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HomeMy WebLinkAbout1034 SANTUIT-NEWTOWN ROAD - Health 1034 SANTUIT-NEWTOWN COTUIT --- -- -- -- - - - A= 027068 - --- - - - OF BARNSTABLE LOCATION ® SEWAGE # "' `7' / VILLAGE .{- ASSESSOR'S MAP & LOT Gg?711 Odd INSTALLER'S NAME 6z PHONE NO.Cc �. SEPTIC TANK CAPACITY Ov l LEACHING FACILITY:(type) AA lS (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 4, BUILDER OR OWNERS DATE PERMIT-ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No J� �In 0 /moo d-�� No3v-,._� - 3: .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ApplirFation for Diipnial Works C owitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: .............. (�? i._._..�__-�..._....``.................................... .................... i --.---------___------------• --•--•------ Location-Address or Ot No. - -•-------------- ^" .......0=' ........................................... ----------------- iJ a �-A................................................... s Installer Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms-___ __ ___-______--___Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a, Other fixtures ------------------------------ --- - - -- - d ........... Design Flow------...�1.. g� P P P y y W ________________ Mons per person per day. Total daily flow--____-�_,l�_____.__.._._._._._____gallons. WSeptic Tank—Liquid capa6ty............gallons Length________________ Width................ Diameter----............ Depth................ x Disposal Trench-- No ____________________ Width.................... Total Length-_-___.__._.`_..__. Total leaching area....................sq. ft. Seepage Pit No______ ___________ Diameter----1 �------ Depth below inlet----- __......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit__-_________________ Depth to ground water........................ 9 ---------- •-------------------------------------------- -----....................... •••••---------- _........ __.....--•....... _-....._..._...... ------•--..... 0 Description of Soil................................................---•---•------•-----------•---------...---------------------------•--•-•---•----------------------------•••------_-•--- x W --•------------------------------------•----------------------------------------------------............. ............................... ............... UNature of Repairs or Alterations-Answer when an plicable._..; �Y-�- -Lr ..._.. ... ___C _._ _ b Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned f rther agrees not to place the system in operation until a Certificate of lance as aL o health. Signed ...... .. ----- ..... ,... . .. ........................... .-................-t!.....a.:...... Dace Application Approved By ... . --.. Z --- r... ................................. ......-.................-............ ........7 v ".. Due Application Disapproved for the following reasons: ..................................... --. -.........................................-..............-..........--............. .................................................................................. .................... ..... .................. ......- - ................................ . ...-..... ........................................ Permit No. ......... .. ...... .`.. ............... Issued ..........-...--..-....-................--....... .-...-Dace...-.. Dace Y ••• V�e v -- tr 4' � s4" r. _ I .� 4i. ry v {,v wy. w `+_ ' - -.. _ - V THE COMMONWEALTH OF MASSACHUSETTS V BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di�5pwial lVorkii Cnnnitrnr#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ..................... ...... e w-r caw '12Q. ...............................,1 .j�... ............................................ Loc:ttion-Address _ orrt No.�(! - J}.1I.s-( "............. ......--•------•-•..................•.._...• ............--- In '.-.--..... ...... ........................... owner Addr s Installer Address UType of Building Size Lot...........................Sq. feet �. Dwelling—No. of Bedrooms.___ .��_______________________________.-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures __________________________ _ W Design Flow-.------- ..-...............gallons per person per day. Total daily flow_........................gallons. Septic Tank—Liquid capacity------------gallons Length______________ Width.__.____-_- --_ Diameter._-..___.-__- Depth................ Disposal Trench—NTo. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....../----------- Diameter.-.- Depth below inlet..._........... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) `4 Percolation Test Results Performed by------- ----•-•-----•------•----••-------------------•-•-•••-•......----_. Date........................................ a Test Pit No. 1----------------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........................ 0 Description of Soil------------------------------------------------------••-•------•-----•------------------------------------------------------------------------••--•-••-•---..._....... V _...-•.............. •..................... ------------------ •--------------------------------------------------------------------------------------------------- ....... ........... . W U P / b � . Nature of Repairs or Alterations—Answer when aB licable___... S _-_._� .. ._: ^�- �___... �4 ` . ----........ �-:-- . .....0.��.G.-----,fie.._--�---- - -----?�-------•----------------------------------------•---------._......:-----------...--------.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned f rther agrees not to place the system in operation until a Certificate of Comp-'lancZ:ee d_b. e bo do health. Signed .............. ..... ........... ........ .. .... :_:................. .. .` . Date Application Approved By .......... .(J,�- C�1.. ............................................................................ ..... re Application Disapproved for the following reasons: .... ' ..... ......... . .......................................:............................. ......................... ........................ .. ....... ............... . '- .............................................................................. -- . ............................. '- ........................................ �/ Permit No. ......... l-Q- -f ----....-.,/....,�............... Issued .......-.......... ................................te j Date THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH TOWN OF BARNSTABLE C�Er#ifirate of CZIImplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �� by -�;. .... u.. -' ........ -- ... m taut has been installed in accordance with the provisions of TITLE .Vof The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...__V,.... ...�L ......... dated ................................... _... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIS_A T RY. DATE_... � .'_.......-...` ...... .............. ............. Inspector `-. _._........_.__.-..:... 'L? f............ Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No � TOWN OF BARNSTABLE Dintt1 Inc Tnmfrinnprinit Permission is hereby granted V4 -------------------•----------------------•---•------•--------•- to Construct ( ) or Repair/( -a:ti-Individual Sewage Disposal Syst at No......................................./o _ !(! 'Q0.(.u.�✓---- -n __..-...__.1__.. _.P.... _. __...._.__ _ /. �. Strl.'Ct q t, - as shown on the application for Disposal Works Construction Permit NOY,y..-. Dated........ ..i._� �....�/.�!.._.. -' ----------------------------------•-•------- ord oHealth DATE................ .................................. FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS l0 CAT ION S E W A G E PER MIT NO. tft &� roe - 3 � VILLA C E ' l I N S T A LLER'S NAME i ADDRESS r e UILDE R OR OWNER ye- Iho DATE PER-MIT ISSUED - DAT E COMPLIANCE ISSUED r X,9/x It ���� A401 r1bW /4&- v 1 r / �� ��� r� �l-� ��� x t 2 � /� �� ,�� � �o � b �g THE COMMONWEALTH OF.MASSACHUSETTS e BOAR® OF HEALTH -. -------------QW.A.......OF.......... ---------•-••-----........ Applira#inn for Disposal Works Tonstrnrtion Frrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: Q .. ---------- --------------------- ......------... .....---...-----------....------.......... ------------ �Loccatioon-Address \ or Lot�N,�o.�q r \ p ��(y ......-•--...... ..�! l.d°�� _ �. v.L`�r4i1 9� s1.( i�,...kk— ....... Addr s a ................ ....... .......................................... Installer Address d Type of Building Size Lot-ZZ �-� _--Sq. feet aDwelling—No. of Bedrooms...................Is......................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures ------•--•---------------------•--••------------•-•---.••---------------------•-•----------------------..........._...----••----••-------••----••-•••. 657 Design Flow....................... _.---........gallons per person per ft. Total daily flow...............5. -q..............gallons. W Septic Tank—Liquid capacity l PPPgallons Length.!-4.,_. Width.4-!_�Q.IeDiameter_____��.. Depth..45_"—t9c� x D isposal �o -•-- Width la ` Total Length Total,leaching area....................sq. ft. ee a Pit No . /.---•••• Diameteld.1-0-.'Depth below let._ . ® otal leaching area..�-.16 7•-sq. ft. Z Other Distribution box (p-) Dosing t nk ( ) '-' Percolation Test Results Performed by.... __.C!u l'':__._ /$�..... Date....... �_ � -----•-___. i_ u Test Pit No. 1....... ....minutes per mch Depth of Test Pit.��__.__©._. Depth to ground water,(y.eTff�/��_>, _ r—� Li, Test Pit No. 2........:?�-.minutes per inch Depth of Test Pit�%`-.d-_`.'. Depth to ground water.__'_`......_..`..____ P4 e -----•.............••••-••---------...... � -------••........_•-•_._......--•---`............---- --••--.....------•----......---........ O Description of Soil••d �"... ��.._�r� c�� // ! ter `° � e�� ----- z��d x v --•------------•-----------••••---•-•------••-••-•-....•••-••••••-•••-••-•........--•-----•....----•••••-------------•••-••---••---••------••---•---•--•••--•-----------•-------•-----••------••••...... w -------••-•----------------•-----•--•------------------------------------------•-------------....••------•--•--------------•-----•-------------•-------•--------------------------..........-•-•-•--•- U 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 issued by tl� o hQealth.Sig ••. •---•- . .... .............. _.. ... •------- e Application Appro ................ ate w nApplication Disapprov fo following reasons: •• -•-----•------•-------•- •-----------•------------------..................................... . ,. ._ Date PermitNo......................................................... Issued........................................................ Date - ----- --------------- ----- ---- --- ---- `N_ �`-•�-•-- —�" ,q............. kf ' Cy ;THE COMMONWEALTH OF MASSACHUSETTS 3 BOARD OF HEALTH' Applirat ion for Disposal Workii Towitrur#inn Errant Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: ' --......: .. ,....... .� ................. ................................ Location-Address or Lot No. Owner �^ , ,W� .............. r lia. - ---_-___-____----------•- -----•--- ""' " :l �,�`4�:....--� ` ::-•-•-----.......................... Installer Address Q Type of Building Size Lo q. feet aDwelling—No. of Bedrooms________________......................Expansion Attic ( ) Ga. bage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------•------------------------------------------•---•-•-----------------------....••---------------- Design Flow..................__6_!5...............gallons per person per day. Total daily flow............5 A gallons. W #:� WSeptic Tank—Liquid capacit�!0.0.C?__.gallons Lengtl0!:n•�,'d__ Widt�ir;a../i()."_ Diameter... ..____ Depth _r • _r.o xDisposal Trench—No_____________________ Width.........:.......... Total Length___._____________.__ Total leaching area....................sq. ft. Seepage Pit No_______ ___________ Diameter_/Z)_.' ::/,d_:`_ Depth below inlet !%•n.f:.___ Total leaching area2__g..I.....sq. ft. Z Other Distribution box)`• ) Dosing tank ( ) Percolation Test Results Performed by.�l,45-- — +fit , _.. _ A Date_. _ r------------ ,--a Test Pit No 1 2—.......minutes per inch Depth of Test Pi Depth to ground water_ p p Depth to ground wate........................° + ..'' f% Test Pit No. 2.....7.�-.:.....minutes per inch Depth of Test PiU,�.�;+ _.�_s-._.. W ---------------------------------------------------------------•----.........--------....-------------------._......_..---•-•------------....-•----•-•------- O , „ - x Description of Soil_ _ ._.. -.. r E ' - -�- -•- -•------ --•-----•----•------------------------•-•--....--------------._.....-•-•-----------.._..-------•----••-•-------......_•----------•------•---•- W U 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 issued by the bo ,d of health. Si t'dh_ ....................... Y� e Application App ved B, ---- --�--. •----- -••--- ----- -------- ------•--•-- f:- - -- Date Application Disappro d r the following reasons------------------------------------------------------------•-•----------------............................... -•-------------------------------------•-----------------••-•--------------•--••------.......-------•----------------------------------------------••----•-----------•--•-•--••------•---•-•-----......_ Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................I................................... �/ I CDrdifirate of Tu plianrr ISiU CERTIFY, That the Individual Sewage sposal System constructed ) or Repaired ( ) b ....---•-•-•--....••... ----------•-•.................••••••-------------.................•-•--...----•--•--••--••-••- f n er at. � - ----- -------------------•-••••--•----------------------------------------••--•-•----•---------•-------•-- has been installed in accordance with the provisions of F j�f The State Sanitary Code as described in the application for Disposal Works Construction Permit No. '�-„� 2w' ►__________ dated--------------------_---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W FVNCTION SATISFACTORY. DATE...... ...� ...... ........................................................ I nspeef ok:_:::. :__ Sy•, j.5: ,.r. s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N .....r.. .�..._. FEi..............•---•- io u u (9nns r wit Vantit Permission is ere y granted. - ---•---t•, ............... . •••--- -•-•-•-••--•--•---•-----..._••---••--••-----._.....--------......._-••-.....----•••- to Construct ( epair ( In i wa sal System at No. Street as shown on the applica ' n for Disposal Works Construction Per ------------•----- Dated---------='----------------•------_........ Board of Health DATE---------- ----- -- --••- "........................................... ,. FORM 1255 A. M. SULKIN. INC., BOSTON �A n ro D"Am.��� L-or f9 ¢e� �r EFrec-r vie Z 3, 6Z 5 5F r, f rj ,t,,rQ:T q D1Sr'S0K '000 CZ�►L.COAX, S PRIG TAM K Pic'oP06eo qyx n q j3 _j! .�•� _ �� _.� . .� 3 Bar m .1 0 44ousrL 36 9! Lo J ol d Ll m .0 o �o a 0 F 1,14,4 y WALTER P. r OLDHAM #23207 N� SURN ! s Po s A" L- PEA tQ REGISTERED S"TVE CN EER '3A f.I D V\J 1 G iA , A S WALTER o� E.SMITH, JR. �C Le ,s� ��� 4 APR z`Q #15128 A�O,rF IS S/pTE NAL E ' .. , �}�� .� •. f 1. , � '- r �r � - • .. `• - � - r. 'mil' • - � too ._ •�1ST Bg1C \ _, ..- - (pFT DiAAQLgA; S ) 000 �• CcRc l�� de,< • , .• " _- `. - �•P+cc..:`Tip�l� .'`�?• .� d ad qq. ;^ � • -,.. .' , - a e a r 3 "_.!•'�ttlyvs�61(►��°sto+ie o' - � y� D�� t'E +V RAT�•:� th1;11ti1EJ Qo`� - EDR®0l�t5 57.p 4 0 - P,Fz'e�i E °D� vo A U. "gE f 4O C-�A�..=S ccT4 4 , .' yr. r. � '��• .+• , ..a � � , �.- t vt t�. �� 4 i G t;� ! r4Y1<• \ 6 V - 1• P r tih}:�t �,t ¢y �V� V C M` ��.-A� i x} rz�l y j',`Y y _ 1 r -tom p c i. ✓r 1 Ti T � + �lY y.� �F,� Kl � ✓-3rtl,f.{ � '�= � 1 1 '.f ,a' Lk 7.. - � f� r � ~ - r r � -i) Y JL. la{ i ! '• u[� <•:.. -. 4 �1 �� r� �� 1. .• r , � .- � � r „ L r l F -1...r rr a r Jsli 'f Y. r - 1 `-✓> > a. t r t '. t.' � d •tr Yi � �i� S t'�a t ! rr r 1 � �� i 1 s 1.t , � • �.i '�..� �f,. { e � t ej� � H _ t r, t 1 "r - r. • V4a 0 ��. �r�� •r ,. r�t ,`Fs �-�'�� 4 `.�f+2i .�� � 1.,•,y,t b `i;��K�� } � .} .� , �`-Q•. �, �J !a'✓ �+- Y i etil�^ �✓ �d� C �r ? � �' �� � w MP tb��1l� y � t��a � q y�� {• f- 1 � � t•.� rµ �r • f'at 7 , .1'Fr �f C} }y r ; V t1' f �Cyltr�r�_ Vw�►'�h��-�� ,Yf� 1' ,y�' ,. r- „� M ,`+. .�1 �r'S.. t.�' yr � � ,• J , ice.-. t_`• �.�_ y� �7 ��•�. ��� ~k � t �j�'rF, "� `v��• �a-.'- �_��r9.•iii�;e.► '" " � r o '_ �'.�_�...�:���°a�.,�r1A.. > Commonwealth of Massachusetts Executive Office of Enviroiunental Affairs' Dept. of Environmental Protection Jolui Grad One winter Street,Boston,Ma. 02.108 D.E.P. "ritle V Septic Inspector P.O. Box2119 Teaticket, MA 02536 WILLIAM F.WELo (508 - 813 Governor ARGEO PAUL CELLUCCI 2 Lt.Governor 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM V� PART A PIc CEIVED V s CERTIFICATION OCT 20 997 hutvIf' W(2L4 ocov )�d 4 Properly Address: 1034 NewWM Rd.Coutiut Address of Owner: _ TOWNOFBMAfSTgBLE Date of Inspection: 10/14/97 (If different) HE41tTHOEPT. Name of Inspector: John Graci Micheal Day I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number:" L CERTIFICA TION TION STATE MENT ENT ., 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 was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on criteria dented InTRI*V _ code 310 CMR 16203.My findings weof how the sWemis Conditionally Passes performing at the time of the inspection.My inspection does _ Needs F rth Evaluation By the Local Approving Authority not Imply any warranty or guarantee of thelongevltyorthe a septic system and any of Its components ussrul life. FeiIS Inspector's Signature: �� Date: 10114197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 SUMMARY: • 4 Check A, B,C.or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. 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 ColTipliance(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 exlillralion;of lank- { failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 0411707) One Winter Street • Boston,Massachusetts 021108 a FAX(617)556-1049 • Telephone(617)292-5500. y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM' PART A 1, $ CERTIFICATION(continued) Property Address: 1034 Newtown Rd.Coutlut Owner: Micheal Day Date of Inspection:10114197 _ Sew.aoe bacltuD or.breakout or hiah.static water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution'box..The system will pass inspection if, (with approval of the Board of Health). Describe observations: . broken pipe(s)are replaced : obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The , system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction Is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. " 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 4 Y rc 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 FUNCTIONING IN A 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 lo'a y surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. " The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: have determined that the system violates one or more of the following failure criteria as defined in. 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or ' cesspool. Discharge orponding of effluent to the surface of the ground or surface waters duo loon ovnilonded or clogynd cesspool. SAS is in hydraulic failure. .Yt (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . t 1034 Newtown Rd.Coutlul Address: �Property � f P Y a Owner: Micheal Day ` Date of Inspection:10114197 D]SYSTEM FAILS(continued) Yes No 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 1/2 day flow.'.. ' Required pumping more than 4 times in the last year NOT due,to clogged or'obstructed pipe(s). t Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater a►evation.',. 1*7 Any portion of a cesspool or privy is within 100 feet of a�surface water supply or,tributary'to aF surf ace;water.supply. Any portion of a cesspool or privy,is within a Zone 1 of a public well F: Any portion of a cesspool or privy is within 50 feet of a private water supply well'. a 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. w E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: * r The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions;exist: , Yes No A. — the system is within400 feet of a surface drinking water supply k. the system is within 200'feet of a tributary to a.surface drinking water.supply =L s the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a public water supply well) '" ' The owner or operator of any such system shall bring(lie system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the;Department for further information. - a. x" y .y yi." 4i ra � _ _.l �1� y 3��F 37,� n � f ,�9t'«` +c •: . n x 00lesd04127/97i' 3 } p# y � . •Y •- .. �I t w r+ rF fin, Y i L,� *' r 'i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART B CHECLIST Property Address: 1034 Newtown Rd.coutlut Owner: Micheal Day Date of Inspection:10114107 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _x_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period.,Large volumes of,water have not been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x _ The facility or dwelling was inspected_for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x 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. x The size and location of the Soil Absorption System on the site has been determined based on , — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is x — — unacceptable)[15.302(3)(b)] i (reyited 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1034 Newtown Rd.Coutlut Owner: Micheal Day Date of Inspection:10114197 FLOW CONDITIONS RESIDENTIAL: Design flow: aao g.p•d./bedroom for S.A.S. Number of bedrooms: a n Number of current residents: e - Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye: If Seasonal use(yes or no): No Water meter readings,if avatlable:(Iast two(2)year usage(gpd): nra - - - ! Sump Pump(yes or no): No ^ Last date of occupancy:nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla " Design flow:0 gallons/day • �� - c' Y; Grease Trap present:(yes or no) Na Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no)Na Water meter readings,if available: nra Last date of occupancy: nra OTHER:(Describe) n1a Last date of occupancy: , GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last year. f System pumped as part of inspection:(yes or no)Yes If yes,volume pumped: 1300 gallons Reason for pumping: Maintenance TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any)° s• I/A Technology etc.Copy of up to date contract? Other APPROXIMATE AGE of all components,date Installed(if known)and source information' 1991 with nre pit Installed In 1994 Sewage odors detected when arriving at the site: (yes or no) No c (nvleed0412T1B7I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1034 Newtown Rd.coutlut Owner: Micheal Day Date of Inspection:10r14tg7 SEPTIC TANK: x r 1. (locate on site plan) Depth below grade: t' Material of construction:x con create_metal_FRP_Polyethylene_other(explain) If tank is metal, list age q . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: t.e•e"h5•7^w4•10• Sludge depth:7" Distance from top of sludge to bottom of outlet tee or baffle: 20" Scum thickness:+' Distance from lop of scum to top of outlet tee or baffle:s'" - Distance form bottom of scum to bottom of outlet tee or baffle:6" How dimensions were determined: Measures 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.) Septc tan*and all components are structurapy sound.Recommend pumping system every two years for maintenance. GREASE TRAP:_ (locate on site plan) + Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain} Dimensions: rda s Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda �< Distance from bottom of scum to bottom of outlet tee or baffle:rde " Date of last pumping' Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles;depth of liquid level in relation tooutlet invert, structural integrity, evidence of leakage, etc.) We BUILDING SEWER: (Locate on site plan) Depth below grade: 1' ~ Material of construction:_cast iron x 40 PVC other(explain) ' Distance from private water supply well or suction Iine:Te Diameter: 4•'— Qmments:(conditions of joints,venting,evidence of leakage,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1034 Newtown Rd.coutiut Owner: Micheal Day Date of inspection:10114197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda 4=; Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) ` Dimensions: nta Capacity: rya gallons Design flow: rya gallons/day Alarm level:_nia Alarm in working order? Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda - - DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: rda Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) - rda ` v PUMP CHAMBER: �r (locate on site plan) ' Pumps in working order.(yes or no)No Alarms in working order(yes or no)_vee Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) nla i 4. (reylaed 0 412 7197)- z , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM „ PART C SYSTEM INFORMATION (continued) Property Address: 1034 Newtown Rd.Coutiul Owner: Micheal Day Date of Inspection:10114197 ° <t: SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required, but may approximated by non-intrusive methods) If not determined to be present,explain: Na " Type: :, • teaching pits,number: 24W leach pits leaching chambers,number:Na leaching galleries,number: Na °`'- leaching trenches,number,length: nla w . leaching fields,number,dimensions:Na overflow cesspool,number:n1a Alternate system: Na Name of Technology:_Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Thi leach pits are atructurally sound and functioning properly. CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) _ Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) " Na „ PRIVY: (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation; etc.) Na (revised 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "PART C SYSTEM INFORMATION(continued) 1034 Newtown Rd.Coutlut Micheal Day 10114197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) of 63 o A N2w AC 39 AD H (rov1.•d0427197) Pape ! of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM• PART C SYSTEM INFORMATION(continued) '' 1034 Newtown Rd.Coutlut Micheal Day 10114197 Depth of groundwater 12• , Please indicate all the methods used to determine High Groundwater Elevation: c y, Obtained from design plans on record. 4 Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers F ri x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts e e .rh_ k c a fi r (rwlud0421197) rage 10 of 30