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HomeMy WebLinkAbout0036 CAMMETT LANE - Health 3 5 CAMMETT LANE ATARSTONS MILLS A v3 q _---- -- ---- - ---- --------_ _ _ i � 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE;OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION fd1AP PARCEL 0 3 q LOT TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 36 Cammett T ane RECEIVE® Marstons Mills, MA Owner's Name: Evart Pilayis Owner's Address: AU G 1 900 . Date of Inspection: 'j— — TOWN Or BARNSTABLE HEALTH DEPT. Name of Inspector:(please print) W i 1 1 i am F_ •Rob i n son Sr. - CompanyName: . William E. Robinson Septic Service Mailing Address: P .0._,Box 1 089 Centerville, MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and.that the information reported. below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the.proper function and maintenance of on site sewage disposal systems.1 am a.DEP approved system inspector.pursuant to Section,15340 of Title 5(310 CMR 15.600). The system: L'I ses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: a ✓�' Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 1 Page 2 of I 1 OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART A t CERTIFICATION (continued) Property Addiess. 3 6'--Camme -Marston Owner. Evan Pilavis Date of Inspection: o Inspection Summary: Check A,B,C,D or E/ALWAYS complete.all of Section D A. :yst Passes: e failure criteria described in 310 CMR cafes that an 0 f th dt ,have not found any information which m y 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced On y Pigs. re aired.The system,upon completion of the replacement or repair,as approved by the Board of H , An wer yes,no or not determined(Y,N,ND)in the for the following statements..if"not determined"please exp in. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits,substantial.infiltration or Wiltration or tank failure is imminent System will pass inspection if the exist' g tank is replaced with a complying septic tank as approved by the Boardof Health: •A m tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indica'ng that the tank is less than 20 years old is available. ND ex lain:. Observation of sewage backup or break out or high static water level in the distribution box due to-broken or or uneven distribution box.System will pass inspection if(with obstru ed pipe(s)or due to a broken,settled approv 1 of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expl in: e system required pumping more than 4.tmus a year due to broken or obstrtxted pipe(s).The system will pass inspe tion if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain. Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALS,YSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address 36 Cammett T,anP - Marstons Mi 11 G r 1`L Owner: Evan Pjlayi Date of Inspection: 7' D C. Further Evaluation is Required by the Board of Health: onditions exist which require further evaluation by the Board of Health in order to determine if the system'` is failin to protect public health,..safety or the environment. 1. S tern will pass unless Board of Health determines in accordance with'310..CMR 15.303(1)(b),that the, sy tem.is not.functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50:feet of a bordering vegetated wetland or a'salt marsh. 2. Syf em will fail unless the,Board of Health(and Public Water Supplier,if any)determines.that.the system s.functioning in a manner that protects the public health,safety and environment: The system has aseptic tank and soil absorption system(SAS)and the SAS is within 100 feet of a su ace 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. _ e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a priva water supply well".Method used to determine distance - "Th system passes if the well water analysis,performed at DEP certified laboratory,for coliform bacte is and volatile organic compounds indicates that the well is free from pollution from that facility and.. the p sence of ammonia nitrogen and nitrate nitrogen is equal to or.less than 5 ppm,provided that no other fail criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SY$TEM,INSPECTION FO , PART A CERTIFICATION(continued) Property Ad dress: 36 Ca P arstons Mill ►v1A - Owner. Evan Pilavis _. ._ Date of Inspection: 7 v D, Failure Criteria a stem pplicable to all systems:. You s'e indicate"yes"or"no"to each of the following for all inspections: ustYes o 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 4 _ 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 _ Required pumping more than 4 times in the last year OT due to clogged or pipe(s) obstructed :Number N of times pumped _ Any portion of the,SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ within a private vrater supply w Any.portion of a cesspool or privy is in 50 feet o ell. _ Any portion of a cesspool or privy is less than 100 feet.but greater than 50 feet from a private waur supply well with no acceptable water quality analysis.[This.system passes if the well water analysis, PP y wand vb6t'0e`organic'comp erformed at a DEP certified laboratory,for coliform bacter� P ` indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form:] (YesMo)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. arge Systems: To considered a large system the system must serve a facility with a design now of 10000 god to 15,000 gPd- You In t indicate either"yes"or"no"to each of the following: (The foil wing criteria apply to large systems in addition to the criteria above) yes no . th system is within 400 feet of a surface drinking water supply the s stem is within 200 feet of a tributary.to a surface drinking water supply the sys em is located in a nitrogen sensitive area(lnterim Wellhead Protection Area IWPA)or a mapped Zone II of a public water supply well . If you have answe d"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D bove the large system has failed.The owner or operator of anY large system considered a significant threat un er Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system caner should contact the appropriate regional office of the Department. . � 4 r Page S of 1 I ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 36 Cammett Lane Marstons Mills,, MA Owner: Evan P i l av i G Date of Inspection: 7--Q—O'7!> Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No/ Pumping information was provided by the owner,occupant,or Board of Health; r�Wcre any of the system components pumped out in the previous two weeks? ; ✓_ Has the system received normal flows in'the previous two week period Have large volumes of water been introduced to the system recently or as part of this inspection.?, Were as built plans of the system obtained and examined?(If they were not available note as,N/A) Was the facility or dwelling inspected for signs of sewage back up? d _ Was the site inspected for signs of break out Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material 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:: Yes no Existing information.For example,a plan at the Board of Health. ' r/ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CUR 15.302(3)(b)j 5 r - Page 6 of 11 OFFICIAL;INSPECTION FORM-7 NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C; SYSTEM INFORMATION Property Address: 36 Cammett Lane Marstons Mills. MA Owner: Evan Pilavis Date of Inspection: : -4 -0 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): 3G G Number of current residents: Does residence have a garbage der(yes or no):Ae 'P. is laundry on a separate sewage system(yes or no):Ati6 [if yes separate inspection required] Laundry system inspected(yes or no):ALU Seasonal use:(yes or no):�v Water meter readings,if available last 2 yClis usage d 2 0 0 2' 9 4;0 0 0 Sump pump(yes or no): J1- O 2 0 01 -61 , 0 0 0 Last date of occupancy: COMMERCIA NDUSTRIAL Type of establis ent: Design flow(bas d on 310 CMR 15.203): fnd,: - Basis of design o.'.:w(seats/persons/sqft,etc.): Grease trap pre ent(yes or no): Industrial was holding tank present(yes or no): Non-sanitary aste discharged to the Title S system(yes or no): Water meter eadings,if available: Last date of occupancy/user OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: /r/ dv Was system pumped as part of the inspection(yes or no): d If yes,volume punipcd:__gallons-=How was quantity pumped determined? Reason for pumping: TYP,L OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):Afu 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT-FOR VOLUNTARY ASSESSMENTS SL`BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .' PART C SYSTEM INFORMATION-(continued).. ; Property Address: 36 Cammett Lane Marstons Mills, MA Owner: Evan Pilavis Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of cons ction `_cast iron 40 PVC ._other(explain): Distance from p ate water supply well or suction line: Comments( condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: r aocate on site plan) Depth below grade; c/ / Material of construction: concrete_metal_fiberglass_polyethylene _other(expl.ain) . If tank is metal list age:_ Is age confirme&by a Certificate of Compliance(yes or.no):_.(attach a copy of certificate) t Dimensions: I? Z. Sludge depth:- 'I�Ir Distance from top of sludge to bottom of outlet tee or baffle: Ad Scum thickness: 6 Distance from top of scum to top of outlet tee or baffle: �l Distance from bottom of scum to bottonA of outlet tee or baffle: How were dimensions determined:0 i`zs-'- Gd z Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): BYE—G �� l'" >y,*. L w � /s�✓ V c C w I✓�- GREAS TRAP:_(locate on site plan) Depth belo grade:_ Material of onstruction:_concrete_metal_fiberglass_polyethylene_other. (explain): Dimensions: Scum thickn ss: Distance fro top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle:Date of last umping: Comments n pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION`.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM`INFORMATION(continued): Property Address: 36 Cammett Lane ' Marstons Mi_11 s, MA owner: Evan Pilavil Date of Inspection: �o an cafe o ns ite l . o )ction 1 , TIGHT or HOLD TANK; (tank must be pumped at time of inspc )( . ..., p _ Depth below grade: _�. Y Y Material of constructi n: concrete- mewl fiberglass of eth lene other(explain): Dimensions: Capacity. allons Design Flow: allons/day Alarm present(yes no): Alarm level: Alarm in working order(yes or no): Date of last pump g: Comments(condi on of alarm and float switches,etc.): DISTRIB UTION BOX: " (�t 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order()es or no): Alarms in working order qycs or no): Comments(note conditio of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Cammett Lane MArstonc Mills , MA Owner: Fj7an pi au, c Date of Inspection: SOILABSORPTION SYSTEM(SAS):Zoocate on site plan,ezcavation'not required) If SAS not located explain why: Type eachmg pits,number: 7 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system .Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,'damp /soil,condition of vegetation, etc.): CESSP OLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Number a d configuration: Depth—to of liquid to inlet invert: Depth of so'ds layer. Depth of scu layer: Dimensions o cesspool: Materials of c nstruction: Indication of oundwater inflow(yes or no): Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: ( ate on site plan) Materials of cons ction: Dimensions: Depth of solids: Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of l 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART C FORM SYSTEM INFORMATION(continued) Property Address: mmett Lane 1�l41stons Mi s, MA - Owner: � p; 1 av—is Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. po Y gy ya 3L1. . 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3h Cammett Lane MarctnnS Mills- MA " Owner. Firs„ v Date of Inspection: — —p SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established.the high ground water elevation: y y 11 iIt TOWN OF BARNSTABLE LOCATION aOCGJM(NkQAiSEWAGE # VILLAGE S `l ' 1L �_ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wets exist within 300 feet of leaching facility) ` Go Feet Furnished by d' �5Ins6 gc 0 c COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION I a a d r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039�— Owner's Name: HENRY PERRY C/O FRAN CANARIO Owner's Address: 9 NANCY LANE MASHPEE MA.02649 Date of Inspection: 511101 S D Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS 001 Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536Telephone Number: 508-564-6813 FAX 508-564-7270 PT.BLE CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15I,340 of Title 5(310 CMR 15.000). The system: �, X Passes _ Conditionally Passes _ Needs Furthpd 9valuation by the Local Approving Authority Fails Inspector's Signature: Date: 5/1/01 The system inspector shall submit 1copy 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 (low 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. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 0264E M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a r _ _ Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ]This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection '? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out" X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil stem Absorption S A p y (SAS)on the site has been determined based on: Yes no X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] S Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: 4/1/01 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1988 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 24" Distance from bottom of scum to bottom of outlet tee or baffle: 0" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD P OF WATER IN AT THE TIME OF THE INSPECTION. PIT HAS NOT HAD MORE THAN F OF WATER IN IT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a n Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I A (4 pec1C A o � 09 AB �� AC _1'' 4 S-/L L �I in • ; Page 11 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 CAMMETT LANE MARSTONS MILLS,MA 02648 M099 P039 Owner: HENRY PERRY C/O FRAN CANARIO Date of Inspection: 5/1/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET 1 No .- ..ram. Fss THE COMMONWEALTH OF MASSACHUSETTS BOARD �F��HEf- LTH icon OF.........f3al. ..n.I.l .r�U Apphratiun for Diupuuttl Warkii C9unstrur#iun rrrmit 0 Application is hereby made for a Permit to Construct (k or Repair ( ) an Individual Sewage Disposal �Ss at. 1-6 (Z ..................U_� .. .... cation- r s or Lot No. fie) ............... .- - n ------------------•----- ---------------------------------.--•-•--- - - O Address Installer Address U Type of Building Size Lot.. j_d©Q...Sq. feet �.. Dwelling—No. of Bedrooms.............CQ--.._---------___---.-Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building .......... No. of persons............................ Showers — Cafeteria Pr Other fi u es ----•-------------•-----•---•-•. _ % W Design Flow..................... ......._ .gallons per person per day. Total c ily�flow.:_..__..... S�Q.. .......... bons. WSeptic Tank—Liquid ca.pacity......_._...gallons Length.. ... Width.:!........... Diameter................. Depth.. ............ Disposal Trench—No..................... Width.................... Total Length............. Total leaching area____..... .... ...sq. ft. Seepage Pit No.........I........... Diameter......'01...... Depth below inlet......��....... Total leaching area.,51..1°. 1;.4e.6?�. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed bY------ I ..t,..................;�9.. ... Date....6............................... a Test Pit No. 1-----.... __minutes per inch Depth of Test Pit...... ... Depth to ground water..U------- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -••---------•----------••-•........................................•----••------•---........--•-•---....-------•-------•--...---•-------•--•--............--. 0 Description of Soil........ ---------------•-----------•--•--•-•-•------------------------------------------•----•-----------------------------.._........_.. x W ---------------------•-•-...--•--------------••---•-•----•-•----------•------•-------•-..._....--••------•-•----•----.._....------•--•-------•-••-------------------•---•--•-•-.......---•-•---•-....... UNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------------------------------•---------------------........--------------------------------------------------------------------------------------._..................---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT , y g g p y 5 of the State Sanitary Code— The undersigned further agrees not to place the system in eration until a Certificate of Compliance has been issued by the board of health. Siaed.......... _- ---------- - ----------- ---------- ------------.•---- ..........................- �� Dale Application Approved By..............� _ ax _ _ -- 2:_ jl!p��'._ ---- Date Application Disapproved for the following reasons-------------------------------------•---...------------..._...------------------------............--•-•-........ ....................................................-----------•------.......----------•----------------._...........--•-------------------------------------------------------------------------....._. Date Permit No.--- --- Issued---------------........................................ --._ ..-•----� Date q 7 Z Qa_ ...........Noll ...... > THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. ..................1UQ0 . _� - �1, -.5 �,. � ........................... ....OF..... ....... Appliration for Uhipaoal Works Toustrurtion Vantit Application is hereby made for a Permit to Construct (1) or Repair an Individual Sewage Disposal System at- ii- ) Of C( .................. ...................... 'A .....k....111 k)..... . ................. _1' t')n-Address ...................... . .................................................................................................. Owner Address JjE�c) (y) .................. .. ............................. .................................................................................................. "-ng 1.7t7all;r Address 410 Type of Building Size Lot..............C. ...C.-)....Sq. feet Dwelling—No. of Bedrooms.............C-2........................Expansion Attic Garbage Grinder Pk Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P. Other fixtures . -------------------------------------------***"*----------------*--------------------------------*.......... ----------------Design Flow.................X)...'..........:......gallons per person per day. Total daily flow............�Q................g-411ons. . Septic Tank—Liquid capacitv.!(XPgallons Length.-b.......... Widfh.��.... Diameter............... Depth. 5�.... i; Width_._.__..._....._.... Total Length_...___.._.._..,...: Total'leachingarea....................sq. ft. Disposal.Trench—No.................. 0 1 1 Seepage Pit No.........I........... Diameter......A0 .1...... Depth below inlet-%40 _11,� �j p...j.. ...... Total leaching area.!allt.d�sq. ft Other Distribution box Dosing tank ( ) I r ,ct Percolation Test Results Performed by......uui)-i.................�.f.......t. 9.. . ........ Date.... ........ Test Pit No; I......—A--minutes per inch Depth of Test Pit.....�AT�... Depth to ground water..rM, rT4 Tesil Pit No, 2.....­.­.....­.minutes per inch Depth of Test Pit--_--__--.-.____-_- Depth to ground,water....._.................. ............. 1 y .................................................................................................................................. yw 0 Description of Soil........... . ................................................................................................................................................ ------....PYI(A................................................................................................................................ ----- ..... ................................................................................................................................................................................................. 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 T I T 1E 5 of the State Sanitary Code.— The undersigned further agrees not to place the system in erat* m until a Certificate of Compliance has been issued by the board of health. Si,gVd­................................................................................... -------------------- .......... Date V ................ pp,, Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date 41 PermitNo.--.... - ----------------- ....... Issued_........................................................ Date ——————————— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ .....OF............................ ........................................................ (Irrtifiratr of Toutpliatta THIS IS TO (qERTIFY, That-the IWividual Sewag e Disposal System constructed --T—or-Repaired .... ..... by..................... ..........=.. ........ ---------------------­*.........."­------------­----- ......at.................. 4 ........... ...................................................................... * has been installed in accordance with the provisions of T. ate Sanitary Code as (1, cri ed in the da application for Disposal Works Construction Permit No.. ............ a.... ted- ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT,THE SYSTEM WILL FUNCTION SATISFACTO RY. Inspector..................................................................................... DATE..... `:) !-v------------------------ ——————————————————————THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH r---__ N - -- -1 14�zw�s7ro 0 ...................................... ..........................................OF......................... .................N FEE�� ......... .. ........... Disposal lvv�h onotrudion "Pamit ................................................................... Permission is hereby granted_.....�- RA........ to Construct ir an Individual ewag Dispol System a .................................................... ........ t No............ . ...... Street as shown on the application for Disposal Works Construction Permit No-_-._---_---~_'_'-----(- Dated ..... ------ . ........... .... .... ... .............. ........................ DATE_C�. A�L_Q_8 ...0�......----------------- ------------------­----- Board of Health -------------- r-r � 1 VJ_t�C� 1LMT)2n7)tin ti n x aew ST��a. 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