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HomeMy WebLinkAbout0940 OLD POST ROAD (CT & MM) - Health 940 Old Post 'Road cotuit P A = 055 063 I'L CCU Ne BORTOLOTTI CONSTRUCTION,INC. off19 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508429-8926 FAX: 508428-9399 E 4* SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Z PART A , CERTIFICATION Property Address: Date of Inspection: Inspector's Name: oT#es Name and Address: I CERTIFICATION STAT . FNT• I certify that I have personally inspected the sewage disposal system at this address andthat the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper,function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Pass , Needs Further Ev tion ocal Aproving Authority ' Fails M Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thin- ty(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. , INSPECTION SUMMARYo � _ 1 A)SYS M PASSES: ; I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated"-,"51 101 below. b B)-SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. W . Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination iwall instances. If "not determined",explain why not. r 1 The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exSitration,or tank failure is imminent: The system will pass inspection if the'existing Sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): -1- y ;n'��v> �"• E t ���3(,• ,X' ��,.r ,#� •,�gs�,�,t .q it `F'R ��'r�>� r+,k"��i r ,4'k a.'•tc r^s« � i �, a-- '� �r t��;i, � �"." '�4�,_,.: tl�,'4- , '-.',v�'v .3' ;7 s *,:�;t `��,:.'a;si. ��.- ft trP.*i.=� Y�:... - �'�`w.: � `7�'�.�•r ��ar�SaCv�,c_ :,,F�,�«,'�''# `�''�31t i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A g0, CERTIFICATION (continued). r , Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed Pipe(s)- The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced y Yy Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. i 1)SYSTEM WELL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - Cesspool or privy is within 50 Feet of a surface water _. Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. ' 2)SYSTEM WILL FAIL UNLESS THE BOARD_OF HEALTH-,(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN&MANNER THAT PROTECT THE PUBLIC HEALTH.AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil'absorption system and is within 100 Feet to a surface i water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. ' f'• The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform-;$. bacteria volatile or anic com ands indicates that the well is free from pollution from _rta and g � the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to orrless than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria'as defined in!310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.!,, Backup of sewage into facility or system component due to an overloaded.or clogged SAS or cesspool. = , Discharge or ponding of efluent to the surface of the ground,or.surface waters due to an overloaded duclogged SAS or cesspoo .: Static liquid level in the distribution box above outlet'invert,:due to an-overloa**orrclog ` ged'Sm or Cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- i r- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _. w _ PART A CERTIFICATION (continued) Any portion,of the Soil Absorption System,cesspool or privy is below the high_groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a,oesspool or privy is within a Zone I of a public well.,; Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy;is less than 100 Feet but greater than 50.Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: 4 tr *ri The following criteria apply to a large system in addition to the criteria above The design flow of a system is 10,000 gpd or greater(Large System),and the system'is stgutficnt threat to public.health and safety and the environment because one or more ofthe following. :-P I a � ., �>, conditions exist: A. ° The system is within 406Feet of a`suiface drinking;water supply, , The system is within 200�Feet.of a tributary to a'surface drinking water supply The system is located nitrogen sensitive area Interim Wellhead'Protection Area (IWPA)or a mapped Zone II of a public water supply well. - ` i.,{os„ The owner or operator of any such system shall bring the'system and facility into fwi compliance with'the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.`Please consult the local° regionai;office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B t. CHECKLIST Check if the following have been done: '✓(Pumping information was requested of the owner,occupant;and Board of Health None of the system components have been pumped for atleast two weeks and`the s.I .I has ,been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recentlyoi 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. ' t j The site was inspected for signs of breakout. °; $ ' ': . • t r�`' r " ! All system components,excluding the Soil Absorption System,have been'loca tted o tisrta Y' k The 'septic tank manholes were uncovered,opened,and the interior of the septic ta*4*in- Wed-:t; - - ryr t..$ for"condition of baffles or tees,material of construction,dimensions,depth° ;+ ° 5�`"�Y 4 depth of shidge depth of scum. ! _ n, The size and location of the Soil Absorption System on the site has been determmed'basea existing information or approximated by non-intrusive methods. -3- 41 �.'` ``s4;�«',,,�,t"-'µ' :l,-,t. Kti,;:€ � x*Z-' ssr -;s*1�4' "-t"'h .F. '`r`� ' '•r _ .," F ,... r ,{ sx �" n t ? ' "b•st3i. ''-'n u' 's 3 n yy4 ,r. 'mr `w�'11FC1E rS ai ^1e. . ' . ' ir. .f :..-3 tir%err t syvs�•..k ,,.�' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION FLOW CONDITIONS RIESMENTIAT Design Flow: gallons Number of Bedrooms: Nu ber of Current Residents: Garbage Grinder:_�Q� Laundry Connected To System: Seasonal Use:/25 Water Meter Readings,if able: Last Date of Occupancy: _ COAUNERCIATANDUSTRIAL! Type of Establishment: ` Design Flow: gallons/day. Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: . Last Date of Occupancy: OTHER Describe) Lust Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information- System Pumped as part of inspection: _ If yes,volu pumped Rallons - Reason for pumping: ... TYPE OF SYSTEM:.. ✓Septic Tank/Distribution Box/Soil Absorption System I Single Cesspool Overflow Cesspool I . ..Shared System(If yes,attach previous inspection records,.if,any) Other(explain): ROXIlYIATE GE,of all com vents date installed(if known),and source of information _ ScAge odors detectedwhen arriving at.the site: 410 _4. r , SUBSURFACE SEWAGE DISPOSAL_ SYSTEM INSPECTION FORM.' h : 'PART C * ` GENERAL INFORMATION (continued) SEPTIC TANK�� Depth below grade: Material of Construction: concrete metal FRP Other{ (expo) F ; Dimisions 1d.5',f4g 1 x Ld�` Sludge Depth: Scum Thickness: •. ter__.. . :. -.;. .. .:.. Distance from top of sludge to bottom of outlet tee or baffle: y Distance from bottom of scum to bottom of outlet tee or baffle: 6 Comments:;(recommendation for pumping,condition of inlet and outlet tees or bales,depth of 11. id`'l, level in relatio to outlet invert,structural integrity,evidence of leakage,etc. '/ 71 GREASE TRAP: Depth Below Grade: Material of Construction—concrete—metal_FRP_Other -Dimensions- ScumT•luckness: Distance from top of scum to top of outlet tee or baffle:' Comments: (recommendation for pumping,condition of inlet and outlet_tees.or baffles,depth of'ligo ••:i level in relation to outlet invert,structural integrity..evidence of leakage.etc.)-,,) .<+a . • '» .: _, . g _ , TIGHT OR HOLDING TANK:w a ':' f ; v Depth Below Grade: Material of Construction:_concrete—metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallonslday Alarm Level• Comments: (condition of inlet tee.condition of alarm and.float switches,etc.) DISTRIBUTION BOX'-.A/-- Depth of ifquid level above outlet invert: Comments:'(note if 1 el and distribution is a 1,evide ce of solids ca •over,evide of leakage,into or out of box,etc.) ...Pump is in"ModWig order. Comments:(note condition of pump chamber,condition of pumps and appurtenantxs,.ctc.) gig i SUBSURFACE SEWAGE DISPOSALS STEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOEL ABSORPTIOk SYSTEM(SAS):,,{ (Locate on:site plan,if possible;excavation not required,but may be approximated by non-introvelAt� methods) If not determined to be present,explain: +: Leaching pits,number: _Leaching chambers,number: Leaching galleries,number ;. Leaching trenches,number,length: Leac4mg fields,number,dimensions: Overflow cesspool,number: Co ts:(note condition of soil,signs of hydraulic failu level of ponding,condition of vegetation, etc. ' Cusp.00I.S........AL Number and configuration: Depth-top of liquid to inlet invert: , y Depth of solids layer. Depth 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 soilk,signs of hydraulic failure,level of ponding,condition of vegetation,e etc.) r PRIVY: Materials of wnstructioi• Dimensions: Depth of.Solids:.. .._ ... ._.._. Comments:(note condition of soil,signs of hydraulic failure,level of ponding,.condition of vegetation, _.., etc.) 6 _. .._.. .. .. iY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C ! SYSTEM INFORMATION(continued) SKETCH OF SEWAGE.DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. go A DEPTH TO GROUNDWATER ! Depth tDgroun t OfDetermination or App •on: i'f7X��14 ©�'L! !�i �• ra ed/ ; -7- L O C A T 10N f -�-�� # �y� SEWAGE P E R M I T NO. VILLAGE f I N S T A LLER'S NAME A, ADDRESS e U 1 L D E R OR OWN ER UDATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �� 1i t 1 r `On TOWN OF BARNSTABLE £5 OCATION 91�6 5Q) P126 V"—)R0qQ) SEWAGE # VI.LAGE �� ° ASSESSOR'S MAP & LOT® NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) ;&(size) NO.OF BEDROOO-�ll dltt E BEDROOMS 't BUILDER 0 0 eC� l I PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a s a ZN -\ COMn,IONWEALTH OF MASSACHUSETTS EXEC JTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED Lor DEC 0 8 2004 TO WN OF BARNSTABLEE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: la- v A _ Owner's Name: \ �.,b 3 � Owner's Addres 1 1 A Date of Inspection: / 'YL!" ° J�• Name of Inspe : (ple me print" �: P �J J ,1�,1�} ' Company Nam /C'( ' Mailing Address. Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspec_,�d 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 SS ction 15.340 of Title.5(310 CMR 15.000). The system: !7 Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa ;s _ Inspectors Signature: _ - Date: / t?� a The system Inspector shall submit a copy of this inspection report to the Approvma Authority,(Board of Health or DEP)within 30 days of completing Pais 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&_e system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 i Page 2 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEiVI INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ` C1 N) ,01 Owner• . �e�r� . '�? ;�. .,,,., Date of� spection: 3 r��t.5� . Inspection Summary: Check A,B,C,D or E/.ALWAYS complete all or Section D A.�ystem 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 medicated below. Comments: B. System Conditionally Passes:. One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as app.-oved by the Board of Health,will pass. Answer.yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as'approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water lever in the distribution box,due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System willpass inspection if(with` approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled orxeplace3 ND explain: The system.required pumping more thanA times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction.is removed ND explain: 2 Page 3 of I'l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ', ; CERTIFICATION(continued) Property Address: jOwner: Zi-j ;f /~ Date of Iection: A 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, safer, or the environment. 1. System will pass unless Boart of Health determines in accordance with 310 CMR 15.303(i)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or priory is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Bc:ard 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 *;*;T.hisisystem.passes if the.well water,analysis,%performe&at a DEP certified laboratory;for'coliform bacteria and volatile organic c_mpounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A-copy of the analysis must be attached to this form. 3. Other: 3 Paae 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property.Address: Owner: Date of I�i pection: 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 o-surface eaters 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 _ v 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. _ ^J Any portion of a cesspool or privy is within a Zone l 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 colifo.rm ba--teria 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 l*q are triggered. A copy of the analysis must be attached to this form.] 1"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. E. Large Systems: To be considered a large system the system.must serve a facility with.a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEV4'AGE DISPOSAL SYSTEM INSPECTION FORM ,�_;: `PART B CHECKLIST Property Address: Owner: Date of I�pection �p , /,r Qco Check if the following have been done_ You must indicate"yes" or"no" as to each of the following: Yes b Pumping.information.was provided by the owner,occupant,or Board of Health _ZWere.any of the system components pumped out in the previous two weeks ? ,_Z_ Has the system received no-mal flows in the previous two week period ? t/ Have large.volumes of wate_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 breakout? Were all system componer,:s, 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: Yes;-no i 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(3,'<b)] 5 s Page 6 of 1 I OFFICIAL INSPECTION,FORM—NOT FOR V OLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORI\IATION Property Address: ^, t.� � /i' �" .`� Owner. Date of Insp tion: ��~ >, 0 CO RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design):_EZ . Number of bedrooms(actual); DESIGN flow based on.310 CMR 15.203 (for example: 11:0 gpd x 4 dt bigdrooms): Number of current residents: Does residence,have.a garbage grinder(yes or no): ��% Is laundry on a separate sewage system(ye's.,or no): � f yes separate inspection required] Laundry system inspected(ye or no):/VU Seasonal use: (yes or no): 6) ... Water meter readings, if available ( usage ears 2 last gep d)): ( x � Sump pump(yes or no): lG) a Last date of occupancy: COMMERCIAL/INDUSTRIAv Type of establishment: Design flow.(based on 310 CMR.15.203): gpd Basis of design flow('seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Sourceof information: Was system.pumped as part of the inspection(yes r no): % p7 If yes, volume pumped: gallons How was quantity pumped d 2termined? Reason for.pumping: TYPE OF SYSTEM J,,ffeptic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system.(yes or no)(if yes,attach previous inspection recores,if any) Iruiovative/Alternative technology.Attach a copy of the current oNration and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DER approval Other-(describe): Ap pp:�itnajtc age of all eortrponents,date installed (if known)and source of information: Were sewage odors-detected when arriving.at the site(yes or no): ; 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEVNAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ' Owner`, Date ospection: .23:30G BUILDING SEWER(locate on site plan), � Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply we[' or suction liner Comments(on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK:Zoocate on site plan) I� Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 11,14) Sludge depth: �r Distance from top of sludge to bottom Zf outlet tee or baffle: J Scum thickness: ; ') Distance from top of scum to top of otrdet tee or baffle: "`— Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: ;,1 ' f460--4 Comments (on pumping recommen` atons,%nlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of:eakage, etc.):: 0 & GREASE TRAP?f (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendarions, inlet and outlet tee or baffle condition, structural integrity; liquid levels as related to outlet invert, evidence of leakage, etc.): I 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: ;a Owner: Date of n pection: / ,,.ems;aZ�)z �Q TIGHT or HOLDING TANK(tank must be pumped at time of -ispection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain); Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping- Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX:4'4 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:r-Lm:� Comments(note if box is level and distribution to outletsPqual, any evidence of solids carryover, any evidence of eakage into oar out of box, etc (, /E,� [ . x , , , fir V PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 1_ le6 ' a1` j Date of kn pection: SOIL ABSORPTION SYSTEM (Sf S): (locate on site plan,excavation not required) If SAS not located explain why: Type �—leaching pits,number: leaching chambers,number: leaching galleries, number: leaching trenches,number, leng-t: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, sips of hydraulic failure, level of ponding, damp soil; condition of vegetation. 07/ Z 9• JLLCZ ° CESSPOOLS i (cesspool must'_e pumped as part of inspection)(locate on site plan) Number and confieuration: 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(ye_ or no): ' Comments(note condition of soil, sins of hydraulic failure,,level of ponding, condition of vegetation,etc.): PRIVO/I)r(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.): 9 Page 10 of I 1 OFFICIAL:INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) /t Property Address: C1 ✓' �� i Owner Date of IJ ection: 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. j i 31 min 6 ` Pot Lea c V1 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSSTEM INFORMATION(continued) Property Address: , '-�'_,z AL Owner: C.l� Date of In ection:, SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water ��feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting prop erty,'observation hole within 150 feet of SAS) Checked with local Board of HeL=th-explain: Checked with local excavators, irstallers-(attach documentation) t/Accessed USGS database=explak : You must describe how you established the high ground water elevation: QP��� 11 Permit Number: Date: Completed by: HIGH GRCUND-WATER LEVEL COMPUTATION Site Location: ` Lot No. Owner: �J t/�/.` 5 d el"IC-1 Address: n Contractor:_ � / ," Address: �` yr�� Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ............ ................................................................. .Date 11/GJ� �� �7 month/day/year STEP 2 Using Water-Level Range '_one and Index Well Map locate site and determine: f Ol✓Appropriate index well.................................Cw/...... ....... �"/ UWater-level range zone, .................................................... STEP 3 Using monthly report "Current Water Resources Conditicrs" determine current depth to i water level for,index well ............................ month/year STEP `4 Using Table of Water-level Adjustments i for index well (STEP 2A), current depth to water level for index w=:l (STEP 3), and water-level zone (STEF 2B) I ��� determine water-level adjustment .......................................................................................... �. STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 41: from measured depth to vrate.r levelat site (STEP 1) ...... ...................................................................................................... Figure j 1--Reproducible computation form: 15 a.. .......... :.R w.. *.:I.:Y`_•.R—.........:.�.. .,„........:r.,...... ......... ..:...• ... ......wwm r�• .::.:min. w: .r ..... ....c•..4-,:..r.w,..............,....r.,.:i..... Arll- 1 No.A.. .... .. FEs.........�.................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ,11.............. .... ..oF....../3........(.......T........ ......---......----------•---•--....--------- Alip iratiun for Piupuua1 Worko Tomitrurtiun Prratit Application is hereby made for a Permit to Construct ('I or Repair ( ) an Individual Sewage Disposal System at: .._.._..... ....................................... ..... -•----•--•------------........----•.....•. Location-Address or Lot N 1 .._ .....c � '----------------------------------- 13VO ..-. .__...._.......------------------------• : .......... a 1+►v_... = O ne�r- Addre F c�2 ................................ .........u?AVs ......--...... _ uic...� Installer Address UType of Building Size Lot.............................Sq. feet I-A 4 Dwelling—No. of Bedrooms.._......._.3............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers a YP g ---------------•-----------• P ( )--- Cafeteria ( ) 44 Other fixtures --------------- ---------------------••--------------.-.-----------------•-------------------------------•--•------ Design Flow.........//C1...........................gallons per person per day. Total daily flow.......3 0..._.................•..gallons. WSeptic Tank—Liquid ca acity/Pj�l allons Length................ Width................ Diameter-_.--_--------- Depth.... -` x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------_-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (>O DosiLig tank ( ) t¢ a Percolation Test Results Performed by42YW-------W LTA........................................... Date... ................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .......................................... O Description of Soil....... � ................. ..... T �7r-- i x U ....................... ----•-•-•-----••-----•-•----------•-•-•-------••----•-••------- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss by the boar,f h . Sig . --: �-----E r {= J ................... - -- --- .......... Application Approved BY ;fo ------ --------------------- •--------------- Date Application Disapproved for the ing reasons:--------•-------•-------------••----••-------------•--------•--•--------------•-----------••--•--•---••---•---- -----------------•--•--••----•-••--•----•••--•-•----•---•-----------••-....-------•-•---•----••----------••-----•----...._...----•••--------•---------••-- .------------•------- Permit No._-----k............................................ Issued --...- .. D -� Date ate l No.rl.....l7Q _I F�$........`�..................... THE COMMONWEALTH OF MASSACHUSETTS �y BOARD OF HEALTH .................. -•��1/1' .................OF..... iC�/7....1 . Appliratinn for Btgpoii al Works Tonstrnr#inn Famit Application is hereby made for a Permit to Construct (✓j or Repair ( ) an Individual Sewage Disposal System at: Location-Address r Lot o o owner Addr s ••--- Installer Address Type of Building Size Lot_XA/........ _......Sq. feet Dwelling—No. of Bedrooms..........3.............................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type e of Building ............... No. of ersons.......__.__.........._.._.. Showers � YP g ------•--•-•- P ( ) — Cafeteria. ( ) � Other fixtures ...-••-•---••-• --•--••----••------•-••-......--•---.•••••••---•-•-------••-••-•••--••-•-•--••----••••-•...-•••-••••-•••----.....-•---•.........•••• W Design Flow........ /Q...........................gallons per person per day. Total daily flow......3.---+a.Q.........................gallons. WSeptic Tank—Liquid capacity/Pj01.gallons Length---------------- Width................ Diameter---------------- Depth................ xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ) Dosi_g tank ( ) C?�Ii Ly"'� a Percolation Test Results . Performed by-�.__.i�__�:_:�_..:._..r•J............................................ Date_.�7d...��.-3'�.................... 14 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........................ P4 ----------•-------------------------------------------•---•--- -•• --•...................._.... .......................................... O Description of Soil•-•_.. '4F1 `'emu i e....-•-•----•--•-•-- I jr".1 -_•_C�7-a/7r. Fd W x ••-••••-••-••--. ...................................................................................................................................................................................... 0 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is by the boar f 11 h�,. Q Q SIg lL .b ..... G� .�G... �CJ GJ ........ Date Application Approved By................:`:..__... ....... .... ....... Date f Application Disapproved for the lowing reasons--------------------------------•----------------....---•------------------------------------••--•••-..........•- --.....-•-----•-------------••---•-•-••....-----------------•-------------------•----•-----•---------•----••--••-••-•....••-••---•••---••-•-••---------_............................................. Date - Permit No.......... ..... ------...-•-----•--. Issued.............. •-••--a• -•-• -----•-•--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..�Q. I ...........OF.......1_0 `IU-,� , t ............................... Trrtif iratr of TnntpfiFanrr I O CERTIFY, That the Individ�. a Sewage Dis o S-stem constructed or Repaired ( ) g r P �' by. --J-- -------................................................................................... �,.,rInstall .- /� r has been installed in accordance with the provisions of TIT 5 e State Sanitary Code s cribed in the application for Disposal Works Construction Permit No.... ......... . �� -----� ......... dated-------�-- -.. .�..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSPRUED AS A GUA A EE THAT THE SYSTEM WILL FFUN TION ATISFACTORY. DATE................... ......... ..4 .-•-•----------------------- Inspector..-•-------- -=- •-----------.............. ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � crc.,)............... oF..... ir ,° .re �-� N . "......... ......... FEE3'D ......................... onstrnrtion rrMit Permission is hereby granted....... --- --- -- ----.......------ - -------- ---••- ------- ----- ------..--....----•----------------------. to Construct ( ) or Repair ( ) an Indivirl Sevtr Di 'S ' atNo. -•---•............•.-•-. •.-.-•--------- -:I --•• � _-_--------_----•.......................... • -- -- . -- Street / as shown on the application for Disposal Works Construction Permit Z ated.......................................... ......................... ------.....-•-•••..................••..........sy of Health DATE ----•••-••-•--• •••-••-•••-....----•••••........•-- { FORM 1255 A. M. SULKIN, INC., BOSTON { �jl►JGsIL- FAMILY - � BCOR�oM ,�1� "(�ARBAC�E- �jWtJDE2 D A►t-�( F�-OW _ 110 A 3 = 3 3 0 G:P.-q rjEPTtG TArJK a330x150"/• = �}9 jG.P. R u5E- ►000 GAL. 5%DMWALL A2E4. y- 150 5.>= x 50TTOM AREA= •. S.F. sa S.F x 1• 0 5o G.Po TOTA. - DESIGN = 422 G.PD. v ••TOTAL. pA I►-Y F�_ow - 33o G Pc� PE2CoLATI01`4 RATE ; 1"IN ZMIN OP LE55 s DAVID 9�'y . . r c I THULIN �^ No 29976 �STE� 'T,r/ONAL G a` -� 92 TF--::op FND= �G -ra -r P-I Qs FG NoL� 418783 90 �Lz 90 n � � 1►`N� �9 I000 INS• 'ScJ> 3dJIL. DIST. INS. GAL_ . Z 0VK SEPTIC. Gay.. 88„ LEA�u PIT INY. INY. WIT14 M.2 B8� r ��� ►'/3/q I% Lsvlr vJASNt:D- 6T�NE . S�.,y� J 82� • CE.SLTIFIao PLOT P�A1.J PRUFIL� l.oC4-Tloti I - T ALE - - A -I N o 5 C 5 c,c.L.C. ( - $4 , / ZeV. 4-4 �'_, �0 w AT�� ��- •r�, p L�.i,N R E F S iZE.N GE GEcz'Ttr- THAT 'THE NI REo►�l GOMPLY5 YJITN-THE _67 A►�D S6T�.GK 26Qt)tR.EM - t5 oFTµ�- ' -Ta W►� O F $Ar?.+J<jT/t:3CtAND I S (JdT" Loep,TED W►TN► "CN6 F .000 PLp.1N 3- 14 CI C BAxTEIZe t�.1`(E INC. D AT E I S'T f ZF-'D't.AW D 5 u izY EY�T�'S -r'VA pLb,Kl I ,5 WorT <3t-5r P 01d AW OSTGP_VILU-__ IW-51-9,uM6NT SVIZ.VeY E,. -ft-IE 0- 1=FSE'T5 ►,Ip�- :per u5ED'Td pE'TERl�I►,t� L•o-r -INE-�j APPt_ICP.NT n _ _ r t . Q4 80, n L.i lot F. Al 4 cap i �• l G1 = of,a-• � � w ��AI�IJ)• P