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HomeMy WebLinkAbout0042 CALVIN HAMBLIN ROAD - Health 42 Calvin Hamblin Road, M irstuns Mills gin= s 1y . 4 4 � No............... �' THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEATH / .................. ... ...... ........OF........... - .......................... I Appliration for Dig usa1 Works Tuustrurtiun ramit Application is hereby made for a Permit to Construct (k-�or Repair ( ) an Individual Sewage Disposal System at kwv ...... '7M �, /yJ2STO .P /LLS -....------- LOT./Z........... .......................... ..- Lorati�-Address or Lot No. ..... TOfif...._. . 5------- .... .................................................... n Address W Instal er Address Type of Buil ing Size Lot__ .._,1)�:�....Sq. f��e��t aDwelling—No. of ..........____________________________Expansion Attic ( ) Garbage.Grinder (/Uc�) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------•----•-•---..•. W Design Flow.. ..___..._. ......................gallons per person per day. Total dad flow............330...................gallons. WSeptic Tank Liquid capacity ....gallons Length.-_8........ Width...5 ..... Diameter................ Depth...�........ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. / 3 Seepage Pit No........I.......... Diameter....... Depth below inlet...... ..:........ Total leaching area .sq. ft.';7-0 Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by_-4!! 41194....L`W.._05'V100V.AA—= Date.... a Test Pit No. 1..<y...minutes per inch Depth of.Test Pit......jz_....... Depth to ground water...... ............ Test Pit No. 2................minutes per inch Depth of Test Pit..................... o ground water..__._.................. -----•--------•----.----•---------------------------------- O / . ....._ ..Description of Soil j TO/!...S /.. --•..................••----------•••-------- •-•-- . Vr -- .._......V. -- SToyES W ----••..................... 3---- ----- --------------------------------...-----•....... -•---•-•------- ............................ U Nature of Repairs or Alterations—Answer when applicable______•_______________________________ ................................. -•---------------------------------------------•----------•---•--........_.....---......----•-•--•-----••------------------------------------------..............=.................................... s Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of SIT .;.�. 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. Sifie ......-•-•-----•.......................•-•-•------•----...:-•••••....... ................................ Date Application Approved BY-----� ------ - •�� - -- -�----02'�---7-j�--••-•--- Date Application Disapproved for the following reasons:..................• •-•-- . --•-•-••-•-----•-•---•••--.....••••-•-••••-••---•----••-••-•••-•••-......---- -----------------------•......---------•--•---------••••---.............-•---•••---------..._.......--•---------------•---•-•-••----•••-•--••-. •---•--•••------•----•-•--- -------....... Date PermitNo.......................................................... Issued-----1-----�---•-• t..--•---....._....•----- Date No.. ...... FE$..... THE COMMONWEALtTH OF MASSACHUSETTS' BOARD O HEA TH Allpiirkinn for Disposaii Works,Tonstrnr#inn ramit,. A lication is hereby made for a Permit to Construct or Repair an Individual Sewage Dis osal system �. ....... a - . ... ................................................ -�= ) ou-Address xor Lot No. i .......................... ....._. .... .... ................. ............. .......... wner sy;N. Address ! Insta lei Address Type of Building - Size Lot.................... ....Sq. feet xwelling—No. oBerooms......................:. Epans>oi Attic ( ) : Garbage Grinder, p l Other—Type of Building _______ _____________b_ No. of persons.' Showers ( ) — Cafeteria ( ) { Design Flow Other fixtures :...-:-.--.;=:_-'gallons per person per day. rota Q ------------------------•-----------------------..._.....--------...._.._... W g g P P P Y 1 daily flow............................................gallons.. WSeptic Tanls Liquid capacif gallons Length................ Width__:.._.:___.__._ Diameter................ Depth................ x Disposal Trench No. .................... Width.................... Total Length ______.....__. Total leaching,,area____ .._..sq. ft.r Seepage Pit No ............. Diameter.___..e.; Depth below inlet...... A........ Total leaching ar sq. ft 00 i Z Other Distribution box ( ) Dosing tank ( ) A ::, ►a P~'ercoTlaetsito nPiTt et Rsiits Prfornedly_} .._.. Date......................................... No 1......... ___minutes,per inch Depth of Test Pit____________________ Depth°_to ground water........................ (i Test Pit,No Z&*." iinutes per inch :Depth of Test Pit____________________ De h;to ground.water........................ Ria Y r ............................................. Descripi on of Soil........... ....... =............................................................ ---- V �__.._.. . !_ ...... ....................................................................- -----------............ V Nature of Repairs or Alterations ;' Answer when applicable________________________________ .____-----------------------.--- . !..................................-------•-••--_-•--- ------------------••----••••..... •---------•-------• -----•• --•--•-•-------------------------•-------•---------- greement The undersigned agrees.(Jto install the aforedescribed Individual Sewage Disposal'System in accordance with r,T` r r`. ; nth provisions of, ' .. . ..5 of the State Sanitary Code— The undersigned further agrees not to place the system in Toperation until a Certificate of Compliance has been issued by the board of health. 4 Si ed_..--_- J. Date /�, ' Application Approved By... _ ....... ,.a+�"7 • Date Application Disapproved for the following reasons-------------------- --- ----•---------------------------------------------------...-••--.•--••------__••..._ ---------------------------------------------•--------------•----------------------------...--------------•----•----•-•-•••--•-•-------•--••----••--•-------------...........-........................ Date PermitNo........-................. ------------------------------ Issue(L................................................. Date F THE COMMONWEALTH OF MkSSACHUSETTS } BOARD OF HEALTH i ........ .: OF......... 4�,E�+,e4- ..:e:.. �r gfirzt e III flu t �t�anrr THIS IS,T rER�T- -------------­---- _`FY,,` at e . d.virhizal Sewage Disposal System constructed ( /'J0or Repaired ( ) by �. ler 53 f has Fen i sta led in a, nce with•,the,provisions of TI j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. _____�4F -___ :.__ ,dated------ ;ZA!-••Zl _______________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE.. AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. {� DATE......... ........................................... f Inspector::: -- .................. ..... ...---. .................................. ,•,.kv _ _ - .. ri1 in .. _ .. r THE SOMMONWEALTH OF MASSACHUSET,T� 4 BOA.RD OF HEALTH d J 04'�" �,. ........ OF .-- ^ A.:.................. No.............1 _ FEE......... `�......... U 7 Uiapn d r ' ( nn l rtf°` erI t . Permission is hereby granted---,.::11 ,_,... .---="----•- ��-•--'----- -------------------------------• -- . .:............. .�LIGJ, to Construct Vo4l.-Repair.,.., an I i idual Sewage Dis gstem f'at No rT .. . as shown on the_applicatio for Disposal Works:Construction Per No :_______ Dated...... — -- ------------ DATE.......... I _. '.... i i �y FORM 1255"HOBBS & WARREN, INC., PUBLISHERS TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: .tV,4 r1w AAC Mail To: BUSINESS LOCATION: eA t yn131W holoct �A Board of Health Town of Barnstable MAILING ADDRESS: ------- P.O. Box 534 TELEPHONE NUMBER: 509- 0(?--109 Hyannis, MA 02601 CONTACT PERSON: ,,To i4A) dilOdl EMERGENCY CONTACT TELEPHONE NUMBER: K me A &&,6 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NOS_ This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case kJ Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Joilet cleaners Engine and radiator flushes --} Cesspool cleaners Hydraulic fluid (including brake fluid) — Disinfectants -- Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) z Degreasers for engines and metal Photochemicals (fixers and developers) ^' Degreasers for driveways & garages Printing ink Battery acid (electrolyte) ._--� Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents -- Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains,dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business v TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: 1 S A)Sou-r r Mail To: BUSINESS LOCATION: a1_MoU]!W ea. OKI Board of Health �► ►► Town of Barnstable MAILING ADDRESS: P.O. Box 534 TELEPHONE NUMBER: 4/.�F - -7 Hyannis, MA 02601 CONTACT PERSON: /'//90T/g y EMERGENCY CONTACT TELEPHONE NUMBER: i// Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO _ This form must be returned to the Board of Health regardless of a yes or no answer: Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: STEVc.5 AR4_�Z,9A 5-v f, Mail To: BUSINESS LOCATION: 16-3 �A" Board of Health MAILING ADDRESS: /00 13OX 7,� Town of Barnstable P.O. Box 534 TELEPHONE NUMBER: .�2e b n6q-3 Hyannis, MA 02601 CONTACT PERSON: Sf�� EMERGENCY CONTACT TELEPHONE NUMBER: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO)— This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid /13071"L15 Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) ��%SdZ- Disinfectants Motor oils/waste oils BAG Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heatin oil Pesticides (insecticides, herbicides, C T(.10E Other petroleum produc : greas lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine �( Car wash detergents Lye or caustic soda l07` Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes / (�,AL aint varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including leac Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers r ju vz usehold cleanser , oven cleaners White Copy- Health Department/ Canary Copy-Business TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: CiLt Mail To: BUSINESS LOCATION: Board of Health Town of Barnstable MAILING ADDRESS: !�)OMQ o1S cAba L sz_- P.O. Box 534 TELEPHONE NUMBER: �`� - �-1afi�- � i S?i Hyannis, MA 02601 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: 5DR-LAQ�8--SQ000 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business i f TOXIC AND HAZARDOiUS M TERIALS REGISTRATION FORM i1� � NAME OF BUSINESS:/eat 4S 14 GJ�AC � Mail To: Board of Health MAILING ADDRESS: Sao Town of Barnstable TELEPHONE NUMBER: SVP� V doz, P.O. Box 534 Hyannis, MA 02601 CONTACT PERSON: C'�,S-Ir-r- b-�'tn,�,� Y Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totally, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registered lwi@li+ Please put a check beside each product thatyou store Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business Commonwealth of Massachusetts all Executive Office of Environmental Affairs ®epartment of Environmental ProtectionWil xe cwwemmorr F.Weld J U L 2 6 CT�rud CoS-ts tary Argeo Paul Celluccl David B.Struhs U.Governor (;` "' Commiubner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:�4Z, A4,V1AJ,, /,t/. Rd,40 eM -- Address of Owner. Date of Inspection.zi-lU PE t 8� �q-Y6 "` �(if different) Name of Inspector. V//LG/AM L 1EBERNfAa— A M-/ C A Dy Company Name,Address and Tel phone Number. _ 235 7_1,V 8 'R LAN£ sOg— 406-X 5�j G MARSTnN 6 MAu.s Mrs 0244rg 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 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 L Needs Further Evaluation By the Local Approving Authority .✓ Fails Inspector's Signature3 r ✓ The System Inspector shall submit a copy 6f this inspection report tttppro uthority 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. INSPECTION SUMMARY: Check A,B, C,or D: AI SYSTEM 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 completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined',explain why not) The septic tank is metal, 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 ponforming septic tank as approved by the Board of Health. One Winter Street • Boston,Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292-SW ii Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:i 4?CA LV I O *At A L10 Rp Owner. (mil 13 U R Gl D S Date of Inspection: TV�{ {�� {y96 Bl SYSTEM CONDITIONALLY PASSES (continued) ^� 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 in removed distnbution 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 Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER ..�v•sw.i �irnsrc5r 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:44 Z LALO Al 14 A M 3l 1 N TZ D Owner. Z-fl kt W T3 U 12,(q O Date of Inspection: DI SYSTEM FAILS: �✓ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of 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 or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: �✓ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. treviseu iiiu„ ,-, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST LVIN V4 0,r1 F3 LI O RnM� Pro Address:�4Z. LA Property Owner. Zo*g V,a9,1,D S Date of Inspection: _-r U t l E 1 Pj� ►��(10 rherk V the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for 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. G As built plans have been obtained and examined. Note if they are not available with N/A. ty The facility or dwelling was inspected for signs of sewage back-up. �( The system does not receive non-sanitary or industrial waste flow X The site was inspected for signs of breakout. All system components, e-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 or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. NJ Vr 41 'T N►S 'R IP-r p O t_T r. 11 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1�4 Z f:AL VIM 14&MLJ W 0 A 0 Owner. TO WN1 'P.) UP,f1i D s Date of Inspection:--V N E `�� l�J 9l0 FLOW CONDITIONS RESIDENTIAL• Design flow: 33 b gallons Number of bedrooms: 3 Number of current residents: Garbage grinder(yea or no):-92 Laundry connected to system fives or no): Seasonal use/yes or no):-L2 Water meter readings,if available: 13 Al S/ E W L LL.- 19/V UJAJ E w EdL 5 E t t,F- 1 o 1 Zb - 2;Z&6 64 ee I-- i W LL N6T SL-v 1"tc 10jz4f8S y4/Vs &C1od 78 G 8 /`3A7¢ G¢/000 �7S 6/D Last date of occupancy:—fLR/Z L v-r yz/y 3 39� 49 COMMERCIAL/INDUSTRIAL: ao Type of establishment: Design flow:_gallons/day 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) N 6 Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of�fo tio��v/?c �t1(�/E�Q - 2D - � y c System pumped as part of inspection: (yes or no) If yes,volume pumped: =i 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) Other(explain) APPRO)[IIMATE AGE of all components, date installed(if known)and source of information: �'-7 7� �, L7►H. E/+)P �` Q Y96 Sewage odors detected when arriving at the site: (yes or no)�0 (rev sPr1 11103/95) b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 44 Z G ALVl N 4AM L•10 DAB Owner. SO k}••o 3 tJ E-4? 0 5 Date of Inspection: S V tj e SEPTIC TANK I o0o 67ALLDNS (locate on site plan) K£rG� `7E6 � _ Depth below grade: 12 Material of constructiun -2�wncrete_metal ---FR.P _•otherexplainI Dimensions: K x ( ' Sludge depth /Z" 22 Distance from top of sludge to bottom of out tee or baffle: �� Scum thickness: n d•- Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet an- utlet tees or baffles,depth of liquid level in relat' n to outlet invert,structural integrity, evidence of leakage etc. �� /� Z a L L GREASE TRAP:v (locate on site plan) Depth below grade: Material of construction: concrete_.metal_FRP_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: 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,) F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: -'�4-2- C ALI/1 1�3 D R10/ Owner. 610 S Date of Inspection: TAN(: 19/ 111 TIGHT OR HOLDING TANK (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—other(explain) - Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:X (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, etc.) 9,u L� 5� o L / E L 2 ' '' 73 E L L- _ 1Af✓ PUMP CHAMBER"'V (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/W/Y5) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,if possible;excavation not required,but may be approxima by non-intrusive methods) LocA,-Tt5P — Noy 6xcr7e� If not determined to be present,explain: Type: leaching pits, number: leaching chambers,number:= leaching galleries, number: — leaching trenches,number,length: leaching fields,number,dimensions:ti overflow cesspool, number: — Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) qb EVIV0066 OF FA ",L) ,jF— v c.�v I� �119 1 V-I V 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,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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q Z G A L V/K) V\;'.,M�b L11J D_ate G Owner. -S'O ftN C.,O S Date of Inspection: TlJl'i t ��� �� (0 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' LG� � � GJS DEPTH TO GROUNDWATER Depth to groundwater: j " feet method of determination or approximation: A r_ L 4 0 VJ AZ Q_ T—/? L: a L�2yvn�r} EL AT SItS Z-y aL) APRP-tJ G La , G (reviseu 11/03/951 9 I I v5 rf� 0 lA. r � oti { �s MANSfIELD qy *,OBcIID NIIC �° +g� Shubael Pond w` �^ FU L GtDSEr @ Rouna T Pd r�E �omDlin and VA -�-- c �. SCALE / 05 I 1 Mile 87.08' LOT#12-22,718 SF EL 69' +/- L1P 429 G1D R�A O • . . 3 - WT EL 40' +/- D1B 16"W X 22"L Z X 8" SUMP ®�N COMPONENT S1T 1000 GALS LOCATIONS 155' +/- - 1 12 13 1 21' 46' 63' i 21' 44' 60' 6 " 34.9 196.290 35.9 A 24:5'X28.5' I ; I 35' 38.8' 101.2' i i 260.74' TITLE 5 PERMIT ISSUED ON 6-20-79. COMPLIANCE ISSUED ON 9-7-79.PERMIT #[79]382 76.8' i; 83.8' I_ SOIL LOG EL SU+/- 161.8 0-6" TOP SOIL 6"-36" SUB SOIL 36"-144" SAND GRAVEL AND STONES NO WATER ENCOUNTERED 137.5' TM 101/31 # 42 74.02'CALVI N HAM B LI N ROAD [N/F J.B. DRIVE] MM SCALE 1"=20' 57' PLAN BOOK 247 PAGE 144 BRD RECORDED AUG 26,1971 SKETCH PLAN WILLIAM LIEBERMAN SYSTEM INSPECTOR SYSTEM INSPECTION JULY 8,1996 LOC TION _ �� SEWAGE PERMIT NO. VILLAGE INSTALE�R' �I�,M� i ADDRESS i yR OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED I J � ��, � M � i - -- - — --- u.. Saeutls.s.,nww.sasr •. , rws,urr:o..rncww.z'anr .�?.—... ...v.. n. • T—r_ _—a w -.rw+.su - - i t SO!L Y,.OG NO. 1 N0. 2 A SITE F � 2 v i 4TO►J . d --a--- TOP OF 3 J 10 N EL.-. _ X 6°• T t?4'' i'>�= '1" 1� i N,E L. ■■ e 2 COMER 1f8 3i8 WASHED STONE I EL SR,3` '- Q m a ° e, IL i Df B W/ G"r SUMP N. Et. 314` 1 1f2' WASHED STOGIE ,' t 4' Lv10 LEVEL . �` b © 1 a R # o c too � Ib u n 1 6�"Do 0 �`� 6- EFF. DEPTH o°� � � . PERC TEST RESULTS PRECAST SEPTIC TAN WITH ��c ' , � � v° PRECAST LEACHING PITS PERC RATE : ' -- S D n °� o� aA -- WHITNESSED CAST IN PLACE INLET AND EL. .__�� � Sao b �' � © NO.: SIZE : � � � � �= �,�, � � ; - —, BOARD OF HEALTH OUTLET T S PER TITLE YCIA . L t— k DATE: --�` SIZE a 1100 41_.LO!( LC— GN11If, 6 PROFILEC)`- F F-i-FlOwf"a'AOSED S E WA GO` E E3 Y. ')','T E'i'kvfti SYSTEM DESIGNED BY TA TOWN OF . R E G U L A 10 N S AND t STATE TITLE X FOR SUBSURFACE DISPOSAL. OF SEWAGE . SCALE a 1/4*`._ V 0'° cPTt( TRH+ I N .B . w r ! 1. ALL PIPES SMALL BE SCHEDULE 40 PX.C. SEWER PIPE 2. ALL PIPES SMALL BE SLOPED 1/4" PER FOOT EXCEPT FUR z� t of SHALL BE LEVEL � �As� �� t56• To TH>�, FIRST Z FEET OUT OF THE D!B WHICHS I . 3. DESIGN FLOW BEORBOMS AT 116 GALDA ` PER BR , GAL /DAY SEPTIC TANK SIZE _ X DAL. ;� x ��� zd`� USE SAL. W/ o 2z, . GARBAGE DISPOSAL LEACHING SYSTEM: USE ij. EFFECTIVE AREA. IUE 0 T T 0 M � 4 :, OTAL FLOW - f TOTAL RE 'B F LOWS __r __ _ _ _. f AL DISPOSAL GALf0AY DESERVE FLDW �-� .� � ��� �� �.: - REFERENCE PLAN , -x t i ...,..... ,.-,,,, `.__._. / c y r•`� � s -a ti «— . ,APPROVED O . .r BOARD OF HEALTH r CATS SITE A N D PLAN PROPERTY OWNF _y--- ____._ _ __. FOR : BEDROOM SINGL C' _ FAMILY DWELLING Y D W E L L I � WI LEA kl a4 cy � i �F ? �r. LOT . �', Mrs ... t.. C . � .r r� ' 4i yr _ _ DOYlE MOHR ASSOCIATES FALMOUTH MASS. ,,,,, n