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HomeMy WebLinkAbout0020 TRUMAN LANE - Health 20 Truman Lane 'Otuit P A = 039 145 d C� cS �y Qp q Q�) Q �.- 0 Cj ol L-;7 I (I 9, 1� 1 1 LOT 44 A.M. 391-46 60� ti D� (b LOT 43 A.M. 391 4� AREA=21,958-i�, Ile ,— , oleee ele.-It le ,,,,,,,,,,,,,, le II PROPOSED ADDITION ,,,,,,, , r LOCUS Q�j� IXO � a o W 4 d W AG ON 8 sue. COTUIT LOCUS MAP PLAN REF LC.- 36608S SH 3 CERT REF- 175182 ZONING.- "RF /d SETBACKS: 30,-15,-15, FLOOD ZONE- "C" ' PANEL NUMBER: 250001 0018 D DA TED.• 07—02—92 PLOT PLAN OF LAND LOCATED AT TRUMAN LANE COTUIT, MA. )T 42 391-44 PREPARED FOR- WALTER & SYL VIA DONNELL Y FE'BUARY 08 2007 �„ ��ti2 ♦♦� REV.• t REV- REV.• YANKEE LAND SURVEYORS GRAPHIC SCALE & CONSULTANTS P.0. BOX 265 30 0 15 30 60 UNIT 1, 40 INDUSTRY ROAD MARSTONS MILLS, MA 02648 TEL• 508—428—0055 FAX 508—420—5553 1 inch = 30 ft. SHEET 1 OF 1 JOB # 54188 JF G 2"3 s: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAMRS } 1 5)7 D. DEPARTMENT O[HEALTH VIRO�. TAL PRO EC ON MEN Y T 2 0 2004 OF BARNSIABLE DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �� r � � Property Address: 20 TRUMAN LANE COTUIT MA 02635 �'� ' P h r,RCM i Owner's Name: MIKE AND NANCY BURDULIS _--�------�---y Owner's Address: 28 CHERISH DRIVE CANT HILL PA 17011 'OT � 3 Date of Inspection: 9/20/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT , I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 10 CMR 15.000). The system: X Passes _ Conditionally P e _ Needs Further ation by the Local Approving Authority Fails Inspector's Signature: ;' Date: 9/20/04 The system inspector shall submit a c y of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectio f the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall ubmit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE. ****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. Titles 5 Tncnertinn Fnrm F/15/')00 1 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 TRUMAN LANE COTUIT,MA 02635 Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements.If"not determined"please explain. n/a 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: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 TRUMAN LANE COTUIT,MA 02635 Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 TRUMAN LANE COTUIT,MA 02635 Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 F D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 TRUMAN LANE COTUIT,MA 02635 Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ 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? X _ 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 X _ Existing information.For example,a plan at the Board of Health. X _ 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 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 TRUMAN LANE COTUIT,MA 02635 Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)):*a �� _ �� ®Q d Sump pump(yes or no):NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a, Grease trap present(yes or no):NO Industrial waste holding tank present(yes or no):NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1978 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO � I Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 TRUMAN LANE COTUIT,MA 02635 Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 BUILDING SEWER(locate on site plan) Depth below grade:20" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK:X(locate on site plan) Depth below grade: 14" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8'6" H 5'7"W 4' 10"" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle:2" Distance from bottom of scum to bottom of outlet tee or baffle:4" How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 f Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 TRUMAN LANE COTUIT,MA 02635 Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan). Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping:n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no):NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 TRUMAN LANE COTUIT,MA 02635 P Y Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a innovative/alternatives stem n/a Y Type/name of technology: nla Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT WAS EMPTY AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS NEVER BEEN MORE THAN HALF FULL. BOTTOM IS AT 8 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a 4 f Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 TRUMAN LANE COTUIT,MA 02635 Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 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. c� o p( v UU k iq T 11J V�lj 32 in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 TRUMAN LANE COTUIT,MA 02635 Owner: MIKE AND NANCY BURDULIS Date of Inspection: 9/20/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. 11 i 3. / •. e,'i 7. r • t •. : :.Ya r - lit.4 p 11. -iu li..' - BORTOLOTTI`CONSTRUCTION,`INC 765..WAV.EBY,,ROAQ,MARSTONS MILLS, MA 02648 t ' 508-771=9399' 508-428-8920 FAX-`508-428-9399 Z �1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 0 / Date of Inspection: 9 9g Inspector's Name:' Owner's Name and Address- T CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informs- 8 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 Ifstems. The System: Passes ,, f► c Conditionally Passes co 1 Needs Further E ationBy �e al Aproving Authority t Fails 0,� Inspector's Signature: �� , Date:'# The System Inspectof"shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completinithis inspection. If the system is a shared system or has.a design flow of 10,000 I 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 w and copies.sent to the buyer, if applicable and the approving authority. INSPECTION SUMAIARYs 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 below. 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. Indicate yes,nor,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,cracked, structurally unsound, shows substantial infiltration or exfiltration,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): I , Illy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART A . CERTIFICATION(continued) ' 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 Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTHi 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 P 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 A MANNER THAT PROTECT THE PUBLIC.'HEALTH AND SAFETY AND THE ,ENVIRONMENT: The system has;a septic tank.and soil absorption system and'is'w in.100 Feet to a surface water supply or tributary to,aysurface water supply. The system has a septic tank and soil absorption system Aid is witl of 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. 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 and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. k 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 Idontillod below. Thq Board of Iloalth 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 or clogged SAS or cesspool. - Static liquid level in the distribution box above outlet,invert due to an overloaded or clog- ged SAS or cesspool, ..Liquid depth in cesspool isless than 6".below invert or available volume is less than 1/2 . day'flow. :. '. r equired pumping more,than 4 times in the,last year NOT due to clogged or obstructed pipe(s). Number of times pumped ` -2- I - .'r °r�v.. 1�.•, a .'3 ,.k. � r. '...,.,i:? 1 ;F' i . i, ,�.... ,:"c 1,. 7C.;', ^3 . SUBSURFACE SEWAGE DISPOSAL.SYS'CEM INSPECTION FORM 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 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 cr 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: 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 a significant safety and the environment because one or more of the following threat to public,health and { conditions exist:. . The system�is,within 400 Feet of a surface drinking water supply The system is within'200Feet of a tributary to.a'surface drinking water supply- .., The system is located in a nitrogen sensitive area Interim Wellhead ProtecUontArea (IWPA)or a mapped Zone II of a public water supply well The owner or operator of any such system'shall lung the system and fac�i�ty 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: JeffPumping information was requested of the owner,occupant,and Board of Health. _1GNone of the system components have been pumped for atleast two weeks 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. he facility or dwelling was inspected for signs of sewage back-up. �As-built plans have been obtained and examined. Note if they are not available with N/A. _ T /The system does not receive non-sanitary or industrial waste flow. p, ✓The site was inspected for signs of breakout ' t/All system components,excluding the Soil Absorption System, have'been located.on site. JLThe septic tank manholes were uncovered,opened,and the interior'of the'septic tank was in- s ed for condition of>iaflles or tees,ma`terial'of construction;dimensions„depth of liquid, de th of sled e,de th of scum. The stie and location of the Soil Absorption System on the site has been`determined based on existing information or approximated by non-intrusive methods. -3- r ' L E .��>y.N:, ` SEWAGE DISPOSAL`SYSTIN INSPECTION FORM PART B CIIECKLIST(continued) `- i different from owner were provided with information on The facility owner(and occupants, f d e ) the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION. , FLOW CONDITIONS RESIR NTIAL: Design Flow: .R,3 / Gallons Number of Bedrooms:. Number of Current Residents: Garbage Grinder IJ6 Laundry Connected To System:(/,26_ Seasonal Use: ,fin Water Meter Readings,ifMailable- Last Date of Occupancy: (,lih - Ai>,2r 12_0.n o4&j"e a COMM .RCLAIJIND UST IAI Type of Establishment: Design Flow: stallonstday' 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) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 'j n n System Pumped as part of inspection: A)() If yes,volume pumped: gallons Reason for pumping: _ _ TYPE OF SYSTEM: _LL-5eptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): ROXIMATE AGE of all components,date installed(if known)and source of.information; Sew ge odors detected when arriving of the site:' 4 _ �_..___.._._._. . ..._.... ._ r SUBSURFACE SEWAGE.DISPOSAL SYSTEM,.INSPECTION FORM r ,x. F 'PART`C GENERAL INFORMATION (continued) SEPTIC TANK: ✓ - Depth below grade: R ,, Material of Constnuction: concrete ` . metal FRP Other (explain) Dittusions: 'X „ '1C �' Sludge Dept}: Scum Thickness:,fj" Distance from top of sludge to bottom of outlet tee or baffle: ,y"P Distance from bottom of scum to bottom of outlet tee or baffle: 7 f Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in 74ation t outlet invert, structural integrit evidence of leakage,etc. , GREASE TRAP: Depth Below Grade: lvfaterial of Construction concrete � metal ' FRP ` Other (explain) -- —> — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet'a`nd outlet tees or batffes depth of liquid,- levetin relation-to outlet-invert stnuctural integn evidence of 1cakage,etc_) b_ x TIGHT OR HOLDING TANK: . Depth Below Grade: `Y Material of Construction. _"concrete__nelal FRP_Other(explain) Dimensions: Capacity: gallons. Design Flo«: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evi nce of solids carryover, evidence of leakage into or out of box,etc.) M PUMP-CHAMBER•, Pump is to working order: -x .,. Zvi Comments (note condition of pump chamber condition of pumps and appurtenances, etc) , .. ,t xw a, t d S ,iRt � , —SUBSURFACE SEWAGE•DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):__/ (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number:_L Leaching chambers, number: Leaching gaileries,number: Leaching trenches, number,'length: Leaching fields, number,dimensions: Overflow cesspool,.number: Comm ts: (note condition of soil,signs of hydraulic failure evel of poll ing,condition of vegetation, . etc.) / CESSPOOLS: ) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool- Ma terials of construction: Indication of groundwater: Inflow(cesspool,must W pumped as part of inspection) .Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:_'&)_b Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil-signs of hydraulic failure, level of ponding,condition of vegetation, etc.) e s —6 - ;a r , SUBSURFACE SEWAGE DISPOS'AL'SYS'IEMXINSPECTION FORM PART C SYSTEM INFORMA LION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: a Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. . r LP r _ v 4 d a s DEPTH TO GROUNDWATER: U Depth to groundwater._ 6 Feet Method of Determination or Ap roxi ation: .� .Yir.'yi° /per. < r° k„ t COMMONWEALTH OF MASSACHUSETTS ID z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL.PRO.TECTION TITLE 5 OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. RC"�. ::�.. .;. ,Ad -- Owner's Name: t, 4. Owner's Address: APR P d 2001 A U CH 5' TOvv�OF BAf1N 'TABLE Date of Inspection: UI HEALTH DEPT. Name of Inspect r: please print) 4 4t' Company Name. Mailing Address:. 'ix 17 IV Telephone Number: `7,z/—!9-3 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,.accurate and.complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on,site sewage disposal systems. I am a DEP approved system inspector pursuant,too Section 15.340 of Title 5(310 CMR 15.00.0). The system: V Passes { Conditionally Passes . eds.Further Evaluation by the Local Approving Authority. ails Inspector's Signatures 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 10,00.0 gpd or greater,the inspector and the system owner shall submit the report.to the appropriate regional office of the. DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions.of use at that time.This inspection does not address how the system will.perform in the future under the same or.different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A CERTIFICATION (continued) Property Addressi CValke Owner. Date of Inspec ion: y&7/e) Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. jystem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or,in 3.10 CMR 15.304 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"section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y;N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over20 years old* or.the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration orexfiitration or tank failure is imminent. System will pass inspection if the existing tank.is replaced with a complying septic tank as'approved by the Board of Health. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if(with . approval of Board of Health): broken pipe(s.)are.replaced obstruction is removed distribution box is_leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of l'l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: X Owner. ///Q t Date of Inspection.: U/ o 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 systems not funcfioning'in'a' mannerwh c`wwill`protect puoi c.heaitii .safety and the environment: Cesspool or privy is within 50.feet of.a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines.that the, system is.functioning in a manner that protects the public health;safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet.of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS.and the SAS is within 50 feet of a private.water'supply well. _ The system has-a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a private water supply well".Method used to determine.distance. "This system passes if the well water analysis.,performed at a DEP certified laboratory;for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and. the presence of ammonia nitrogen and nitrate nitrogen is equal to or less'than 5 ppm,provided that'no other failure criteria are triggered.A,copy of the analysis must be attached to this form. _ 3. Other.: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS "SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFhCATION(continued) Property Address: O�7AIJzMa4/ 1 �,/a-t- Owner: Date of Inspection: &2 1,0 z D. System Failure Criteria applicable to all systems: You.must indicate"yes"or"no"to each of the-folio"wing for all inspections: Yes N _ Backup of sewage,into facility or"system component due to overloaded or.clogged'SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or / clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded orclogged SAS or j cesspool Liquid depth in cesspool is less than 6".below invert or available volume is less than '/z day flow U Required,pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number I 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 waters.4ply. 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 SO.feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is freefrom 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.] (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 if] ow 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 iswithin 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 ' I , Page 5 of 11. OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property.Address: 7169 Owner: . 'Date of Inspect►on:, 9/7/D� Check if the following have been done. You must indicate."yes".or"no"as to each of the following: Yes No Pumping mformauon.was provided by the owner,occupant,or Board,_of Health. fWere.any of the system components pumped.out in the previous two weeks? . Has the system received normal flows in the previous two week period? v Have large.volumes of water been introduced to.the system recently or as.part of this inspection? Were as built plans of the system obtained and examined?(If they.were not available note.-as N/A) Was the facility or dwelling inspected for signs of sewage backup Was the site inspected for signs of breakout? V__*�_ Were all system components,excluding the`SAS, loeated'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 bf.construction, dimensions,depth.of liquid,depth.of sludge and depth:of scum? V — 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 . 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 . . Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE°DISPOSALSYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:goy-0_T Z Z L ,� U_P(� + f Owner:. _ 'Date of Inspe-tion: 9�/ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)::. Number of bedrooms(actual): .. DESIGN"flow based on 310 CMR 15.203 (for example. 11:0 gpd z#of bedrooms):-3 Number of current residents: Does residence have a garbage grinder(yes or no)�" Is laundry on a separate sewage system(yes or no)�Z►-[ifyes' separate inspection required] Laundry system inspected(yes or no)�j— Seasonal use: (yes or no): '� . Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no) ' Last date of occupancy:&&1ZAtd- e�/'e,f COMMERCIALANDUSTRIAL/ Type of establishment Desigri flow.(based on.310 CMR 15.203): gpd Basis of design-flow(seats/persons/sgft,etc:): Grease trap present(yes or no):_ Industrial waste holding tank present.(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: /Q Was system pumped as.part of the inspection(yes or no): If yes,volume pumped: gallons--How was quan ty pumped determined? Reason'for pumping: •-- = - TYKE OF SYSTEM_ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared.system:(yes or no)(if yes;attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach'a copy of the DEP approval .Other(describe): Approximate age of all-components,date installed(if known)and source of information:. U Were sewage odors,detected when arriving at the site(yes or no):�� Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C ; SYSTEM INFORMATION(continued) Property Address: f Owner: L \' Date of Inspec ion: BUILDING SEWER(locate on site plan) _ Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain):- Distance from private water supply well or suction line: Comments(on condition ofjoints;venting,evidence of leakage;etc..) :f - , - K :.r SEPTIC.TANK: ✓(locate on site plan) Depth below grade: f �o 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: a.s �X b`X s Sludge depth: 3• 7 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: /3. How were dimensions determined: Comments(on pumping recommen tions, inlet and outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert,evidence of leakage,etc.): ��V vim• /f GREASE TRAP r ocate on.site plan). Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Paee 8 of 71 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) Property Address: a,iX_. &V)Le- Owner• f Date of Inspection* //-7 IQ / TIGHT or HOLDING TANK;/X'"'(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: J 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level anddistribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): e PUMP CHAMBE,,I'(locate on site plan) Pumps.in.workin?order.(yes or no): Alarms in working order(yes or no):.-=.. Comments(note condition of pump chamber,condition of pumps and appurtenances,'etc,): 8 i Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM`INFORMATION(continued) Property Address T t�. Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):. (locate on site plan,excavation not required) If SAS not located explain why: Type aching.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, CESSPO.OLSr (cesspool must be.pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of Hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE bISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMV INFORMATION(continued) Property Address: Owner: , Date of Inspection: /h/ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal systemlincluding ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where.public water supply enters the building. I P' a� O 10 Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection:S/�:;Zz f SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated_depth to ground water feet Please indicate(check).all methods used to determine the high ground water elevation: Obtained from system design plans on record.-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach.documentation) Accessed USGS database-explain: You must describe how.you established the high ground water elevation- on ell Il {S L�D e-7 LOCATION SEWAGE PERMIT N0. , 7- f3 TRVrYati �A,6t - VILLAGE Gv�v�t INSTA LLER'S . NAME & ADDRESS OA.L tv7- B UILDE R OR OWNER LQvrs SeM/IIARA DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 7 2y 7f' f 9 , 5 � 0 s o� ,�, � b � N R W ' � ,.. �� No...........�_ ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1.0-W.,N-------..........OF...... ........................... Appfiratiou for Ui_qposal Works Tonsttrurtiou Vatnit Application is hereby made for a Permit to Construct (/� or Repair an Individual Sewage Disposal System at: .TAQ1W.fi_Pj.....L.A)A.........C.Q.-r4l.1.7.................. ........... ..........43.................................................... alion-Ad�ress or Now, .7........C,_-VA..A........... Ownk Address C_41Z,110. . . ........ ... ...... ---------"-----­-------- OL-Alff—A..... ...... in"s'tal'I'e'r Address Type of Building Size Lot.2/,8.5.0.....Sq. feet U Dwelling— No. of Bedrooms............�3.............................Expansion Attic (NO) Garbage Grinder (WO) PL4 Other—Type of Building .-A)I.A.............. No. of persons.....__..._..._............. Showers Cafeteria Other fixtures ------------------------------------ &MA6,R----------------------------------------------------------------------*---------------------- Design Flow........./,/.0........................gallons per day. Total daily flow-----------3_3.42..................g-a.1lons. 1:4 Septic Tank—Liquid capacity/PPP.gallons Length&_'&'.. Width.,e/-."/­­0`­'.- Diameter-----------------DepthA�._&.,". Disposal Trench—No..................... Width...................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No........... ./-------- iameter....(3.. ...... Depth below inlet....'.6........... Total leaching area.,2..Q.q..sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by..-R0fjA.t_2>....A!..!�Flte,,C:roan---ft.,S, Date...TV E...R2,,ADS Test Pit No. L.G.'-_minutes per inch Depth of Test Pit---Ix..I....... Depth to ground water........................ (To Test Pit No. 2...4.;rn..minutes per inch Depth of Test Pit..�a........... Depth to ground water........................ P4 ............................................................................................................................................................. 0 Description of Soil.......0. V Z.OA.At..A J_V.,D........S.U.&-sa/I ..................................................................... Nje.0.1VW-------5A-#V.,b........................................................................................ U ------------**--------- ...51,41LAX-------510/4.--------C-0-M-111.72DA).S........./Al--------ZJ-PrH---------re_S�.........Y�/�,drs............................ 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 TLITH' 5 of the State Sanitary Code—The under i ed further agrees not to place the system in operation until a Certificate of Compliance has been issu y the of health. gned... . .................... ................................ Date ApplicationApproved By............. .. . .... . ............ . .. . . . ..... ...e.*.. .............. ... ...................... Date Application Disapproved for the following reasons:.............................................................................................................. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued......................z...... .................... Date F No...../-- (' ! Es.......2`..-- THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH -..................OF...... -- - i _. ........................... Appliration for Dhipoiittl Works Tnnutrnrtiun ramit Application is hereby made for a Permit to Construct (1') or Repair ( ) an Individual Sewage Disposal System at: 3'.....L61t......._t� --•-------------- -----------4-0:- ...._...4 .................................................... ° L tion-Ad ress ,pr Lo o. ti ........................... •----•--•-- -•-• •- ....-..... Owner Add Zess a � v •..............................•--•-••----•-_.... art. r��Yt ._.. - ....lJc?-�. ........ Installer Address Type of Building Size Lot_2,ti _50.....Sq. feet U Dwelling—No. of Bedrooms........... ..........................Expansion Attic ( �) Garbage Grinder (14p) per-, Other—Type of Building ..P)I A............. .No. of persons................_........... Showers ( ) — Cafeteria ( ) a Other fixtures ----------------------------------- W Design Flow........./ 0........................gallons per per-pan per day. Total daily flow.......... . ._42..................gallons. WSeptic Tank—Liquid capacity��'dp-gallons Length<9.._6.---.. WidthAJ.:�A---.. Diameter................ Depth_w._ ..... Disposal Trench—No.......... ......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------------ Diameter....c _--------- Depth below inlet.....( ............ Total leaching area.,Z.0-_sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by.._l�i ?A�1 _ .._./ .�... f �' �.. .__ �.s� Date...;ZV-6J.6..- ,4 Test Pit No. 1-.4.Z-...minutes per inch Depth of Test Pit---,lrt..I....... Depth to ground water........................ Test Pit No. 2....'r 4--minutes per inch Depth of Test Pit.-IX.-*....... Depth to ground water........................ ---••----- :-•;..----------------------••---••-•••••-----•-----•--••--•------._.....••-•-•_---•--------------•------•-•••....-..............._............ O Description of Soil------_Q_.-.2•I ------- -Sly l --------------------------•-------•-------------•----•--......------ w 1 - -------Sots••-•••-•.C-0-A__DI ot.&AI......---� ► r ''" �$�------ �� 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 iIT',^ 5 of the State Sanitary Code—The'undersig d further agrees not to place the system in operation until a Certificate of Compliance has been'issue the bo of health. ... .._---•-----------•----_-__-- ...� � >gne D Application Approved BY if-- ----------- Date Application Disapproved for the following reasons:................................................................................................................ ..--•---•---....-----•-----...---•................••---------•-----------------------------••---------•-----------..---•-----------------------------------------------------------------------......_.- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OJFq� HEALTH i . C�rr#i�irtttr oaf fP�vrnt�li�nrr � THIS I "'TO CERTIFY,, That the Individual Sewage Disposal System constructed ( ) or Repaired by r•-_--�._._.._ ,�• --______ .. ..-. C i / Instal s/ G�J, f Lam_ at • • .......--- - =ram n = i L ff .1r r �, T .,�, haseel i/risf �le`fl lsl a�c'c'6rncewvith the isions of TIm� j of The State Sanitary ode as described in the application for Disposal Works Construction Permit ................. dated__jr7:_. '__1 -_:__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............:....................................................•'..•••..._.. Inspector......................................... .......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...0 l ...._.. No.'.-` !-` _ 'h.... FEE.. ' no ion panfit Permission is hereby ranted.......... ... r..» to Construct fial or Repair ) an In I al S wa'ge Disp tem atNo..' -7 -k e --------- • - . ..... ....... ---s r----------------•----------------°------------.....'....... as shown on the application for Disposal Works Construction Permit N . ............. . teed�.,_,....�'��.�y� it...... ea DATE. "Z� y ' '.....................•-------------- FORMn 1255 HOBBS & WARREN, INC.. PUBLISHERS ' _r' , - r - I. . � .,: , N', , .4 , � � � ' ' , - - � :. ,.i 1. . � I -1:-T-1 , --liz, h - '.- � I -,l. t- , ;-- I I ­� , -- I- "", , 1�7 - , 0� 58.�i. .- 1. -- I .1 . I -,,,,,,-- - f� -�-E,` . 1. . .­ I - I -­- ,4. 1, 1 . -l". I ;,,,;� ;.- . . w . 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