HomeMy WebLinkAbout0005 CARLISLE DRIVE - Health 5 Carlisle Drive 1
M5tons Mills P _
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SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION rORH
Address of property S. Ca r- ) ; 5 e o,,-. 0,5 �<n_r v ,
Owner's name
Date of Inspection
A 5
PART A
CHECKLIST
Check if the following have been done:
IL Pumping information was requested of the owner, Occupant,Health. and Board of
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.
As built plans have been obtained and examined. Note if the
/ available with N/A. y are not
The facility or dwelling was inspected for signs of
✓ g sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on
site. the
The septic tank manholes were uncovered, opened,
the septic tank was inspected for condition of bafflesand horitees, of
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has
been ine
on existing information or approximated by non-intrusive tmethods..based
The facility owner (.and occupants, if different from owner provided with information on the proper maintenance of' SSDS,were
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SUBSURFACE SEWAGE DISPOSAL SYSTEM •INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
o2+Lo4 number of bedrooms
_0 number of current residents
_No garbage grinder, yes or no*
� 5 laundry connected to system, yes or no
ES seasonal use, yes or no b_.4
If nonresidential, calculated flow:
Water meter readings, if available: / q�y = �$� oc� y �/� >
M v 9 S Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
o p,/ Y, ✓� N S i' L L v r S C^ L
1 ✓'e-el, A—tM..a.. on 4•- ":V/c_H
o System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
—I 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)
Approximate age of all components . Date installed, if known. Source of
information:
4tiv c s - 6�
G` G r K �r 6 l t D 4-
-NO Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade:
material of construction: concrete metal FRP other(explain)
dimensions: Jr' / X 1 / 0 0 o C,
sludge depth
1 `10 'distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
1 distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
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c0. 0.c..e, .. ✓ S 4-7-1 c-4LJ re- t AlO fi H !n.c e_c t 6 �J✓M,h h
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DISTRIBUTION BOX: L
(locate on site plan)
W; T� depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
o J �.►� � � � C A i t� o _ k, 6 A - 'e- ,
CJ o C/) C...�-✓ it�j o �/ may^
PUMP CHAMBER
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
conition of ege
c� S tation, recommendations for maintenance or repairs etc. )
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CESSPOOLS (locate on site plan) :
number and configuration
depth-top ,`of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments :
(note condition of soil , signs of hydraulic failure, level of ponding, `
condition of vegetation, recommendations for maintenance or repairs,etc. )
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION Continued
SKETCH OF SEWAGE L=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
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DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
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SQBSIIRFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORH
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y. N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
NBackup of sewage into facility?
Discharge or ponding of effluent to the surface of the
surface waters? ground or
L Static liquid level in the distribution box above outlet invert?
N� Liquid depth in cesspool <6" below .invert or available volume< 1/2 da}
flow?
�v Required pumping 4 times or more in the last year?
number of times pumped
.� Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltr atio n. tank failure �. lure imminent.
t / Is any portion of the SAS, cesspool or privy:
/Y below. the high groundwater elevation?
.� within 50 feet of a surface water?
.� within 100 feet of a surface water supply or tributaryt a
water supply? o a surface
ce
within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well?
less than 100 feet 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 ana1K.
. for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
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SUBSURFACE SEWAGE DISPOSAL SYSTEK INSPECTION FORK
PART D
CERTIFICATION
Name of Inspector
, 1 I ; G jA s
Company Name -
I ro Se �-;
Company Address vo
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Vone:
I
have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303 . Any failure criteria not evaluated are As stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector's Signature
Date / ( 1 �� s
original to system owner
Copies to:
Buyer (if applicable)
Approving authority
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LOCATION SEWAGE PERMIT . NO.
V .VLA G E
t<:l1::.S,.TA LLER'S NAME i ADDRESS
•..U.{L D E R OR OWN ER
D.A,T: E PERMIT ISSUED ,r �Z
0:AT'E COMPLIANCE ISSUED y ;;;1pe
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LOCATION SEWAGE PERMIT NO•
VILLAGE Ls
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I N S T A LLER'S NA-ME i AD`DRESS
0 U I L D E R OR OWNER
IAKI X h Ff'TS rc'S�L 7-
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED X/y
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1 THE COhiKIONW-EALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tw ..-........ -oF.........1 u. z-:4., 4ff.......................
Appliratiun for Disposal Works Toustrnrtiun funfit
Application is hereby made for a Permit to Construct (✓j or Repair ( ) an Individual Sewage Disposal
System at:
........... , 8....... A4� ,�F...D.� .,1?�.T. ✓rL,�.t '_. tr' ? �.. �..�1�9.
Location-Address or L9t No.
Owner Ad ess
a ---•-- --•---------------------------------------------------------------------------------•-•----•-•----
Installer
� Address
U Type of Building Size Lot...,OvG..Sq. feet
Dwelling—No. of Bedrooms.................0......................Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Buildin
a Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other fixtures
W Design Flow....................t�.�................gallons per person per day. Total daily flow.................,0dl'-;,FQ..............gallons.
R; Septic Tank—Liquid"capacity~.gallons Length---&-$W. Width................ Diameter------.......... Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------/......... Diameter....,O...!!�4.1- Depth below inlet.....�7--.Q..... Total leaching area./7 0sq. ft.
z Other Distribution box Dosing tank )
Percolation Test Results Performed by.41 1. Z - -e---"�.. AAA:W_ Date.......941,�l..............
Test Pit No. 1....4.Z....minutes per inch Depth of °Pest'Pit.....1 ¢... Depth to ground water---&VO 1C.,-..
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ---•------------------------------ •... .. ••----..---------•-------........---
® Description of Soil....................
/. r �� 'f! " � -
x
U -----------------••----....-----------••-------......---------•------••--•--------...----•--------------•-----------------------•---•------•------•-----•----.....----....-•----...........•-•..__......
W
x ---•-••---------------------•------•-•-----•----••••---•••-•-••-----••-•••------•-•-•-•----••-•-•---•-----•-••-•----------••----•-•••----•••••-•-•...•••-•----•-•.....•••--•-•--••-••-----•----•---••-
U - Nature of Repairs or Alterations—Answer when applicable.......................:.......................................................................
------------------------------------------------••-•-------•--------------------•---•-•---••---......------....------------------------•---------------•--- ------------....
Agreement:
The undersigned agrees to install the aforedescribed I dividuaI Sewage Disposal System in accordance with
the provisions of TiTIE 5 of the State Sanitary Code— e u dersign further agrees n lace the system in
operation until a Certificate of Compliance has been ' s by boar o
Signed-• -• ------• ...................................... ......... ....................7'
............ate
Application Approved By..
Date
Application Disapproved for the following reasons-------------•--------....--•----••---------------•----------••------------•-----•-----------•-••--•....--•--•---
----•----.......••••----•-----•-•--•--•-...•---------•-•-••---•--•••••--•••--••••---------------•------•-•••----•-._.....-•----•--•-----••-----•----••-••••---••••---•-- ...............................
Date
PermitNo......................................................... Issued_.......................................................
Date
................
THE COMMONVtnEALTH OF MASSACHUSETTS
BOARD OF HEALTH
` L...............OF.........10�?�ic/�T/-7/ ..._............
ApplirFatiun for Disposal Works Tonstrnr#iun ramit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address t No.
...........< i �;��✓ .F E ? c"a;�T"� % :...�r. .:...�......�....... ..rac....... .......... .............................
W y
Owner Address
,-� ---•-•-••••................. -----.....-.-.-...------------------------------ ...---...---------------••----••----•--......-.--.................�V.....................•--
� _ •nstaller Address
Type of Building Size Lot..-':5.._f-�-�--...Sq. feet
Dwelling—No. of Bedrooms................., .......................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures -----------------------------------------------------------------------------•----------------------------....-----•---..........-••••-••.....---••-•.
W Design Flow................... ................gallons per person per day. Total daily flow................25- .5 ..............gallons.
WSeptic Tank—Liquid capacity/ gallons Length...,!!: i2. Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........./--------- Diameter.....l0- .. Depth below inlet.....;-.%-.•--.... Total leaching area,;_MZ 9. sq. ft.
Z Other Distribution box (tom' Dosing tank ( )
`-' Percolation Test Results Performed Date......: 6121---------------
a Test Pit No. I.... .Z...minutes per inch Depth of Test Pit-....14A:�... Depth to ground water..A/a�'- .__..
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' •.........._
..
0 Description of Soil.................... �� ��i�✓sv���. �G� " ��°� f�.��'� _...���:°c�.................
U ---------•--------------------------=--------------=----------•---•----- =
--------------------•-------...------------...---------.......--------------
W
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
== =-•--•---•••..••••••••-----•••-•-••-----••--•••-•-••----•-•••-•....---•-••-•••-••--•-•-••••-••---••----••-•-••...._.
Agreement:
The undersigned agrees to install the aforedescribed dividual Sewage Disposal System in accordance with
the provisions of:ITL; 5 of the State Sanitary Code— e dersig further agrees n place the system in
operation until a Certificate of Compliance has been . s b e boar o
Signed..... .......-•-••- ------ --------- ------------------•- -•- p
.................
Dat
Application Approved By••-•--• � ------------- - •----•------------------------••----•-- /���,/�?d0L_-
Date
Application Disapproved for the following reasons--------------------------------------------------------•----------------•-••••......•--- ----------••...._..
.................................................................................................... ---------------•-------------------------------------------------------------------------------
Date
PermitNo....................................... .................. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...
Trrtifiratr of Tuntplittnrr
THIS IS TO_CERTI Y, That the Individual Sewage Disposal System constructed ( ) or Repaired("')
by---....................K ....------....----------..........-----------------------------•-------......--•--.......-----•----•-•---....---
Installer
has been installed in accordance with the provisions of TIT Z 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...__r.__z"'f� ............... dated..-_---_..:_----__---_--_-____-------_.----•-.
THE ISSIIAN E F THIS CERTIFICATE SHALL NOT BE CONSTRID 'A ARANTEE THAT THE
SYSTEM WILL U TION SATISFACTORY.
DATE.....f�..��.. 1 .......................................... Inspector....... •. ....... .......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF:....................................................................................
No.....f?.:n-CZ. FEE.... !..............
Disposal orkg Tuntr iun rrntit
Permission is hereby granted..............
to Construct ( ) or Repair ( ) an Individual ewage Disposal System
atNo................. .,. '. ....:.....�� ...............................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
------------------•-------------•-••......-••--......
DATE. Board of Health
,,lli,/..�,;X6" .......
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
TOWN OF BARNSTABLE
LOCATION .S C_4,- ) SEWAGE #
M
VILLAGE �---��--ASSESSOR'S MAP & LOT l 22 I O1
INSTALLER'S NAME S& PHONE NO. CT7 ke-y
SEPTIC TANK CAPACITY /y� V s• � � o V,
LEACHING FACILITY:(type) �XG ( et �- (size)
NO. OF BEDROOMS-?f L,,.Fq PRIVATE WELL OR PUBLIC WATER . )c
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VA RIANCE7 GRANTED: Yes No
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I TE PLAN • T YPIC4L PROFILE
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SCALE NOT TO SCALE
L— l " - y
\ _ _ /8` STD. L T WGT C./. MH CO VER
4'C I. PlPf 4"BIT. FIBER PIPE TIGHT JOINTS
t �!/ —-
�•�- ----- —------- OUTL E T L E VEL
min FLOW L/NE _ 0 - - TD FIRST JOIN _
' �� o DWELLING F2.
o j '� -
.I. TEE J 'c c.! TEE H2_3 7
G7 STANDARD PRECAST -� f 4-
l _ CONCRETE GALLON L_g
/ w SEPTIC TANK t e„ TION BOX
fl - -- _ __1 D O SB IN T L L ED ON
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4 LEVEL , STABLE BASE.
N et.Q SEPTIC TANK
/ I TO BE INSTALLED ON
+- --- __- L
/ - 'LEVEL , STABL F BASE
7
2 - 118 TO I/2 WASHED PEA STONE
� LEACHING ALL AROUND FREE OF IRONS, FINES BASE TO HE
LEVEL
PIT
AND DUST IN PLACE�u
BRICK 8 MORTAR COURES 3/4" TO if '-//2 WASHED CRUSHED
A AS R£OU/RED TO BRING
_ STONE ALL AROUND FREE OF
M
COVER TO GRADE 24"C.I. H COVER ` IRONS, FINES AND DUST IN PLACE.
f AND FRA ME
} _ '%ram• p��:t,d-7�' GPti, / / ,.
,s F3A I k-1 }
LEACHING PIT SEC T
/ON-
'
4 _ 8' FLOW L 1NE
-- -,
r . - INL ET--r --
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1. CONCRETE TO BE 4000 PSa 28 DAYS
'1 Y ♦ - 1 i' i �. 2. REINFORCED WITH 6" x 6" NO. 6 GA. W.W.M
3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREATER
t i
w � DEPTH REQUIREMENTS. -
O�EN/NG W/TH 4 //8•� 4. NUMBER OF PITS REQUIRED -1
OUTER DIAMETER 8 NOTE" EXCAVATE r0 ELEVATION --10•50R LOWER AS
/ 3/4 /NS1OE DIAMETER 3" RE UIREO TO REMOVE ALL LOAM AND CLAY BENEATH
PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN
GRAVEL TO DESIGNED GRADE
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EFFFC r'VE OIAME TER
/ (vo r TO iE•XCE<D - FFEC,WATER TA&LEVE DEPTH)
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S_OfL AND i7E RC. DATA GENERAL NOTES --
PERG. RATE 4 2 MIN. /IN . NO 'iEAVY EQUIPMENT TO RUN OVER SYSTEM.
� _ A ` � � = ti_;_-_< SEPTIC TANK, DISTRIBUT!F.^� BOX , LEACHING PITS TO BE STANDARD,
t
TEST BY `� --- -- E PRECAST REINFORCED CONCRETE JN! fS
WITNESSED BY '�- `" _ _ � —u ' ALL SYSTEM COMPONENTS SHALL 9E INSTALLED IN : ^CORDANCE
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE ,
,.' ?EST P!- GR F: DATE 3 / �/ y'' 'AlNIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF
SANITtRY SEWAGE EFFECTIVE I JJLY 1977,
TEST PIT NO
TEST PIT NO 2
A S c AN MUST BE APPRO FD BY THE
0 ---- - _ .
_. ;• - , ,__.__ T ANY
C H A N G E S T O .T kt
..
OF HEALTH
AT COMPLETION OF C:;NST41,ICTION , PRIOR TO BACKFILLiNG, --HE
I
t;)ARD OF HEAL- H SHALL BE N07►FtED FOR INSPECTION.
C ; -
�. PITCH ALL SEWER I INi -' '4" / FT UNLESS INDICATED
OrHFRWISE.
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'= _ _- _.: NM M. r ARWICK i ASS0C/A7ES
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