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HomeMy WebLinkAbout0274 WEST WIND CIRCLE - Health 2,?4 Wes+ W—i.nd Circle .. ,,� s'terville . Is 121-011-026 r ° , s c n P ° r o,. e , F y ° ° ° TOWN OF BARNSTABLE LOCATION, P—IA VJQT lJWJd SEWAGE # VILLAGE ASSESSOR'S MAP & LOT IZ. I 2b INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) (size) (a X 5� NO.OF BEDROOMS BUILDER OR OWNER (°Q<T_fA,1 C� PEie£PDATE: l COMPLIANCE DATE: Separation Distance Between the: C Maximum Adjusted Groundwater Table ` J Feet Private Water Supply Well and Leaching Facility (If any wells exist Nl on site or within 200 feet of leaching facility) 14 Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet a� thing faf c`�ty) Furnished by �3� 3Q 63_ 53r f �9 CO`,; iON\\c,ALTH OF I`LASSACI-It"$E T T; A =- E'�,_7CL;TIVE OFFICE OF E\-VIRONMENT. F.-.IR E. d D OF ENvMONMENTAL PR CTION �VED DEPARTMENT SAY ONE RZNTER STREET. BOSTON MA 02106 (6: 2N2- 8 = � 1999 r Y CO\E 4-4 Secretan A-RGEO PAUL CELLUCCI A 3 STRUHS Governor Co:rr.: sio;ei SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM hq , LZ` PART A (10 T' CM07-6 CERTIFICATION Property Address: ��k_1 t Qz-S ,N A C\ Name of Owner t`, C\1 Gsrt�v�� , Address Owner: Sy�nm{. Date of Inspection: y 1 C1� of� / , Name of inspector:(Please Print)/ !,v c 4 CE c>G �l F�J ECrK U 1 am a DE/PPJa�p,/proved system inspector pursuant to Section 15.340 of Title 5(310 CMR I S.000) Company Name: Clir - �r? Ek r.•.'r. a a.,. a Maiirtg Address: Za fit" a L z 6:e NP_OFF /`1.*t e—Z>Ll 4,-`7 Telephone Number: 4 5'0Z_) C 6 /L,.. Lo CERTIRCATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature u Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I oru `J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �r 'pp CERTIFICATION (continued) 'roperty�Address: %KJ(;� � 'Jwner: l Date•of,lnspection: t INSPECnON,SUMMARY: Check A, B, C, or D: f•' A. SYS TEM PASSES: + I'have•not'found any information which indicates that any of the failure conditions described in 310 CIlR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" 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. Indicate yes, no, or not determined (Y. N. or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are 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 revised 9/2/98 Page 2of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continuedl Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if ttfe system is failin; to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 31.0 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water i Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. i / 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS RINCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption syste (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption sy em and the SAS is within a Zone I of a public wale!supply well. _ The system has a septic tank and soil absorptions tem and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption ystem and the SAS is less than 100 feet but 50 feet or more from a _ private water supply well, unless a well water a alysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine dist ce (approximation not valid). 3) OTHER revised 9/2 98 Page 3of11 ' � f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corttinued) property Addres : Owner: Date of Inspection: D. SYSTE.M FAILS: You must indicate eith "Yes" or "No" to each of the following: I have determi d that one or more of the following failure conditions exist as described i- 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine xhat will be necessary to corre:; the failure Yes No Backup of ewage into facility or system component due to an overloaded or cogged SAS or cesspool. Discharge or onding of effluent to the surface of the ground or surface waters zue to an overloaded or clogged SAS c: cesspool. Static liquid level the distribution box above outlet invert due to an overloadec or clogged SAS or cesspool Liquid depth in cessp of is less than 6" below invert or available volume is less :pan 1'2 day flow. Required pumping more han 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumpe Any portion of the Soil Abs ption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or pr y is within 100 feet of a surface water supply or tributary to a surface water supply. 5 Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is ithin 50 feet of a private water supply well. Any portion of a cesspool or privy is les -than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the all has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compoun s, ammonia nitrogen and nitrate nitrogen. .r E. LARGE SYSTEM FAILS: You must indicate either "Yes- or "No" to each of the following: The following criteria apply to large systems in addition to t criteria above: The system serves a facility with a design flow of 10.000 gpd r greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of t following conditions exist: Yes No the system is within 400 feet of a surface drinking water sup y the system is within 200 feet of a tributary to a surface drinking ater supply the system is located in a nitrogen sensitive area(Interim Wellhead otection Area-IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 MR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 i R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Property Address: ;27y iixs� wl�r� Owner: ` Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. 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 have not been introduced into the system.recently or as part of this inspection. X _ As built plans have been obtained and examined. Note if they are not available with N;A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)1 The facility owner land occupants,if different from owner)were provided with information on the proper=mIntanaws-of SubSurface Disposal Systems. revised 9/2/98 Page.of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART C SYSTEM INFORMATION "operty Address: ` ` Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 0 g.p.d. bedroom. Number of bedrooms design):� Number of bedrooms (actual..CTS Total DESIGN flow- Number of current residents: 1 Garbage grinder(yes or no):jbt> �w Laundry(separate system) 1 es oro.N; If yes, separate inspection required Laundry system inspected yes or no: Seasonal use (yes or no):_ Water meter readings, if available (last t�%o year's usage (gpd): j Sump Pump (yes or no):- Lest date of occupancy: C4AA_CAVJ, COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: clpd ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of infor a� tian:S tlw��� N o �.C,p System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other t APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) . revised 9/2/98 pare 6of11 r 1 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: l Material of construction: _ cast iron_&40 PVC_ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.( �C SEPTIC TANK:_ (locate on site plan) 1 Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene _otherlexplainl , If tank is metal, list age_ Is age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: o-, Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet a or baffle:_ How dimensions were determined: 'omments: (recommendation for pumping, condit'o of inlet and outlet tees or bt foes, depth of liquid level in ti n to ou et' ert, s ct� integrity, evidence of leakage,etc.) ...a 1%30 XA GREASE TRAP:fy&. (locate on site plan) Depth below grade: Material of construction:_concrete_metal_Rberglass _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: (recommendation for pumping, condition of Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity. evidence of leakage, etc.) revised 9/2/98 Page 7of11 ' a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperry Address: OwncY: ll` Date of Inspection: TIGHT OR HOLDING TANK: UZ(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:*S (locate on site plan) I Depth of liquid level above outlet invert Comments: (note if level and distribution qu , evidence of solids carryover, evidenc f leakage into or out t b x, tc.) is C l J v vti V PUMP CHAMBER-W\ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working.order(Yes or No) Comments: (note condition of pump chamber..condition of pumps and appurtenances,etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 4opertY Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): S (locate on site plan, if possible: exca tion not required. location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of Pond'ngr da p s condition of veget lion, etc.! / N 0 CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PRIVY: (locate on vite plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2/98 PaRc9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) 'roperty Address: '1 pe-S rw(rA Jwner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) da L. 33 �1--:, LO 53 _s I' revised 9/2/98 Page 10of11 ~ v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,opefty Address: �1� GJCSTwfr•�C�, Owner: Date of Inspection: NRCS Report name --- Soil Type_ _ — ------ - Typical depth to groundwater_____ __ ___ USGS Date website visited (/t`j Observation Wells checked Groundwater depth: Shallow( Moderate Deep SITE EXAM Slope UeCS k i t5y +— Surface water fj(5 Check Cellar bv_,l Shallow wells p—ro/ Estimated Depth to Groundwater(S Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11ofIt DOUSFIELD SANITARY SERVICE 451 FROUTE GA P.O. HUX 438 EAST SANDWICH, MASSACI IUSEI TS 02537 ;a�,NI; GO90 888-2010 .. . a.I-:�. �,x-.c..,rP•}O:cS.."Ar:.R. ,.,. ... a.l`:ka t�: ._,:tq"°v'i. wS pF 'R cfs�f1 p99 Z14& il L SYSTEM INSPECTIt RH S U13SUtFACE, SEWAGE;UIS Address of property �7% p.S-E2Vil � !e� S it Owner ' s name Wil11 Date of Inspection S'.aja* 6 / RqS �.1 4.� ��,�, ' ., ,r '?'�� �;�+ CHECKLIST check i f thef llowiig''hliav� been;done: ion was requested of the owner, occupant, t/ Pumping it:format and Board of llealth. #; ;r , a ' . s `,.:ta" :'r : =� None of the system ,eomponents,iliave.Tbeen_ pumped for at least two iieek�t: and thes system_has beenrece ivingVnormal'. flow rates during 'that period. , � Large volumes`vf``water`have-not° been introduced into the system .recently' oryasY'part"�of'this- inspection. ;, z , obtai .� rt � z , ;; '• ot As built plans' have been ned attd§examined. `Mote i f they are n p available witli ✓_'i'he ',faci ity,,0.rodwellin,g4 was inspected" fore signs of sewage back-up. The site was inspected ,for 'signs of breakout. s'::.?.e. 9 .Idt4�C,, .ir All system components, ' excluding Tthe SAS„ have been.located 3 on the site. .. F 1.-i • -. I S it �,''11 a � J ,i.. E ! ,.k PV^ .. - F.`� , They-se tic,,; tank manholes,�were uncover.ed,` opened, and "the interior the septic tan�t' i as°'inspected:'fore"!, Rion,,` of`�baffles or_tees; material of construction;'di fliquid,mensions, depth, v tepth of r r us,ukikeSr Y:,a,wsa,v '�✓•. ,� f �; I.- � sludge, deptli of scum.'.},',,." N,. .. ' J.•,y Y ' '1'he size ,ands o4ca i'oni o the 5AS on�tibe;si'td `has 'beenr'.detikmihi d base£# x'R -intrusive' miithods. on existing information�orf appr6x mated by nonj,s a:,.ir:..,..,w,r„�=v.n •;.n"..w.• ,,,.r.:.,w..»r:.r..e .ar....i:::<.+.. !'lie'""tacil"its"'owrier�"'(acidoccupante, ifdi"fferent "from owner)' were tprowided with information `on the proper- maintenance of SSDS:,,{ j l.fii £ t* $.::yXX0, F Tt47.erl SUBSURFACE SEWAGE DISPOSAL SYSTEH INSPECTION FORM PART B � qp SYSTEM INFORMATION FLOW CONDITIONS If residential _ 2_ number of bedrooms _ number of current residents J40 garbage , grinder,.,; yes or , no �0 laundry connected-"to system, yes or no _ seasonal .use, yes or no » yr • .. t ` Jf nonresidential , calculated flow: ' ' Water meter readings, if available: �DUSE �-/AS IQ�rN 6Ir PTY b4,ST' TZA ` yEi9/�S ,TNE'OruL V W6TCj? US 1� l S FO(2 ;LAu/N cARt Last _�.. L date ofoccupancy ' GENERAL INFORMATION Pumping, records and source of .',information: �O System pumped, as part of i.nspection, , yes or no if yes; volume 'pumped' Reason for pumping: hype of system �(/ $Septic, tank/di stribution -box/r?oil ,.absorption system Single cesspool' s �. overflow cesspool . , ;. ' Privy,,; , Shared system (yes F or no) (if yes ..attach preyvious inspection µ ir, ,s records, if any .. - - r � A f,'� b F ,Other (explain) " ', _ .f`f' . r .. f • '_ Approximate. age .of all components. ,Date installed, if known. Source of _7.a.nformation:,t �� €. _ Sewagew odors'*detected "when arriving 'at 'the site, e Y ,S Or»no i • 9 -. SUBSURFACE"SENAGE;DISPOSAL� SYSTEM',INSPECTION FORM W,'TAA` PART B SYSTEWl XFORKATION- continued SEPTIC TANK: (locate on site..plan) , , If, depth below grade: material of construction,: V,4concrete._metal _FRP _other(explain) dimensions: 2r 6 .01-killudgeAdipth, _ Q distance from top..qf sludge to bottom ofu'outlet' tee or` baffle scum.thickness_- it fin dist.ance-from­top of, scum to top`,oVvutlet,�tee, or, baffle`' .distance from bottom of scum ,to, bottom"of. outlet tee, or baffle Comments: (recommendation for pumping, condition of inlet and outlet toes or baffles, depth­,,,ofi,liquid� leveL in, relationAW,outlet� inVert, ',structural integrity, , evidence, of-,+ leakagei,irecommendations,°fork,,,repairs; -=etc. ) ,' to 6FA40�jo-' DISTRIBUTION BOX: n-.. ,- (locate' on_sit,e,.,plan), f depth 9.f I.iq uid, level. above outletjinvert--" , (note if level and distribution is �equal,;",�fevidence;'4,of ,solids .carryover, evidence of leakagq,­into or out of box, recommendati6n ,for•,fe0airs#', etc.) (locate on site plan) t pumps in working order, yes or .no n of pupp-­.qj.a erj . condition of pumps and4ppurtenanceii'l maintenance or repairs etc. ) tk FT,Al !mq mn-�,t'T =r_,SUBSURFACV SEWAGE =.DISPOSAL• SYSTEM INSPECTION FORM r ' ' PART B 'y .SYSTEM`° INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : P (.locate on site plan, if possible; excavation not required, but may be approximated by non=intrusive methods) ]A' not determined to be present, explain: Type =.caching pits and number 1 4� '.eaching chamberst:and=- number=,, leaching galleries and number aching; trenches,,number.',°.­length, J �F :_ aching fields,.! number;. dimensions overflow cesspool , number Co,,iments: (note condition ,of soils .signs rof.� ydraul ic' failure,• level of pondirig, condition of vegetation;�-.recommendat.'ionsafor--maintenance' or repairs,'etc. CESSPOOLS (locate onsite plan): nl..unber and configuration depth-top of liquid to inlet invert s d - ;th of solids layer r. , d pth of scum layer d ;;pensions of cesspool t=. v,-y.jt. F , ,,. , materials of construction indication of groundwater 1-if1ow, (cesspool.. musty-,be.Rpumped�as rt 'of -inspection (n )te, condition, ¢of. soil, -.signs-.of. hydraulic ..failure, level 'of ponding, conlition .,,of vegetation, ,recommendations. for ,.maintenance or repairs,etc.) P, V Y (1�_,=�:ate on site plan) rig; materials of construction dii„ensions dept::h­of�,solids f . Hi ,:P I`ST y% 1�44 ..1 � i 41T i3•r♦ _. .• = ,;F« 7ry z t ei.�Y.fir, �i� ; nr.S.�.G. �. _«.�.,� �.�.,x�.14�,.iwr f�{,i=.• t. .. T'= _ F,, ,, .;q... ' �' +. Ca­ nents: _ ,P_ ,' signs, „of_hydraulic .failureu level _ ..... _ ..,. (n _ condition. et soil of:ponding;- ca xtion of vegetati_on, _recommendations..:for-znaintenance .or- repairs;etc. i 11 Y y Ciil i�i t1'R SUBSURFACE SEWAGE,) DISPOSAL SYSTEM INSPECTION FORM PART A { SYBTEMa,INFORMATION, continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties ' to at least two permanent reIferencesnlandmarks or benchmarks locate .all wells -,within 100 ' 4 _ 4F i i i 63� r •�, 13�`.. 37 ti� :.r F . :�,F ert r � ,{t t'.� �`•y i_ t lea • e • s .7x ..e-x ;f 4w��+"�.;s . �i = t,,� "7 :'w.l '3 '�* s ' . .� • i �� • DEPTH TO GROUNDWATER depth to groundwater ,. . .� -�; Yf fx a�f j3_v . 'V.J x.:,.� .'�•.T I,Y : � ,L+. - method of determinat'ionor a proximation: �9 .1. ....• .w.r:.-V. ...a .... : .E4. y..k. -...wF.X✓ r... .. r. .. .x } l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION POW PART C `FA)ILURE CRITERIA Indicate yes, no,' or' notesdetermined (Y,` N, or ND) . Describe basis of determinationn in all instances. ��e If not determined explain wh ,not) - Y _JV 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 <6111 "below invert or available volume< 1/2 flow? Required pumping 4 times or more in the last year? number of times pumped —A Septic tank is metal? cracked? structur.'ally. unsound? substantial infiltration? substantial enfiltration?­�tank failure imminent? Is any portion of the SAS, cesspools 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 water supply? within a Zone I of a public well? t within 50 feet of a bordering vegetated wetland or salt marsh , (cesspools and privies only, not the SAS) ? �..__._ within 50 feet of a . private water. supply well? less`•than '100 'feet abut-greatel-than 50'feet°*from a private water- supply well with. no-acce to p ble water-- alit analysis? . -has been anal zed - � Y Y If-the -well ell , y to-be= acceptable;--•attach•copy of well water• analys .w - for ,coliform bacteria, volatile-organic-••compounds, ammonia-nitrogen and nitrate nitrogen. I13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name (SOCA-S Company Address , f 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 maiitenance of on-site sewage disposal systems. Check one: _LZ'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.- Buyer (if applicable) Approving authority rl LDCAT14l SEWAGE FERAUT NO. In�y VC i VIL1, AG � NsYA LLCR'S a A D 0 R 1 s s � � 1 ISU8LDER eR OWNER The ® a,vst SO DATE PERMIT ISSUED 6 c2e /Q,� ' UATTI C 0 W P L 1 A N C 1 1S5UE7i—g a g� ---�— l Lile vim_ No.�..-____��•-•-.' �. Fims.............................. THE COMMONWEALTH OF MASSACHUSETTS j BOARD F HEALTH ...... ----OF...... .. Appliration for Disposal Works Tometrurtinn rrrmit Application is hereby made for a Permit to Construct+k or Repair ( ) an Individual Sewage Disposal System at: ..---U4455-�f-1......In!;/_A/,o...... .(. 1��.. .... -� .........at -------- Locatio -Addr ss o Lot Owner ss s. e _Q...- �} r?.d� l�s. ,Q1�......--•- .................------••--•._._..,: --•-•-.Y/� adIelGl. "/ ....................... Installer Address Q Type of Building Size Lot__/J.'; d-----Sq. feet U Dwelling—No. of Bedrooms___..._.....3__ •-•---------------•Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _ID_L4/ No. of persons............................ Showers Cafeteria ( ) Q Other-fixturesY W Design Flow................. ____________._gallons per person perk dap Total dail�.(flow........ _ gallons.// Septic Tank—Liquid capacity]_gW__gallons Length.-/_0._.6 _.. Width---- __.. Diameter____________ _ Depth...�.�. W Disposal Trench—No. .................... Width.......�..._..._. Total Length............... __ Total leaching area....................sq. ft. Seepage Pit No--------f......... Diameter.........6....... Depth below inlet.......6......... Total leaching area..��d q.._ __._ ..s ft. Z Other Distribution box ( /) Dosing tank ( ) aPercolation Test Results Performed by.... _ _�..0-L! _. 1 �.��/L!/._ 1/✓.(n Date.......s�,�.•�..�,�` a Test Pit No. 1................minutes per inch Depth of Test Pit... ...... Depth Depth to ground water_._�f_ ______-____-_y_'�'�. LL, Test Pit No. 2................minutes per inch Depth of Test Pit._. 7- ...... Depth to ground waterh.0.�rl..7" ---•-------• m................................ ......................................................................... ::.... O Description of Soil________________________ ....... _,NI_.----_-- x V .....•••-•-----•--------------------•--•------•••-•--•----••-••--••----------•-•••-•-----------•-•-•-•-------•-••----•-•-----•-•-------------•-•••-••------•--•---••-•-••••--------------------•---•••--- W .......................... •----------•---------•-•••--••--•--------------------••--••--------••-•------•••---•---------------•-----•------•----••-•-•••••--•----••••-----•-••--•--••-•-••...__..._...•- U Nature of Repairs or Alterations—Answer when applicable.......................................................................:........................ ----------------------------•--------------------------------•------------------------........---....------.....---------------•------------------------....---........................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ued by the board of heal rowing .... a w......................... Date . ApplicationApproved By.............. -------------------------------••-••-•------•---------•--------- Date Application Disapproved for th asons:----•------------------••--••-----------------------------....--------------------------------................. ..............••--•---••••--•••-•-•-•---•.....--••••--•-•••---•--•-•-••-•--•----•-----••--...•------•----•------•---------------------------•-•---•----•--•••---••••••---•---•••----------•••------...._ Date PermitNo......................................................... Issued_....................................................... Date No., '� �--°. Fims...�...1...:............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT f f -r f OF.... ' 4............................................ App iratilan for Disposal Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct.(�►� or Repair ( ) an Individual Sewage Disposal System at: VV kd T y3..., �r�% ��- g;„ flz or Lot No. 6.� . Location-Address `Owner J EAddress W1 ----.----= -r r'------• t "� -..._...�. t�t�/1�1r r--_ i___ __ '...__. P.a.� ..,.. X-' _i•l_'i•y'.^_L.-..�..... ..................... Installer r � Address �,,, U Type of Building Size Lot j__�,0_a......Sq. feet .., Dwelling—No. of Bedrooms........... ..................----------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building _ %�_. ..,� No. of persons____________________________ Showers ) — Cafeteria ( ) Otherfixtures . " --------------------------------------------------------------------------•----------------••----------.-..----- W Design Flow.............. ................gallons per person pe�y. Total daily flow....... _ _: ..................gallons.{,r WSeptic Tank—Liqui capacit �...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�s._��.r7 sq. ft. Z Other Distribution box (r ) Dosing tank ( ) '-' Percolation Test Results!! Performed by---� 1... Date..... Test Pit No. 1...........:....minutes per inch Depth of Test Pit__ _._e r--- Depth to ground water...... Depth Test Pit No. 2................minutes per inch De of Test Pit.p p �. .I�+.___..._ Depth to ground water..,_.:: R4 0 Description of Soil----------- ::.4 _.. ....... " " ........................................................... U ..............................................---------------------------•--......---........-••-.......-------•----------------.....---•-------•-•---••---•-----------...----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations-- Answer when applicable............................................................................................... ............7........................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL%, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. s' Date ApplicationApproved By.............. ---••.•--`--------------------•--.................._--------__----- Date Application Disapproved for th fro owing reasons---------------------•--•---•--------------------------••------•------------------•----------------------------- ......................................................---.....------------•------------•-•---•-••-------.---•------------------•----•---------------------------------- Date PermitNo....................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS r- BOARD OF HEALTH j r .;17....OF....J�.7. .:?.<�rl.. xc r ' } C�rr#ifir�t�e n$ �u�n�rl �nrr -----. .. ............ .:.... THIS TO CERTIFY, That the Individual Sewage Disposal System constructed (h or Repaired by................u+.. .E iie�' :.................................... -----....---•----...--• ---•-•. In at- f ? ----- --- . = "' f ............4 _..._... has been installed,in accordance with the provisions of TITLE 5 of The State Sanitary models es r'bed in the application for Disposal Works Construction Permit No...K� ._20bve............. dated-.�`..._._.... .._................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE SYSTEM WILL F NC ION SATISFACTORY. � DATE................_._. .._..U:.-----...................---------....... Inspector....:_._ 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 49_�6 No...� .......r v } �� BEE.. ................... Utopsal� Works Tnntrndion ramit Permission is hereby granted.--- .........�,,-M-1- ............................. to Construct (-F) ork'Repair ( ) an I dividual Sewage Disposal SysVn ,ri" X" Street as shown n the application f Disposal Works Construction Permit ................... Dated.......................................... a , ......... .............................................................................. Board of Health DATk =.. -- T............................................... FORM r1255 A. M. SULKIN, INC., BOSTON AsBuilt Page 1 of 2 L0CAT ! � 5LWACL PERA9!T kQ. ffy- VILLAGE. I N S T A LLEA'S 9! 11E U' AOQRE.SS ct 'llUILDEA OR, OWNER he \ GATE P �RMIT ISSU e G, aG gs" 0AT C0 'PLIANCE ISSUED 8 oaf Li 0�8 Lot 9. 5Z:9 Wdgjj& 339 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=121011026&seq=1 12/9/2016 _ _►a-� ' C�EAJC0Al- MOTES LrL Inc /-=J Ix Z LL-rr-v. -T-)FSr'C. i ---- - _ -- �I 41_L ELf�G. 9Lk>>t/ AftE ME,,,Q SEA L-SvcI_ I — BAD D ba.l J �� =�j S TJM.T U>� PLJs►.11E PIKca AaLL 11.1tAE5 A I"I1MrMU4�A of 1/b �Fc T f II _ vw►t_ES5 or►-a�e�.�tsE S.t�EGF1ED. �� t — ALA_ PIPES TO At�D ral TfiE SYSTEM SHP.t� 2d' y •• l - — ftE CAST I Q�►J GV` X-t•t 6 D t>`E AO P�/C q O l l ® ALL- SEPTOC TA►JK-5 P15Te18��oJ ><, A► D n/,; !vJ,�i , M LE^Ct-1t�-1G F'fi� SHALL gE -DEStGj.1E0 FOP_ 30 0 01 mil` C1 ti-1 2-0 �:►�EE� ���.n .�C�S WHEN INSTALLEPuNDER PAVING '' ---- - - --- rJ� /' �CJ �-- 2rcN10✓E Au._. 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TA.1 L: 'P I CF.4►L � S H L►�Ca -—Q 1T 065E,cVA7i0A/ e/T5 ' eEl►1FOPrti) sevm-lc -iW--LW- 1sy AF•tEelc-^,j PC-zLr.ST II /{OT >n SCALE MOTTC Sc..LE � Ofr;- G Q UA L 1.1orTc.: Taws k S Qt�c t►.d FoCCE D TNto u4�Oa T - _ ,l;eCOGA r/oN o"7z"- 21/41n IMG11 �. � ,,,,_._ _ _ t•JITId E l�iC T1=.�L tL.!EL(yE a W f¢e \ti!T}-# 0a1eeYA7'10 6 6y: J0114-1 ✓' / u - `fi" �MBEOOED s�I- tto ,.J Scv is�.�tc A�� e.16 Prrg ffA4?A/---r.4ns� 6o4pt F o a At=ALTH 4 bon•or 1. Cooc. is 4o00 Psx. TEST tw,r1{eZ T a r� �.v�t.T uF To 12. • F. TL��;�4 te A,-nc-.,� 8E LGw F r�.t 15N 6�s':7•S FfhL15►1 6[AOIL F IAt►Sr4 GQA-CW- F ►WIS�F 6c^ D G-/LrG ►YS�-) GC�.>�• �Z'= tJJER T�++sK���Q_ twEit`1�bcx -f (_EACH1FIG Sa.Cie 9" FtiS-To+s�E ' �I►Jt�f T * • • 1n/V+ lrt : A • t s m O of 30)-t(.3 • O B O m RtlSF1E D O00 bAL © a) .O ' bTd3t ecalFoccev cn.sc. DIST r5OyC 0 0 O m imffi.. 3 4 �EPrI� TAla) • . t ELJEV r- �3tZ -b m LL9/EL_4 STA@.LC L' � TYP I GA L. SE V/AGE �SV$t`E M PfrarTF►L.E �' �• Ne'T To sC^.LIE LE/+GN INCy Prr Et i MAP SECTION PARCEL., /,01 ADDRESS + TANS L,EG EAIP -V ,r � ) _ er,sr ��r� PROPOSED PWE�C�I NG LOCATION DES/GN t;efTE!/� it I°� Atom-v �awTd'dK ,'� -a �l _.. E ;�, �, �-r � — �t, , �� �9 PiPOPOSEP SMAGE RISPOSAL SYSTEM iH S\ - AI�vM A oje aF j*"A0oM s _ Exi�� tat 6cFd y:�a. cy ^A` a k ;� )BERT. � �. � �� `T� �d►aeW3 Axe i�CXL✓ oE+eRAY ��� d �.eCh1f�llJbt� � o tzn,Y , �•, eAIAV6 "QVAeEo GPU t*JOsEnt t�elT + PiT. , \ � P120POSED LL'ACH IMOP PIT 'QAr / � ' EI.E{'� t 1.1 �1 NG i 1� ,� �p U►SPpSs.�,. _ ��IGIN Io0% Ex PA►.151QN 'Z ccAcr p PC's �7N �-���.A►1.�Cx7t'N 1{lG�Yla4 UTH t4 j, o. YkAw-hag .AC • ��%sw-Alo utA 1 c� RG =R; \3 V rL4 G do Na. L3IL 5 / 3 AS NOTED ,, �'wH1�11�1• dsc 7 Y _