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HomeMy WebLinkAbout0126 HINCKLEY CIRCLE - Health 126 HINCKLEY CIRCLE, OSTERVILLE A= ° e I o ° a COMMONWEALTH OF MASSACHUSETTS t EXECUTIVE OFF ICE OF ENVIRONMENTAL AFFAIRS DERl�R:TMENT bF 10NfMRONME�ITAL PROTECTION . - . TITLE 5 OFFICIAL,INSP•ECTION•FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE WSP!:OSAL SYSTEM)FORM PART A -CERTIFICATION Property Address: Wt `0— l A Owner's Name. Owner's Addr �� R � Cg FC Date of Inspection: �(.t Name of Inspect r• please p iut) r°�c �® 1 APR E ' Cvmpttny.Name: 7 n dfo,_, �C rOw . '2 �!f ?oO Mailing Address: • X e NOF Telephone Number. '• '� '� : ' . L a CERTIFICATION,STATE NT 1 cttt6 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 tithe of the inspection.The inspection was performed based on my training and experience in tho proper futiction'and maintenance of on site sewage disposal systems.J.am a DEP approved system.itispector pursuant to .ecidon 15.3a0 of Title 5(310 CMR 15.000). The system: Passes _ Conditionally Passes ds F er Evaluation by the Local Approving Authority ooll Inspector'sSiguafiure Date: The system inspector shall'submit a copy of this inspection reliort to the Approving Authority(Board of Health or D5P)within 30 days ofcorppleting this inspection.If the system is a shared system or has.a design flow-of 10,000 god or greater,the inspector acid the systemwn oer shall submit the report to the appropriate regional office of the DEP,The original should be scut to file system'owner aud'copies sent to the buyer, if applicable,and the'approving • authority. ' Notes and Comments ****This report only describes..conditioul at the time of inspection and.'under the conditions of use at that time.This inspectlort does not ad4ress•1(6(the systeto will perforin in the future under the saute or different conditions Ouse. Title 5 tnsnenrmn Rn"N Alt annnn la e2of1 .UFFIGIAL INSPECTION FORM NOT FOR VOL UIYT ,RY ASSESSMENTS SUBS'Uitx'ACr�.SEWAGE'DIS0dSAL.SYSTEM INSPECTION VORv . :PART',. CERTITICATION(continued) Property Address: • Owner!: Date or spection: ��lam✓ Inspection Summary: Check: A,B,C,I)nr E 1,?, �Y5.rratnplete all of section D A., ,Systems asses: 1 have not found any information.-Which indicates that�any of the failure criteria described' 15.303�or in 310 CMR•15.304 exist.Any'failure criteria not6aluated'areindicated below, m 310 CMR. Gomm�nts:,�• • B. System Conditionally Passes: ' One or more syscefrt cofrtponents as.described in the"Conditional Pass".section need to be replaced or •repaired.The systegt,itptin-completion of the replacement or'repgir,as approved by the Board of Health,will pass. Answeryes,no or ttot.detcrTttined'(y,Irl,btp)in.the for the following statemerim If"not determined"please explain.; _the septic tank is-•nietal and over.20.years old:"or the-septic tank(whetter metal oe not)is structurally unsound,exhibits substeAtiai inftltration:pt•eYfiltration or tank•failure is imminent,System will pass inspection if the existing.tarik is roplaced:witb a complyin ;septic tank as apptoved:by the Board of health. "A metal•septic tank will pass;inspection;if.it is structurally s611nd,'not'16akigg and if a Certificate of Compliance indicating that the.tank is.less than 20:yedrs old is available. Nl)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•brokan;settlad'ofuneven distribution box.System will pass,ir:'spection if(with approval of Board-of Health): _,,,_broken pipe(s)are topinced obstr►tet an'is retltpved. disiribitton boX.is leveled-or eeplaced ND 6xp1alm. I'lte system•regv'1md•pumping Mora thany 4'tiines a year due to broken-or obstructed pipe(s).The system will pass'inspection if(whit approval,of the Board of Health): broken pipe(i)are replaced ' obst mctioit is i6moved ND explain: Page 3 of I 1 0FFICIAL INSPECTION FORM NOT FOR VOLUNTARY.ASSESSMENTS r SUB5URI�ACE'SEV�ACE AI > SPOSA.E SYSTEM INSPECT F0121vI PART A CERTIFICATION(continued) fj Property Address: Owner: Date off pection: C. hurther Evaluation is Required by the hoard of Health; w Conditions exist which require further evaluation by the 13oard of Health in order to determine if the`systcm is failing to protect public health,safety or the eavironinent. 1.. System-will pass unless hoard of Health determiues,iu accordance with*310 CMR 15.303(l)(b)that the systeIn is not functioning in a manner whleh will protest public health,safety and the environment: Cesspool or privy is within-50 feet of a surface water Cesspool-or privy is within-SO feet of a bvrderittg vegetated wetland or a salt marsh I. System will fall unless the Doard of Health(iud Public Water Supplier,l[any)determines that the system is functioning in a ntantter that protects the public health,safety and environment: _ The system has a septic tank and soil absorption systeny.(SAS).and the$AS ii within 100 feet of a -> surface water supply or tributary to a surface water supply. ,The systein has a septic tank,and'SAS and thc,SAS.js within Zone l of a:public water supply. The system has a septie-tank and SAS And the,SAS.is within 50 feet of:a private water supply well. The system has a septic•table attd SAS and•Ute SAS is less tltao;100 feet but 50 feet or more from a. private water supply.well«*.Meihod use :to dete[iim'e distance **This system passes if the well water,analysis,perforated 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 presetice of antnionia nitrogen and nitrate nitrogen is equal to or less than.5 ppm,provided that no other, failure critdr'hk;t-e triggered,A copy of the analysis tntist be.attached;to this form'. ' 3. Other: r :<�,o.,...,.�.v�.,...s.,w,t.,�u.,_��„<,.�.-.,�,al "�:.,.�����a�,�<.•.,.m..�.�...__.._..�--__..__�.,w.,a�...�m,n�».�,,,�..w._:.,,._..,....�_._ .,,.w. .� .<.�,��, .._____._.�..�,��r..�,�.,ma_-- Page A of I'I UIT><CIAL INSPECTION' IORM w 1VC1T I��DII;'VOLU7VTAI2'Y ASSESSIVIENTS S'LIBSURFACE SrWAGE ISPOSA7, SYS'Tl,1VI INSPECTION FORM PA•RT'A CERTIFICATION(continued) Property Address: . / 4 • � . ', obi ' F � . Owilcr. ✓y✓,P�C t Date of pectipn: v� • D. 'S t ; . • ys eai Failure Critoria.0 livable to all systems;l You n,,,iust indicate yes,or no. toeach'ofthe folowing f6r at inspections; • /t 1! It 91• Yes No/ 1// ackup of sewage into•facility or system toniponent due.to overloaded or clogged SAS orcesspool Discharge br.ponding of etl]uetit t4'the•surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool'. ;.. Static liquid ievel in the distributi' bax.above otitlet iilvert'due to an overloaded or clogged SAS or cesspool (quid depth in cesspool is less than 6"below invert or available•volume is less than'/2 day flow " Rcquued pumping more titan 4'times.in the last year NQT_due to clogged or obstructed i e s .Number of tittles pumped P p ) Any gortioti of-the SAS,'cesspool or privy is below high grouted water elevation. A Y p0tz106 of cesspool OF privy is within 100 feet of a•surface.water supply or tributary to a surface water;supply. ..Y�Y Portion ofa cesspool or privy is within a Zone 1'df a public well. Y PottiOn elf a cesspool or privy is•within 50 feet of a private water supply well. Any portion of a cesspobGor privy is less than 100 feerbut greater than•50 feet from a private water supply well with no accopt66 water quality analysis. [This'systetn passes if the well water analysis, performiod'at a Dili certified laboratory,for coliform bacteria and volatile'**rganic compounds indicates that the well.is free fr4ttt pollution.froin that facility and the-ptesence of ammonia nitrogen and nitrate nitrogen is equal to or less than.$ppm,provided that no other failure criteria are triggered.A copy of the agslysismust he attechcd•to this-form.) '(YcsMQ)The sysfc>Yr ells:J have determined-that one or more of the above failure criteria exist as deacril2od in 310 C1viR 15:303;iWefore the'system fails.The system ownef should.contact the Board of Health to determin6 what will be necessary to correct-the failure. •:,•CI �.argcSysteins; .' .. �. Ube eonslderod° 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'trio"to each of the following: (The following e[iteria'apply tit largo systetns'in addition to the criteria above) Yes no the system is withinn 400 feetof a stirface drinking water supply the syseeiit'is within 200 feet.Ora tributary.too surface drinking water supply the system is located in a nitrogen sensitive ayes(Iriteritn'We'llhead Protection Area--1WPA)or a mapped Zone II of a public water supply,'welf. If you have answered"yes"to'any-question;in on E life system is eonsidercd a significant threat,or answered des in Section D.ttbove•tbelarge.systeai has failed."C1ie.owner or.•operator.of a:riy large system considered a .Significant threat under Section E or failed under Seatiop D.shall upgtade the system in accordance with 310 CMR 15:304.The system•owner should cohmet'thc appropriate regional o ftice of the Department. Pale 5 of 1.1 OFI+ICIAJL INSPECTION, ,OItM--NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART D cIIIC><cLrT Property Address: ' ... _' q Owner. f=1. Date o I pectionc / Check ifthC.fQ_110win have been done..you must indicate' • es".or" h of as to each f the followin No ' Yes • . - � Pumping information was provided by the owner,occupant,or-Board of Health . Were'ahy of the system components pumped out in die previous two weeks ✓^___ Has the system recciyed normal flows hi the previous two week period? : Have large volumes of Water been introduced to'the system recently or as part ofthis inspection? t1 Were as built plans•.of the system obtained and examined?(If they were not available note as NIA) .tG Was the facility or dwelling inspected for sighs of sewaa oe back up J� Was the site inspected for sins of break out? Were ail-system components,.excluding the SAS,located an Site? —UI- L 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,dimetisions,depth 9 liquid,depth.of sludge and depth of scum? Was the facility owner(and-occupants if diffe m tnce of subsurface rent from'owner)provided witlr.infotmation on the proper ainena sewage disposal systems?:: ;:._ The s[ a and locatl0q pf the Soil Absocptlon Systen►(SAS)on the site has been dcterntined based on: Yes no p Existiaig infonttation:l^or example,a plan at the Board of Health. Detergiined in the field(if any..of the failure Criteria related to Fart Cis at issue approximation of distance is unacceptable)(�10 CNiT 1 ,30 (3)(b)] J. _ 4 ' .. • � . ♦ • P -pit,. .i - 1 Page 6 of 1 1 OFFICIAL I NSpECTION FORM, NOT FO R VOLUNTARY S t� .SIESSMIJNTS SUBSURFACE SEWAGE DISPOSAL S- ST _+ x. EM 1NSPLCTIQN 0 • I". It.M PART' SYSTEM INFORMATION- Property Address: Owner: Date of b ectioh: � v/ RESWENTIAL.' 1� FLOW CONDITIONS Number of Wroorirs(design):„a Nunrl,er of pxm for bedrooms(actual): DESIGN flow based on 3 I Q'CMR 15:203 •( rrple: 110 gpd x#of bedrooms): Number of current=residents:. Ddes�tesidence have a garbage grinder(yes or tro);IW Is laupdry on a•separate sewage system(yes Laundry system inspected(yes.or no or yes separate inspection required) . ' Seasonal-use:(ygs or nq):;�)_ :):�y0 Water meter readings,if available(last 2 years usage(gpd))r . Sump,pump(yes or noJela— Last date of occupancy: tJ Yew ltmullev:✓�L lr � /�(/�, .�a.�'n COMMERCIAUJNDUS'}"R[AL Type of establishment; : .. Design flow(based'on 3 l0 CMR 15.203): apd. Basis of design flow(seats/persons/sgft sto.); Grease trap prosenf(y6 w no): Industrial waste holdingaank present(yes or no): ..Non-sanitary waste dischargedAQ the Title 5 system.(yes or no): Water meter readings,if-available.' Last date of occupancy/use: - - OTHER(describe): GE NETtAL INFORMATION Pumpitig Records. Source of information. �qyi_4111 0/34 Was system pumped as pan of the inspection(yes or no) If yes,volume pumped: —gallons How was quantity pumped determined? Reason for pumping TYPE OF SYSTEM' Septic tank,distribution box,soil absorption system.. Single cesspool O.vcrflow cesspool' .�.Privy Shared system(yes or 60)(ifyes,attach.previous inspection records,if an _Inriovative/Alte�tive teclutQlo$y.Attach a copy of the Current operation and maintenance contract(to be obtained from system'owne.0 T lit tank A tt a copy o f the pE>�approval Z_Other(describe). � -' A roxi Hate _ age of-all aom on at .pp g p ants,d o installed(if known)ar�d source.af information. C U S • • Were sewage odors detected when arriving it site-(yps or pp):. . r• Page 7 of111 'OT FICIAL,INSPECTION.FORM NOT-FOR VOLUNTARY ASSESSMENTS SUBSUIWA.CE SEMAGb,DISPOSAL SYSTEM INSPEMON FORM 'PART C SXS`I'EM ZNT'OIIlV1A't'ION(continued) • Property Address: .' Owner; Aare of ectioa:': ©/ 'BUILDING SEWEI<t•(loeate.onsiteplan) Depth below grade: Materiais of cottstructian:ast iron r_40;PVC odki(exlilain) R r D[stanci from private water supply weltot suction.line: •Co►nmepts(on condition of joitit% renting,,evidence of leakage,etc.): SEPTIC TA,NKj Iocate on site plan,) Depth below grade; • . Material!ofconstruetion: concrete jheta[ fiberglass polyethylene othec(explain) If tank is metal list age;: is•age c6hr=ed by'a Certificate of'Compliance(yes or'no); (attach a copy of ccttific8te) .. • . �' Dimensions - Sludge depth. ' Distance from top•o f sIW6 t0oitpm ctf.otitlet tee or.baffle: Scum thickness: ,Distance;from top of scrim to-top of outlet tee or baffle: 'DiMance-.from bottbiri.of scum to-bdttom:of outlet tee or baffle: How were.dimensions dgtermined: Cptnmerits(on pumping-mcomwi datil n,;:.Wq and outlet tee or baff]e condition,structural'integrity.Liquid levels as rotated to outlet invcit,.evidcpce of leaiCage,'etc.): , GREASE TMTA�Iocate on site Depth below grade: Material of construction:—concrete jnetal__:fibetgtass'___,polyetiiyleno— other (explain) • Dimensions: ' •• • Scum thickness: Dlstanac ffom top of south to'top 'of'outlet tee or baffle: Distance#nt bottom o'k6uz t6•bottom'of outlet tee or ,17AftIe:'.. Dato of last pumping: Comments(on putriping cecpntntendatiotio;,inlet and outletw or•baifla Fondition,structural intc f{ity,liquid levels ors related Yo outlet it vett,evldenee.of leak M etc,); Page8 of 11 OFFICIAL INSPECTION FORM—NOT F'Ofi VOLUNTARY ASSESSMENTS SUBSURTACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TART C -SYSTEM INFORMATION(continued) Property Address; Owner: , Date of eCf10n:.. TIGHT or HOLDING TAN i6: —(tank must be pumped attune of inspection)(locate on site plan); Depth below grade: Material of constriicdon'^concrete—metal- fiberglass,_polyethylene other(explain): Dimensions: Capacity Rallbns . Design flow,. ' $tlons/day Alarin present(yes.or no): Alarm level: Alarm iri working order(yes or no).: Date of last pumping: Conunents(condition of alaim and fldat switches,etc.): DISTRIUT-10N.BOX: )(if present must bo'oporied)(locate on site plan) Depth of liquid level above-oudei t invert: Comments(note if box is-level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP OHANUti : oc$te 01i site plan) !Pumps in working eider(yes or tio): Alarms in working order(yes or tio):_ Conunents(note conditions of pump chamber,condition of pumps and appur(enances,etc.): pcge 9 of l 1 OFF IOIAL INSPECTION.FORM--NOT, 0R-VOLUNTARY ASSESSIV>;I NTS SU9SURF A;CC SEWAGE DISPOSAL SYSTEM INSPECTION.FORM. PART C 'SYSTE M INFORMATION.(continued) Property Address; ' Owner: Date of ection, +/ SOIL ABSORPT16N SYSTEM(SAS); locate owsite plan,excavation,not required) If SAS not located explain why: . Type �eachint;Pits;nurta6er;,,,� •• •.. leaching chambers,number:' _ leaching galleries,number: ~_leaching treal}es;number,hngth: T_ leaching 40ds,number;dimensions: overflow cesspool,•number. •. 4movat1ve1altel•nati,a systm' •Typgoomd of technology:' Comments(note condition of soil,signs of'hydraulic failurc,level of ponding,damp soil,condition of vegetation, tESSPOOLS:Z(t;tsspool tttt stbe pumped as part of ihspection)(locate on site plan) Number.and•configurationr 1— Depth—tqp of iiquid:to.inler•invert-------' Depth of solids:luyef: Depth of scam layer.. . Dimensions of cesspool: �— Matedals of construction; Indication of grountivirafer.igflow(yes or no): ' )• ..{. ottuttcttts(note coitdlkion of sett,si•its of llydrau is failur evel of ponding,••condition f gctatioi ctcPr';• ;Havy (locate on site plan) Matctiaal$''of construction:' Ditneasions: •' ' Depth of solids: Comments(note condition of soil.signs of.hydraulic failure,level of pgtiding,condition of vegetation,ctc.); Page 10 oft) ' OFFIC)CAL INSI ECTIO.N FORM-NOT FOR VOLUNTARVASSESSMENTS SUBSURF.ACI SEWAGE DISPOSAL,SYST'I;M INSkECTION FORM PART C SYSTEM INFOR1V ATIQN(continued) Property Address: Owner: hH'LC of 1t ectiant C y[yl l C n k) SKETCH OF SEWAGE DISPOSAL-SYSTEM' Provide a sketch of the sewage disposal system ineltidipg ties to at(east two permanent refcreoce landmarks or benchinarks.Locate all wells within 1,00 feet.Locate where public water supply enters the building. • Parr. I I of 11 '. OFFICIAL.INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'PART.I: .. SYSTEM INFORMATION(cootinuctl) Property Address: Owner. SITE,EXAM Slope Surface water Check cellar Shallow wells 4 Estimated depth to ground water 7 feet Please indicate(check)all"methods used to detennine the high ground water elevation: Obtained from system design plans On record-If checked,date of design plan reviewed: Observed site'(abutting prppertylobservation holc w thia 150 feet of SAS) Checked with local Board of.Hcalth-explaitt: Checked with local excavators,installers-(attach documentation) V Accessed USES daiabase-explain: You must describe how-yau.established the high ground water elevation: /? 7 SUBSURFACE SEWAGE D=SPOSAL SYSTEM XNBPECTION FORM Address of property Owner's name 1 Date of Inspection -- 3 - PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. V-None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water p g r have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not -available with N/A. The facilityor dwelling was inspected for signs of sewage back-up. 9 P 9 g P he site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the -- site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. P 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B SYSTEM INFORMATION FLOW CONDITIONS If residential _ number of bedrooms number of current residents garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If no nresidential, cal culated flow. Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: 4 v' Lr,tj System pumped as part of inspection, yes or no / if yes, volume pumped Reason for pumping: tt Type of system //y&;L,,,.gagic-tank/distribution box/soil absorption system Single cesspool 77 Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: , Sewage odors detected when arriving at the site, yes or no l ' t. 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK• (locate on site plan) depth below grade• material of construction: -"concrete metal FRP other(explain) dimensions: D O d / T S 6 sludge depth / distance from top of sludge to bottom of outlet tee or baffle scum thickness �/ distance from top of scum to top of outlet tee or baffle '<1G`` distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs., etc. ) . PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued �-- SOIL ABSORPTION SYSTEM (SAS) : 6 c� / Q (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 and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ). SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART H SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �CtY6 1 41 5 5 L,2 DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: , A �� � t IF0h OP r-. 12 1. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA `- Indicate yes, no, or not determined (Y; N, or ND) . Describe basis of Bete mination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or 'available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration. substantial exfiltration. tank failure immi nent? / Is -any portion of the SAS I,' cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within • 100 feet of a surface water supply or tributary to a surface Zter supply? thin a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh Z(Cespools and privies only, not the SAS) ? 0 feet of a rivate water su ply well? in 5 p P less than 100 feet but greater than 50 feet from a private water 1 with no acceptable water quality analysis. If the well 4L supply wel p has been analyzed to be acceptable; attach copy of well water ana ly si— for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name Company Address _5 U� _ 7 C__� �� Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Ch one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date{ Original to system owner Copies to: 06,0 Buyer (if applicable) Approving authority O LOCATION SEWAG PERMIT p0• /�2 /Si r e/s l r VILLAGE JK INSTALLER'S NACRE & ADDRESS //}/GJ'I Q.0 tL DE R OR OWNER D-A T E PERMIT ISSUED , 1a DATE C'0 M-P L I A It C E ISSUED � �� O(� ,��1� FRic..... ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.....................................­.................................................. Appliratiou for Uhiposal Works Toustrurtion ramit Application'is hereby made for a,.Pern4t to Construct or Repair an Individual Sewage Disposal System at: 4 _,A .W. . ...................... ...................... .............................................................................. Locr................... ;X.s —,/ eL 0 r..V44, e.................. ............. .................................... .......... Qvner Ad es ......................... ..............14...;90&?!t/:f........................... ..... .............. --------- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...........-1...............................Expansion Attic Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons-----------------_-------- Showers Cafeteria ( ) Other fixtures ............................................................................ -------------------------------------------------------------- ------ Design Flow............................................gallons per person per day. Total daily flow..........................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width--.............. Diameter................ Depth................ Disposal Trench—No- -------------------- Width.....---.....---.... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1­4 Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. L...............minutes per inch Depth of Test Pit.--................. Depth to ground water......------............ Test Pit No. 2................minutes per inch Depth of Test Pit----................ Depth to ground water.--------__-.--.--.---- Q+' -------------- -------- -- 0 Description of Soil . J ------------------------------- ....... ----------------------------------------*......."--------................................... � W ------------------------------------------------------------------------------------------------------------------- ---**--------------------I--------------- ........................................................................................................................................................... ..................................................................................................................... ........................P"t ✓U Nature of Repairs or Alterations—Answer when applicable-.---------- - .... 14, ....................... .................... ....................................................................................................................................................................................................... Agreement: The undersigned agrees to, install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T=112' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be *ssu by the board of health. �s* ... ?�ed......... ............... ............................................ ............................... Application Approved By 4t X", .................. . ....................................................... ........... Date Application Disapproved f the ollowing reasons:.........................................................................I....................................... ......................................................I..................................................I............................................................................................... Date PermitNo......................................................... Issued_....................................................... Date .' .,, Q..11. ........................... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................................OF................................. Appliration for UiipnaFal Works Tomitrurtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 'f Cal ,1�r sf, ................_........... .. ............. Loc n� des f�'G�7O+�//r I I♦ o ♦ "Ve oy Ail of ... ,�� ` -........-------- ------------.. ------•.............. . ---- ................ ._. / a � ner I/ �g "�af�iD(gJTAddr�� jyy`t�9ff Installer Address Type of Building Size Lot.................... .....Sq. feet U Dwelling—'No. of Bedrooms.•_..._..a..............................Ex ansion Attic p ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers a YP g ---•--•-•------•---••---•-•- P ( ) — Cafeteria ( ) Design Other fixtures ----------------g-----------P----P•---••---- ---.....- --------------•---. -------------•---------------.......-------••-•-----�....... W Flow............................................ ons er erson per day. Total dailyflow...........................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY................................_.................0....................... Date....................................... aTest Pit Ne. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+' ------------------------ --------- ODescription of Soil---------------------------••---.... J !i. ` ......------------.....--------------------------------......__............-------...._................_.. "4 / U ••----•---•---••--------•••-••-•••---••----•--•----....••••-•-••----•--•-••-•••••---•---------•-•--•••---•••••-•••-•••---•---••......-•-...._..---•-•.................................................. W r. --- ' ..................—Answer --------- ........ .................... -------••--------------------.---•--•------•----------•----•---•-•••--••------------.........--•------------...------------------------------.....------------------------------------------•--•------•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE y g g P y 5 of the State Sanitary Code—The undersigned further reel not to lace the system in operation until a Certificate of Compliance has b n 'ssu d by the board 9Lhealh. ed ........................................•-•-•------.---•• ---- -•• --------- Application Approved B ... a Date Application Disapproved f r the ollowing reasons----------------------•---------•----------------....---•----------------•------------------••--••-•-----...._._ ..-----•-•-•-----•-•--------•-•................•-•---•--•=_••........-••-------•--•...-•-------............--•-•-............----•-......-----------------------•----------------------------------•_.... Date PermitNo......................................................... Issued....................................................... Date r THE COMMONWEALTH OF MASSACHUSETTS f BOARD/ OF HEALTH .... £..................OF...6�r :r........ ....................... ...... (Intifirtttr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-----------------------------------------------------------------------------------------------------------------------------------------------.................................................... Installer at--------------------------------------------------------------------•----------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION 5ATISFACTORY. DATE............................ Inspector.... --.-.-e.............................................................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH No..!!t......... ... FEE........................ I isposal 3 nrkii Tnntrnrffou rrntit Permission is hereby granted..*p//"...1 *d.f ....................................... to Construct Re air an Individual Se gage Disposal System at No. ✓ - ................... tr � w/ as shown on the ppli tion for Disposal VC orks Construction t No........'�..:. .__. Dated..___•.�8 - """'.2�---".............. DATEV. ,/? � soara of Health j... ........................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS