privy is within 50 fe t of a private water supply well.
Any portion of a cesspool or privy is less-than 00 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the we has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compou s, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or -No" to each of the f Ilowing:
The following criteria apply to large systems. addition to the criteria above:
The system serves a facility with a design ow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment b ause one or more of the following conditions exist:
Yes No
the system is within 400- eet of a surface drinking water supply
the system is within 2 feet of a tributary to a surface drinking water supply
the system is locat in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such ystem shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for furt r information. .
{
revised 9/2/98 s :iTage4ofII T
e•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTS
CHECKLIST
property Address:
Owner: -
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or."No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
No
None of the system components have been pumped for at least two weeks an&the system has been receiving normal flow
rates during that period.: Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N;A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout. . t
_ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For exampleA Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance it,unacceptable)
(15.302(3)1b)1
The facility owner (and occupants,if different from owner) were provided with information on the propermaintenam"-of
Subsurface Disposal Systems.
.. - .. .. .. ... ...w ,. ..-b.,, t t fl•::ai 4• #}?;j.'•#., °74?L-�' 'IDS:+y'.'�'�r;.;.,
[revised 9/2/98 page4ortl
.. -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORN.
,.., —PART C
SYSTEM INFORMATION
'roperty Address: ( "4' G jj)�
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow d g.p.d./bedroom.
Number of bedrooms (design):92ES Number of bedrooms (actuall:QSI
Total DESIGN flow!93(n
Number of current residents: - a
Garbage grinder(yes or no):w
Laundry(separate syitem) or no): r-3: If yes,`separate inspection required•
Laundry,system inspectedr nol
Seasonal use (yes or no):N
age( d)s if available (last two year's us g gP : �N
Water meter reading .
Sump Pump (yes or no):
Last date of occupancy:
COMMERCIALnNDUSTRIAL•
Type of establishment:
Design flow: gpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tan'k'present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter`i•ea'dings;'if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION -
r �
PUMPING RECORDS and source of information:
�r
System pumped as part of inspection: (y s or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information: VioL�-
Sewage odors detected when arriving at the site: (yes or no)dip
' '.5 f Yte :�w_T� �' ,. • J,yt�..M' 1 •""SYi y
revised 9/2/98 ;page 6(if ll
T
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction: _cast iron_40 PVC_other (explain(
Distance from private water supply well or suction line
Diameter
Comments: (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 Certificate of Compliance_(Yes/No) t
Dimensions:
Sludge depth:
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 bottom of outlet tee or baffle:
How dimensions were determined:
r �
'omments:
tion of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
(recommendation for pumping, condi
evidence of leakage,'etc.)
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:
Distince from bottom of scum to bottom of outlet tee or baffle_ _
Date of last pumping:
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
2 -'
revised 9/2/98 page 7oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
'roperty Address:
Owner:
Date of Inspection: 'nh
TIGHT OR HOLDING TANK:JA0 (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete metal Fiberglass_Polyethylene ._other(explain)
Dimensions:
Capacity: gallons «
Design flow: gallons/day
Alarm pres e nt
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
• (condition of inlet tee, condition of alarm and float switches etc.) --
DISTRIBUTION BOXVS -
(locate on site plan) VV ��
Depth of liquid level above outlet invert:24.
Comments: -
(no a rf lev I and dis�ribution('s equal evidence of solids carryover, evidence of l"kage into or out of box, etc.(
� tL7Q k `RA3rRx �I�SV 11+�NJ y �,ZBL/�) �GQ
PUMP CHAMBER:�U
(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.)
iV:F: t{
.. - .;.. .. .r.�-.... ... ..ems`.... ...:,.a.:.•«i.n...nt.y..-a,...y,,.,.pt-n.•,.w.«nr..r»,eri.+ e.�
.....«.....-....-...«.--.- ..«..w,«.....,..,.a;..w.. .....w.. � :11r.. wr »w-w.-:-•+. ...w...wa--..._...,.. af4 y1e:�in`.`. '� w,.h.)• '.I
♦__�....w.,...... r.. .....,... .n .. .,w....+. W.......p,,...wt .Yxt«. +....e.+,:.« .. �' .. _ ✓N'w++«.+.-w...,' __�• ram....«.- .«.......• _T..F,+en, ..r.....-........ ...
pa;csorll
revised 9/2/98 _ =nt °� + < y
. ;rc err_� ;.� . .,�,;•�. ._.,z.,: r..,.; _..,,� ,. ..__�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION (continued)
'roperty Address: Z �1 wl
Owner: 4
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible: exca a—to n not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers; number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology
Comments:
(n a condition of soil, Vgns of hydraulic failure,level of poncling, damp s it„conditio of v tation, etc.)
CESSPOOLS:
(locate on site plan
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: r
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
w
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
kill
revised 9/2/98 Page 9o(It
:,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C''
SYSTEM INFORMATION (continued)
,roperty Address:l i-I w� �
,weer:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM: .
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
�. 33 r36
'+w; -,�. �A,�,i w:•r �r 5"s,4. .�:� i�e'�n„�is;>>;1Rr ."..:;#t3i�°<$::"...'S'Y a.s.. :`Y�'i'
revised 9/2/98 P geioorir
f �
F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r SYSTEM INFORMATION (continued)
ropefty Address:
Date of Inspection:
NRCS Report name - ---
Soil Type_ — -
Typical depth to groundwater_ _
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope U`lU
Surface water
Check Cellar
Shallow wetls,.VJ(W
Estimated Depth to Groundwatert5l`eet
Please indicate all the methods used to determine High Groundwater Elevation:
' t
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
r 'j
Checked pumping records
Checked local excavators. installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Pagelluru .
LOCATION ( �I/�dISV�Cof, SEWAGE #
V LLAGE }- -UA-W it S, ASSESSOR'S MAP & LOT�Qj
INSTALLER—'S NAME? 'TONE NO.
SEPTIC TANK CAPACITY I0001#1 51 1
LEACHNG FACILITY: (hype) 1 1 (s zc)NO.OF BEDROOMS_ �_®
BUILDER OR OWNER COWS t
PER.MTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist
on site or, within 200 feet of leaching facility)
Fee;
Edge of Wetland and Leaching Facility(If any wetlands exist
witIdn 300 feet of leaching facilirf) Fcc'
Furnished by Da--0,Qjc(L,-=>
��
��_ _ �
i � � ��'�
(�
.. � �'
� � �' {'.
� � � ',i
� � � � , �
'�'
�i
� �:
.�.�t
� _
,,
,_
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME & ADDRESS
ell-
BUILDER OR OWNER
DATE PERMIT ISSUED 77
DAT E COMPLIANCE ISSUED 7p
_ ' i 4
i
' •`v
{�r�
//'
� �� \ Q
�:_ � `1
.�� ��
� :
4
.31
��
C
�,
(•- ,
f1
No................. Fizs....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..-----....OF....... ! '---------------------------------------------------
Appfiration for Uhipvii al Works Tuntitrnrtinn rantit
Application is hereby made for a Permit to Construct ( ''-Jor Repair ( ) an Individual Sewage Disposal
System at:
L tion-Address or Lot No.
�---------------------------- -------------------� . ..............................................
Owner --------------------------------Address
Installer Address
Type of Building Size Lot_ .!!?C)_._.......Sq. feet
aDwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder (4)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ----1 ! ---------------------------------------------------------------- -------------------------------------------------------------
Design Flow................t',1_.......__._._..._ .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./ below inlet......... ......... Total leaching area...��s S.—sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) p,6- 0641-t-
a Percolation Test Results Performed by........&-n.M!.77...:. 4 _,1111le........ Date.._..,1.,/_ ...........
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........................
Ix ------------------------------------------------------------------- --------------- ------------......---
0 Description of .oil...........
UW -------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------•----
Nature of Repairs or Alterations—Answer when applicable................................................................................................
......................................•.........................................................................................................................---------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'i LE 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.
Signe !*,Z� .. ...1 , - _�3. � � /-2—
Date
Application Approved BY ... �� ,i ...... p ............. ....... ..._ ------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
•........-•---•------------------•••--------------------...---------------••----•--...---------..........._
Date
Permit No......................................................... Issued-...... -•... ...............
SIUGLV--- V=&m L`-{
QO GA28AGE p
2ad1�.�( F Low _ l lb 3 • 33d G:pt7. - �,._. .
5c�r'1c Tl�I�tIC = 330,. (So % • 145 i6.Pp.
f
bI5Pp5At P1T uSE loco GAA_ ;,s
SUP-WAL- AV-GA - lso S-F. �2d
1
TOTAL 425
Flow * 330 6.P.D. ' i i �, } ; 7 rr T
Pmgr_DLQTlO Q to t IQ -M I W''oR
_Y:P'ON(B `SH OF
� `may �+`'� J � , � -' i•� r �f+
�o RlCHARp Gn 'o ALA •< '.. .. .. .
A. 9 w
O.
N AXE R ° VFS
040
100 O i
��o � o S G>
S�R �or'iaLEN
`��T , ,7U�f:•1• ', J(J ,.tom .- - f � .. :�. .'. ,. . r .- ..•«
Tar Fw s
q� O 100.0
4 Ave
A ;
i i
ePM
Pic,. Spl.►ny 1 - Ta t;'� _.
4IW.
L r
LEAcH A ;..1
�! PST
Mrs iwlrN i 4 •� `
�D WASHED
' cEeT�F�Ev pl.dT' �.�4N
Gen✓ FIzo1F'(L:.E
LOCAT101�4 �yAwu107 ,
1Z $S' �.Jo Sca,o..�• . , .. .3`�S 4r= ("_,Q.o� bAT� ' Il -�0-11 ;
GGIZ-rlp�q TI-4A•r THE `pWL-U-iQ4o 5WOW14 PtA1.l 'R�>=6RL1.iCE '
W6 v,unw GanMPL%PS W 1T" TNE: 51 DE.-L(WGi
A1.(t> OF TNT LOT
PATE 1-3o-
J
to/s XTG;Z ueE I..Ic_ ,
RCGtS't•cR6D L. Wo, 5Ueva%foml
TI-4IS PLAW I'S LJOT ZASev OtJ AN OSTE2VIl-LCz c.''MASSo-
U•IS(�:JI✓�EIJT' ;Uk'.�/r_�{ Ti•IC- OFC:,Sa v, Sa1owLD ApPL.I GA1�1T �• `
r.�vr er ust� ro. veTCQM�WC:. LOT LIwCE:45
Fiz
No....................... .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............OF.......... ..... ....................................................
Appfiraftjau'jor Dhipaaal Works Tomitrurtion Frrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
SYT
.... . _
...................................... ....................................A.....
........ .............
anon , or 4t No.� k ................................. ..............
Owner 1-0 Address
Installer Address
Type of Building_, Size Lot/.k....................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic' Garbage Grinder (14P)
,Other—,T e of Building . .......... No. of persons. 11
—Type - --------- Showers Cafeteria
Otherfixtures ... .................................................... - - - - ------------- ---------*------ ------
aily. ;q
-------------
',flow.......07" 40
Design Flow----------------------------------------i..gallons per person per day. Total d ..................................gallons.
Septic Tank Liquid capacity/ -gallons-gallons Length................ Width.. Diameter-_:_:- ----- Depth_._..__..__.....
Disposal Trench—No. Wicith....... Total Length.._....._ 1�... Total leaching area -.. "sq. ft.
Seepage Pit No12q5?*.41 etof/4_k:t.A h below inlet. g
... .... Diam ;;a.............. Total leaching ar q. ft.
z Other Distribution box Dosing tank /-10-77
Percolation Test Results Performed by...... .........�;_Date.... ...........
Test Pit No. I----------------minutes per inch Depth of Test Pit.______............. Depth to ground water--_-___-_--__-__---_---.
G%, Test Pit No. 2----------_---minutes per inch Depth of Test Pit___..................Depth to ground water........._........_.___.
........................................................ ------- 5.......... ............ .............
--------- .... ....... --- ...............--------A, _&V- '_d'-'7dt...
0 Description of oil..... 0.-�t...
....................1h.......................4�.... ...... . A•
...... ---;.............................................................................m.............................
U
W
�Ii ------------------------------------------------------------------....................................................................................................................................
U Nature of Repairs or Alterations—Answer when ----------------- -------- .. --------------applicable------------------------------------------11-----------------------------------------------------
-----................................................61.............................................. ------------------- ---- --------7------- .... ... --- --
Agreement:
The tinde'r�.signed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T ILE 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.
Signe ... ....1�......
..............
Date
7 7
Application Approved By................ .............
---------- .. ...................
Date
Application Disapproved for the following reasons:................................................................................................................
......................................................................................................... ---------------------------------------------------------7----------7-------------------------
C, Date
PermitNo..............................I.......................... Issued.......................................................
Date
THE COMMONWEALTH, OF MASSACHUSETTS
BOARD OF HEALTH
........................... 0 F.. ..............................................
Tatifirate of Tourpliana
THIS IS TO TI at the Individual Sewage Disposal System constructed (4-ror Repaired
by-)... ............ . .... ..... ........... .........
-------Installer
has --------------------"-------------------------------------------------- ---------
at ....... .. ............A".. ........ V.................................................................................................
has been installed in accordance with the provisions of 5 of The State Sanitary Code as-described in the
application for Disposal Works Construction Permit NoRI-7P
.......... -------
THE
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEWWILL FUNCTION SATISFACTORY.,
C
r
DATE... . .. . 7
............. Inspector...
......... . .................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ,HEALTH
Colo
.......................0 F.......r............................................................................
No......................... FEE. ...............
Big Eanotrurtio pamit
tosal Worko T n
Permissionis hereby granted..............................................................................................................................................
to Cons tqcj r Re pa� an Indlyioual Svvage Disposal System
m�X 4.."'.A at No.. . ............. ....................................... ............................................................
Street
as shown on the application for Disposal Works Constructioi�,J.Permo* ,No.. ............... Dated..�A.-_29-.77*..............
. .. ............
......II&A ----------------------------------------
BoardMea t
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS