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HomeMy WebLinkAbout0110 CAMELBACK ROAD - Health 1 .0 CAMELBACK ROAD Marston' Mills A = 064 - 101 , i r �O TOWN OF BA NSTABLE fl;"'.7/ I SEWAGE # VOCATIONi VILLAGE 0A1 / �� ASSESSOR'S MAP & OT INSTALLER'S NAME A PHONE NO. Aev SEPTIC TANK CAPACITY a 0 Q I LEACHING FACILITY:( (size) 4 00 S v� PRIVATE WELL OR UBLIC WATER NO. OF BEDROOM S a} s • a BUILDER OR:OWNER &N I DATE PERMIT ISSUED: 5 Q� i DATE COMPLIANCE ISSUED •� �' � No � VARIAN CE GRAN TED: Yes 1 f G6 v s TOWN OF BA NSTABLE LOCATION v SEWAGE # VILLAGE N-4. ASSESSOR'S MAP LOT 0611 /0l INSTALLER'S NAME & PHONE NO. }v Ae0 b® Df� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (sue) NO. OF BEDROOMS v'7 PRIVATE WELL OR rUBLIC WATER 1` BUILDER OR OWNE N/ fi SAS` &.�5 Q' DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: • �� / 1�� VARIANCE GRANTED: Yes No I /J �� r- �'`� �� v � V ,. �9 ®��� Vj N FBIJ��........ THE COMMONWEALTH OF MASSACHUSETTS BOARD Off` HEA THI .......... OF Appliration for Disposal Works Tonstrurtion Vrrmit Application is hereby made for a Permit to Construct (741 or Repair ( an Individual Sewage Disposal System at: ............ ........... ....... Loc n-A ress or t No. I? ...... 'Co. ....................... ........................ 0 er ddr.e.s.s .......................... ............"E.A.0.....771 ........ ...................... .. Installer Address Type of Building Size Lot,!ZAMI---/17..Sq. feet U Ms........... __--------_-----_- Dwelling—No. of Bedroc Expansion Attic Garbage Grinder aOther—Type of Building o. of persons..........;6-------------- Showers Cafeteria Otherfix ram'---------- ............................................................ .......................... pov Design Flow.._..._.._._ ....................gallons per person pex day, Total dPY ...............gallgins. 1:4 Septic Tank—Liquid capacity./#".gallons L r!'!Width_.4...IS--- Diameter................ Depth.... Disposal Trench—No..................... Width_....__(----__------ Total ngth................11-1 Total leaching area....................sq. ft. Seepage Pit No----------I--------- Diameter........ ........ Depth below inlet.........4�....... Total leaching area---4.,Z..f sq. ft. Other Distribution box Dosing tank Percolation Test Results Performed by...... Date....... Test Pit No. I................minutes per inch Depth of Test Pit.____..__.........._ Depth to ground water. 'A- W 97(14 Test Pit No. 2................minutes per inch Depth of Test Pit._.______...__..____ Depth to ground water__/ .# P4 ................................... ......• A.... ........W ... . ........................................................ 0 Description of Soil----........ 11----- ...... .M_V ..... ......................... ... W X U ......................................................................................................................................................................................................... W ........................................................................................................................................................................................................ Z 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 TL I TL 1Z 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 bbo r of healtv - .1 -_----------------- C Datp Application Approved By.............. ................ _2�Ad;,........... ............................ ............... ------- Date Application Disapproved for the following reasons:.............................................................. ...... -------------------------------- ...................................................................................................................................................... --- - ---------------------------------- Date Permit No.- Y3::0_--------- D Issued.... ............. .:? 00,940 ate ---------- ------ ------- ........—----------------------------------------- Y No._ _-Q----• ...... � � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �f... ... L-'t�..OF...... yl Appliration for Disposal Works Tontrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......_----ram f�i - --••--. :7.. ...... �` f ==�' s>' �/;~ 4ion-Address �>l � 'T,f �t/ Loc �n or Lot No. .......... t,J ?': ' .. r�.a t/_ =' e ..f �;>.. ••---••--._......._ ... "` .mil, ................................ /) Owner Address. a ........... . : . SAC �� 11f� :;�.1,{..:2.1. ! ...:C..� .: N.!' 4l- __ Installer Address UType of Building r Size Lot !_r__.k___Sq. feet Dwelling—No. of Bedrooms.__._._.._. t_____________________________Expansion Attic ( ) Garbage Grinder ( ) p-I Other—Type of Building J11)We• a -!Ai,No. of persons.........)_______________ Showers �(' ) — Cafeteria ( ) a' Other fixtur Design Flow_____________�-: .__.___..._______gallons per person per day. Total daily flow._________ _?_�!...................... W g �- g P P P Y Ygallons., 9 Septic Tank—Liquid capacity1 gallons Length_k'�...Z_.�' Width_J...J_� Diameter________________ Depth............-__. x Disposal Trench—No.____._._........... Width____________________ Total'Length..................... ____.�__.__.____ Total.leaching area....................sq. ft. Seepage Pit No.........j---------- Diameter_._____ _.,__.__ Depth below inlet_._..___......... Total leaching area__%j,.%!_'='_.sq. ft. z Other Distribution box (� ) Dosing tank ( ) ' '-' Percolation Test Results Performed by....:�_�!?.'`_!!___.__�_✓{ _ .. fJ��-1_ !.-•,!- Date...... _:'. -----------. a Test Pit No. I................minutes per inch Depth of Test Pit_____._.__._________ Depth to ground water_.__..__.._._____.___._. 40 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water✓A/C!4i h, r c�, P4 ..................................................,----•------•_--•---•-----------------•-- ------•--•-------------------------•-----•------------------ O Description of Soil_____________f3� .t.f_ _ '1._.. ._ ry/�13 '� � U ....--------•-•--•---•••------- Uw ...--------•----------------•------------•-•------------••---••---------••-•-•-----••••-------•--•------•-•--•-------•--------------•-----------•-------•-••------------•-••----------•--•--•----•-••••- 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 TITIj 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-•' e�}3�41�-� ---- -------------------------------- Da Application Approved BY................ ....... ..__ ,C .. .'`',- .. ._. A .......... Date Application Disapproved for the following reasons:____________________________________________________ - _____________••-----..........•-•-------......•-••-••--•--•-...-•-•--_____--•---••----••______.._..---••-•-------....-•---•-------------•••••---------•--------•••------••---•-- ....................... �/� ate Permit No........ •:- ............" _ Issued 41, --•----- �� Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrtifiratr of Tumplinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed a—) or Repaired ( ) af°; 1= fi / y•/.'r-1 r'/ �_�_{ Installer ...................... t has^,been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as escribed in the application for Disposal Works Construction Permit No.... dated----------- - ......... ----_.. ---- TFIE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUAR TEE j /' ` SYSTEM WILL F_CTION SATISFACTORY. �Ql A t !,G`' Q• �DATE...... ._l.._ l .........-•-•••-•---. Ins ect� . �.i /�. THE COMMONWEALTH OF MASSACHUSETTS BOARDS OF HEALTH LL�� OF._ rf?� `lF -- 7 r. 4. _.. FEE. �z7....... _1 Disposal Works Ton#r ion rrmit Permission is hereby granted.......... 1/•_-_-- :`-^'!-� �;- j • '" ," r to Construct (�) or Repair ( ) an Individual Sewage Disposal System at No .,...-.,. ..,, . , , r ,-, -a/ ,,1." ;tea -, r 0 _ �� 1..- -••------• .....................................................r 6 ; y . ." - ; ; Street as shown on the application for Disposal Works Construction Permit No._ 7__4Q'_7.,Dated........ "'� -' ••-•• Board of Health DATE........... - - -- -••-� -- FORM 1255 A. M. ULKIN• INC., BOSTON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address inf rrn Ory ner's Name / j /� /rJ�,(/ information Is �(,t,.-s�--,A�f / -r� '/i l required for every page, City/Town State Zip Code Date of Inspect on Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out fo on the computer, use only the tab 1. Inspector: key to move your cursor-do not it y the return Na me of Inspector key. s ti l /7 Company Name Company Address City/Town 5,0 c,?8D-- 'J',�(� state �O l ' Zip Code Telephone Nu e� License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maotpriance Ogg site sewage disposal systems. I am a DEP approved system inspector pursuant to 5edtlon 16.340 of C Title 5 (31o. MR 15.000). The system: r [� Passes ❑ Conditionally Passes ❑ Falls " ❑ Needs Further Evaluation by the Local Approving Authority Inspect 's Signature Date The s stem inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP, The original should be sent to the system owner ¢ and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. l5ins 3113 Me5officiai Irepec 6 F1j Subsurface Sewag 0 Disposal System•P e 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Cy Property Address Ory ner ON ner's flame Information is required for every page. Gty/Town State Zip Code Date of lnspectioff B. Certification (cost.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System "sses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health, "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins,W 3 Title 5 Of ficial Ire pec bon Form,SubsLrf ace Sewage 01sposet System-Pape 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage/Disposal System Form - Not for Voluntary Assessments Property Address VIES 4 rl LA� �n / Ow ner ONner's Name __// '' // /!/information is G fS 7'��S S required for every page. City/Town State Zip Code Date of In ecti B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title501hcidlrtspectlmFnmSuburfeceSewageDisposal System-Page3 W tuns•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address L ON ner Cw ner's Name ,p information is4ctL requiredforeverypage, City/Town State Zip Code Date of Ins B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all Inspections: Yes No ❑ �'`� Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ❑ / due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3/13 No5Official Irepec bon Form Subsurface Sewage Disposal System•Pago4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /O La V !e " L /V Property Address 25 jV1�,V ON ner Ow ner's Name n information is / A,/f AA Qo)� required for every page. City rrown State Zip Code Date of I pec on B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s), Number of times pumped: ❑ I Any portion of the SAS, cesspool or privy is below high ground water elevation, ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or / tributary to a surface water supply, ❑ D Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Le1 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ L2 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ED// The system fills. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ 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 If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department, tans,311 g Title 5018de1 lrepecdon F orm Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / r ON ner ON er n me s Na / information is �( required for every S o�S �/l/r //" Oo.) 6/ //L page. City/Town State Zip Code Date of Inspe tior C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No I-, ❑ 03 . Pumping information was provided by the owner, occupant, or Board of Health ❑ T ,Were any of the system components pumped out in the previous two weeks? ❑ -Has the system received normal flows in the previous two week period? r volumes of water been introduced to the system recent) or as art of ❑ Have largey y p this inspection? Were as built plans of the system obtained and examined? (if they were not available note as N/A) �❑ Was the facility or dwelling inspected for signs of sewage back up? 2� ❑ Was the site inspected for signs of break out? L/d' ❑ Were all system components, excluding the SAS, located on site? 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, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: [� Existing information. For example, a plan at the Board of Health. [�" ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CM R 15.302(5)j D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ty�,3/13 TiUe5official Ins pecdonFarm Subsurfoce Sewage Disposal System-Page 6of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cw ner Owner's Name Information is ,�j Q0 f / !'�S i4 required for every page. (Ay rTown State Zip Code Date of In ecti D. System In / ation Description: / �7 4 i1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ZN on a separate sewage system? (Include laundry system inspection Yes Is laundry p 9 Y ❑ information in this report.) ov Laundry system inspected? ❑ Yes �7No Seasonaluse? ❑ Yes Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203), Gallons per day(gpd) Basis of design flow (seats/persons/sq,ft„ etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15in9 3113 TiUe5QffidallrepectonFamsubstlaca sewage Disposelsyslem•Pogo 7of17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Pf vt f" f Cw ner O+v ner's Name lnformation is required for every State Zip Code Dateo I specti n page. Gtyffown D. System Information (cone) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: j� Source of information; / of the inspection? ❑ Yes No Was system pumped as part p If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of stem: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, If any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): title 50fficiel IM pecGon F orm Subsvf ace Sewage Disposal System•Page 8 of 11 Ons-3r13 r Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not forr Voluntary Assessments /l 0 (� Property Address e Cw ner Ory ner's Name information is ors 0✓�f111,( Z2" required for every page. City/Town State Zip Code Date 6f I spe tion D. System Information (cont.) Approximate age of all components, date installed (if known and ource of information: Were sewage odors detected when arriving at the site? ❑ Yes 2- No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi�40 ❑ cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, a\Adence of leakage, etc,): Septic Tank (locate on site plan): Depth below grade: feet Material construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 'X Dimensions: Sludge depth: t5ns,3113 Title 5Official inspection Fam Subsurface Sewage Disposal System,Page 9of17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / Pl KwT ner Cwner's Name Inf (!� Information is Ax 0'�(� / required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 3Y Distance from top of sludge to bottom of outlet tee or baffle 'f ` t7 -Sc V � 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 o -e �C c�e vac. How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): o-Wt r ✓t � � 2G ' "' �, ✓t� G✓l f-� Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date . To5ofwallrepectmForm Sut LrfaceSewage0lsposal System,Page 10of 17 t5ns 313 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -/Not for Voluntary Assessments d~ Z/ G,V,1-e/Y�iG�� / G Property Address � Ow ner Owner's Name !L information is rs y�,�r f r�� � 0,;G a required f or every page. C yrrown State Zip Code Date of Inspe lion D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Mateial of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *A.tach copy of current pumping contract (required), Is copy attached? ❑ Yes ❑ No TW0501fidal InspectionForrn Subsurface Sewage Disposal System-Page 11 of 17 15ins y13 a Commonwealth of Massachusetts Title 5 Official Inspection Form IS stem Form - Not for Voluntary Assessments Subsurface Sewage Disposa y Property address 11 ino ner ON ner's Name information is _.._— required for every State Zip Code Date of nspe tion page. City Rbwn D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet 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.): / y ©/ s �/ -------------- .. ............................ .... .......... Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass, Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title501ficiel impectionForm subsLeace sewagaOlsposBI System-Page 12 d 17 15re•3M3 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -/Not for/Voluntary Assessments lug Property Address I Owner �ner'sNan-e information is /�/ i i/I t/��O O �rs`1�ovtS required for every State Zip Code Date4flpe�tiony_ page. City/Town D. System Information (cont.) 6Y & Type: ,-• leaching pits / number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): n� �l � � � ✓1 �r� .� a9 ' f0 n 0v� cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Tide 5 Official ins pec bon Form Subsuface Sewage Disposal System.Page 13of 17 0ns•Y13 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments // 0 C��e 6GC� Property Address ory ner Cw ner's Name information is ✓s f �/� �a g required for every page. City f'own State Zip Code Date Ff—Insp6ction D. System Information (cont.) 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,): tuns•3113 Tjoe 50fficiel Inspection Form Subsurface Sewage Disposal System-Page 14 0(17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments d ��- Property Address ON ner Cw ner's Name information is required for every page. CitYRown State Zip Code Date of In pecti n D. System Information (cont,) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where tic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately //4 c� �7 V t51ns-3113 Title 50fficiel Inspection F am Subsurface Sewage olsposel System•Page 15 d 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address PS 64 1" O,v ner Cw ner's Name information is G✓S��r j A, jzl�4 _ required for every State Zip Code Date of irispection page, CftylTown D. System Information (cont) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells l� /K"e-- Estirmated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting prop ertylobservation hole within 150 feet of SAS) L!d' Checked h local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must desc ' e how //you established the hi h g r9and water el vation: C�k Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51ns•3113 TiUe5018cial IrspectionFornc Subsurf ace Sewage Dlsposel System Page 16of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address f I Ow ner Ow ner's Name information is ✓ o rqJ � �� �� G �_ required for every page, City/Town State Zip Code Date of I spection E. Report Completeness Checklist Inspection Summary: A, B. C, D, or E checked Inspection Summary D(System failure Criteria Applicable to All Systems) completed D S tem Information —Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file P t5ma 3113 T1095Official Inspection Form SuW'A19ce Sewage Dlepoeal System-Page 17of 17 � ✓ GENERA 4, IVG TES t y ^[ �`'•jy T G4 _-- _ _ _ _ _�� c 4 EY,4 T'�Q1 vs SNOW,`t/ ARE -. a( '^'t_ ^- Tl.�• , ,+' - ( " -. -. - .may ' A�5 t�M E-fit lzATLt r'I J Z. PITCH A LINES 4111J/Mc:IM OF �/S`` , , l 1 T ER 15E SPECIF/EO3O � > ,S C .py _{ �� (/'(�,j �/{�) �� (/��} .3 A�,�t. PIPES TO A1'VO /N Tr-rE' SYS'`E'� S-'�'A�..4, "C Y'i � � �� i 1I ( i} w ; �_Y O �1i O �_L' { ! __ I. .,_�, BE' CAST IRON OR SCHEP414,E 40 PVC. ! I ! -�'.. ____ .•_ -__ } _ i-i - O O 4 .4kk SEPTIC T,4/1I�'-5', L'iSTRIBl1T10N ,50,k;E`�, 0 �. A,NO 4 EACH".N!i Pi T� StlA4,{., BE OES/Gr�E�= 1 Q o O OOO O (D � o f. FOR N,e O t l-lEE�C �OAt�/NOS �YhjE ttl s ' 1 O0 � UtVO�"R ,�Alli✓VG. ► �- ; - , ; OO � O 0 � � � I _ � S RE,tiJrJYE A,C.•,�., UNSCII TABS.,E ,�,.�TER.J.A�. CD O c� O BENEA Thr TIVE //V YE/f T 4 4,Cik4 Tr0!Y,5 f O O �D O (DO O O OF THE OIFFIISORS FOR A PIS TANC E OF �. `ter � (S'Ar�l T.�fi:� TEE- � � ., , j. Q (D C O � O O (D i /� A NO BAL KF/ .�. Yl"!TIl C�,.4 Y FRS E 1 �; J S,4NL3 4/{f'O vRgVET `/9Y1NG A �'E�S'Cc AT/0,V T YPICA�, DISTRIBI/T/O/V BOX � � _ .. , # I R.4 T6" OF Z rNINUTES PE 1�r 1NC'H 09 4.E,5,5 uo �aT�Z J]c ou�l{-�2�D NJT TO �SC.Q, E _.T L -= _ - - TYP/CAS, ,GEgC'N/NG P1 T OF HEAk rH IOV,5T NOTE O/STR/BUT10N BOX i�N013" GA.L, NOT TO SCALE B'E IV07,rr-;1z"t� 41'Ar AV / -c SYSTz��f lS �'E r 05 SERV 4 T/ON P1 TS fi'E/NFOh'CEO SEPTIC r.4NA' z5Y TYP/C41,�� _::7 G•44. SEPTIC TAN1'C ,4,v� PT10,� Tc PERCO.GATI4/o/ RATE = ±� :�_ r_I� Ail�/Efs'1CAN P,4'ECAST OFr' EQU,�3� 7.' ZlNkESS OTHERVYISE NOTEO,,44 SYSTE-R OBSEA'IYAT/4NS BY A,�� - r.�c•► ? c�t.1 1/c�T TLC Sc ,4 E C'CIr�1PO/YE/VTS SH4: I, BE /fVST�444EO 1N N0TE 7-41 rAS ,?E1NFORC,cjP T�!h''�UcaNOUT• 4=15'R,41VC�F WITll T1T�,E Y 0tc THE"37,-4TE B0A fP OF HEAL.TH W1 Tf1 E4 ECTRIC YY�4��EG' kVX,5'Z'- PYIT11 Z 4 - �z'" tiSANI TARY COOE AN,7 ANY 4 OCA4, AVkEIS ENG/NEE R ARROi�V ENG/NE'ER/NG />�� �y,�d E_.t�IBEO0E0 S72 E7 C. l'?OP,5 /Ail TOP� BG TTOW, I�YHICH �I�4 Y APf'k Y SATE-: -1 - , - _ - CDNCRE-TE /5 4 00 0 PS:/ TS S T _ _... ..- NOTE ACC,E55 MANHO,C_ES To S,EPT G TANK A ND I.,EACH11VO PITS TO B,E f3U/,C.JT UP TD 74 ___ t. E y' = 5ord 1z C3�LoW F/.N/SH G,QAO,E. " --t WISH GRAOE 011ECf 74- ,V FIN/ H vFr'AOE FI A11514 G,QA D,E O VE,Q �OYE _ 1 BOX F'J T = �+o P �_ _ ✓ _. / '7�"'� li Dios irrh`ail �c'`t � . . r E.GE +z LEACN/ G Ire _ � FA,S>TON t!:._ 00 1 ANY 0 C �0a`►� 3 1 , ` n p oc �1 a� OF /4"/:,2 1/1l 4t to i r °0� Y m U � C:1 � O BE YE � �` �-U� � 'C '� � �.�C;�N.,h'�"-E �'+ � t: STr9Bd: ) o a` r a r,` OTT B CO/'1 {l �^ i 61, i C,,EACH/N6 /=/7- TO BCE .LF VEL ,5 TA B,C E j TYP/CALL SEWAGF- 5V5T,EM P,�oFj�.� 7.. NOT To SCA,� E: � A _ 4�fAP' SECT/O/Y P4RC&, OT 4fad�r�ESS \\\\ ..__. _._.- __ ...-. ___.- - -- --- --- - ----------- -- - R _ _ - �� -�CAN//11G P1�5 T`t'/CT fC C�QO N,$.Zr4ft' ZC?�►/ _. �Es1GnI cR1TE�lA PROPOSER LOCATaON OF PMEZZ,/NG NUMBER' of BEDROOMS �'. EX;°°;ST "GN T CSC/R ___. h' t� � SEWAGE 0!s✓o�'05A t5X5TEIV PERSONS PER BEDR00M ._ '7R0ROk5,ER CON TOUR GA�(,A.ONS PER PERSON PER PA} �C EACf /NG 1 L-- k f A �C,EACNING PRQY/PEO `_'..' -. P6"14?C0kAT,10N TEST NO O/SPOSA�, ?f3SERt�4T/Q 1/ PIT �4PP4ICANT : ENGINEER : _>��'�'1= JTAZ �>.JtT C. A,RRCIIkY EN61NFE911V G INC. CoO E F,44C1/©UT9 hWWY. SE'!NE'R DES/G/�V , j--' �::. ���,�.���.� �! ►- t S1PEINAL4, = do -''r ti 4 < x °2 µ 7 r �,_ .SC.44E ©ATE ' SHEET BU T TOM - 'fir K !1` x - `'S �i4 ' i7 4-7 1 4 �, AS NOTE17 y TO TA�, = 4 �-3 �r P PR..4YY/1/ BYE CHECKER SY, Af'i'F B Y: Rk,4N NO. a�. : fN SN �e