The URL can be used to link to this page

Home My WebLink About0015 GOOSEBERRY LANE - Health 15 GOOSEBERRY LANE, r A= 102 059 GtrSn s 1r1%1 L.o:r 33 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property f5 6col��r-AERR,, LV /'1144S�oN,5 n11-44 /',45S Owner's name Date of Inspection 12 FART A CHECKLIST Che k if the following have been done: Pumping information was requested of the owner, occupant, and Board of ./ Health. Y 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 they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive .methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 11 l2 °� �MLIY6M J U N 2 9 1995 0 w moot q 8 g c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms — — number of current residents 6=_ garbage grinder, yes: or no ,�� laundry connected to system, yes or no „ seasonal use: yes or no If nonresidential, calculated flow: Water meter readings, if available: a / ou Last date of occupancy GENERAL INFORMATION Pumping rec rds and source of information: ct �r A.'ME: acr, r gg2 06f 1gq,3 System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Ty of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: _ 1 8 H No Sewage odcrs detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:—V—/ (locate on site plan) am depth below grade:_ l material of construction: co ncrete metal FRP other(explain) dimensions: YX 4 x = lODO CrAL sludge depth _ distance from top of sludge to bottom of outlet tee or baffle scum thickness 1` distance from top of scum to top of outlet tee or baffle /4'1 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. ) fi�,4SF rdV 2e rQ W,&W lAt G`r DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site lan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 1 l: 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 T- 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, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration �11A 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. ) SUBSURFACE SEWAGE DISPOSAL SYSTEMS INSPECTION FORK PART B SYSTEMS INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' RR,v �ID USA I ff 4�ck �' -09 42 DEPTH TO GROUNDWATER Jr_Q r depth to groundwater method of determination or approxima ion: Fs M�fi�Q 6�� 9-/V2? IVAIER 5 f5y 056-5 ZY"s fia 02 1 G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 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) Backup of sewage into facility? Discharge or ponding of' effluent to the surface of the ground or surface waters? A Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? —d-- 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) ? �I 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 analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Dio Du13c,n Company Name 15 y 3 MA1 `'T ( j w"oT E R, MA Company Address (508) Sgto- q39 0 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 conplete 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 . Ch k one : I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 Cn 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 1/2 '71q-5 Original to system owner Copies to: T—o pl V OF QNRAV.SfA&E 8.o4 H Buyer ( if applicable) Approving authority ' LOCATION SEWAGE PERMIT NO. �' VILLAGE IN.STA LLER'S NAME & ADDRESS -0h A) J MRFEE] BUILDER OR OWNER DA T E P E R M I T I S S U ED ( DATE COMPLIANCE ISSUED � •,a'•f�'� �� ,j � � .�. �?�� -� '— � � ` � t � �� s No........ ..`f�...... Fim....'. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH JOWA................0 ..................................... Aptira#ion for Diipusal Works Tonotrnrtinn Vamit Application is hereby made for a Permit to Construct ( lel*'or Repair ( ) an Individual Sewage Disposal System at: �. Location-Addr - or Lot No. S!Lt.l.l]�..cYt:l. .......... . :. CQ.:l1 .. .. ......-.... S - . .:.,1...: Lam................ Owne Addr s _. I s ]ler A[d(�ess �, U Type of Build Size Lot.. g+7171 �..___..Sq. feet Dwelling—No. of Bedrooms................5.......................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria dOther fixtures •-••-••.............•--••-•-••••-•••-----•----•••-••••.••-•••-------------••--•----•-•---•--•-••--••--•-••-••-•-•----••.._...._.....--•._............. w Design Flow.............5S......................gallons per person per day. Total daily flow..............5.�5 .... ............gallons. WSeptic Tank—Liquid capacity-.gallons Length... Width... .-So. Diameter................ Depth.. �� .... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq.•ft. Seepage Pit No...........1--------- Diameter.......co........ Depth below inlet.......(P......... Total leaching area....2§to...sq. ft. Z Other Distribution box ( ✓S Dosing tank ( a Percolation Test Results Performed by.B .&Y-T.M.F*_91 Date... a Test Pit No. 1.......L.....minutes per inch Depth of Test Pit.......i ......... Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...----................. a ----------------------------------=•...•-•---••----------•-..._.._..•-•.............._....--•--•----......................................................... 0 Description of Soil......iAtXx ?49[ ...-.M...QAOS>9.._. O�-........ - ......................................................... 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeki issued by the board of health. 3D S Signed----- _ ..� Date Application Approved By.....:.._-• •..��..............•-----••-•••----------•._._.....-- •-------•- ----------•---'r s� 7t ..... - - - •............... Date Application Disapproved for the following reasons:.......................•------------•---....._......----------•-........-------•--•-...................._..•-- ....................•-•-••--.....-----•--••---•••----•---•--•-----•---•-------••-----...---•-•--.....------.............._..-...----------•--------------.....----------------....•---------------...... Date Permit No.......r�:.y�.........---------------------...__... Issued_.. `�-�.-•�"•- --- Date THE COMMONWEALTH OF MASSACHUSETTS��'� BOARD OF HEALTH TAC,u".....O F......� �t,4-1 T/b/LC- ..............0.......... . ........................................0........................... Tatif iratr of Tampfianrr THIS IS TO CERTI Y That the Individual Sewage Disposal System constructed ( X) or Repaired ( ) by -._..�Z>�tµ- �l�i°F l --------•-- ....•--._......-•---•••-- •-•--••--•-------- Installer o O C 7C K / L k-L LG has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as describ in the application for Disposal Works Construction Permit No.--.....j9.l1z...................... dated---- ------- -'.s^:-7� . -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE®AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY �pDATE.... - rig - ..... bector.'...... , { /( --------------------•---•-••----------------•-•----- No..........:. ....... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T ...........OF. ...... ..... ............................................. Appliration for Bhipaaal Workii Tomitrurtion lirrutit 01,11" kpiplication is hereby made for a-Permit to Construct or Repair an Individual Disposal System 4t: LA- M 1_13 is ................... ............ .. .................................................... . Location-Address or Lot No. ................ ................................................................................................ ..........---------..._..............................I............................................ Owner Address Installer Address Type of Building Size Lot.....' -------Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) i,_1 114 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Pi Other fixtures ...................................................................................................................................................... Design Flow............5-S. .......................gallons per person p 13.SP.. ...................gallons. ,er day. Total daily flow---------....... .... 9 Septic Tank—Liquid*capacity l ..gallons Length...V Width.-A.Z.12- Diameter________________ Depth..` ......... Disposal Trench—No..................... Width. ............... Total Length.__._............... Total leaching area....................sq. ft. Seepage Pit No-----------k.......... Diameter...... ......... Depth below inlet_......_......... Total leaching area....:Z!?q...sq. f t. Z Other Distribution box Dosing tank ( -) '_q -�3A y .................Percolation Test Results Performed b TM 4- q jr Date...��-Z&-.1................ y-------- - .............................. Test Pit No. I-----It......minutes per inch Depth of Test Pit____-_A3t........ Depth to ground water________________________ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........._..........____ ............................................................................................................................................................ 0 Description of Soil......ft-t> 4 Ze j�.....Tp te >g SA�!�O.i.......................................................................................................................... U ......................................................................................................................................................................................................... ........................................................................................................................................................................................................ 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 TITTLE 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. Signed..................................................................................... 14 - D2:� ApplicationApproved BY----- ........................................................................................... ........... Application Disapproved for the following reasons:................................................................................................................ ....................................................................................................................................................................................................... Date PermitNo.;.-.AA............................................. ---------------------------- Date Y�kE COMMONWEALTH OF MASSACHUSETTS -1 14 BOARD OF HEALTH ............ ... .............0 .......................................................1..,,,,...�... ..... (9rdifiratr of Toutpliatirr" THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.......... ...... .....................................................................:..................................................................................... Installer at....... ...... .........14 ............................................................................................ has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the application for Disposal Works"I'anstruction PerYri�it,INO.- *. ........................... dated-------- ,,I f -7------------------------ V M44LL"NOT BE CONSTRUED AS A GUARANTEE THAT THE THE ISSUANCE OF THIS CERTIFICATE SYSTEM WILL FUNCTION SATISFACTORY. DATE.-I* - = •--------•----------------------- Inspector. 7-------------------------------------------------------- yit THE COMMONWEAL'. OF MASSACHUSETTS BOARD ji 'WEALTH I,-- Af,It j 1P.4( f-` ....................................0F................................................................................... N o........... i�,10� �Ik .......... id FEE........................ L 0" Permission is hereby granted.............................................................................................................................................. to Construct or Repair an Individual Sewage Disposal System I atNo................................................................... .............................................................................................. ..... 4 "'Works Cons�fiorAidiv- ii- it No.......... as shown on the application for Disp6,s I? ........... Dated ------------------- -------I-----------------Z.................... ........... DATE_ . ................. Board of Health' .............. ....... .............. FORM 1255 HOB13S & WARREN, INC.. PUBLISHERS vo GArz�cAc c� vrrl•.t[��2 t H Titer•! ;:LcIw . IIC) t S • S3b G.P^v T'4*4K = SSov ISO %. • ��g�r.RL7 � .._.��' ,t�..r+l.� , ' � t o USE`: �OOC] 6.41.. , '• i E r .r k POS AL PIT - USa✓ (000 GdL., Al.L AeE A z (5o s;7. ' t ` ' 15o SF ,c 2.S • 3 7S G.P.D.. ,. �,.a�., ,...�. �.� /��' $4r1'7T)AA Q¢EA s So SP. �A fry'. R t .o - SD �.PD. 1. ' a C•t � l) ' '►� ` } { ' " O TOTAL 'V ESI&W = •425 ,. L j TbTQ L �,dl�� F•Low * 330&M PWGOL&"now ' UT&II I IQ 2MI u•oR:lbKr tp, 3Zf x ''' Of '+4� ice, 1� a� ��= ! ! j:: �4 t T.: {.:t � •.. I y s r.,i .� k.! i._,r �t M�11f� ��. r ;, .A SL�1f �•` }'^i' �.;,� i � � i � � � � I f _. / � t 1t:;►PAX it I .. ^) a1 .^` 4�I 1 .11<k.i.}. je! } j {r 1.. 1 TeST S Tor l`�t+•Abe.,. _. .a., .•'y,.R. R y Q rI/P (W• COAL... C .�,� 'q4, SynUP,0-014 Ilia . . .• j , t + 000 Iwy uM. s 4 ,r±. r •t r ' 1 r ' �: . . t GILL. 96•� q�1 j Pi i I ..�,,1 • } 1 C04% WASNBD '' a } . t ` i I t CEQTtF1ED pL.�Tw Pt.-.A. PCOF--1 L E- LoCATIOW �IAr -Uj l� i N o SG e.L6- I t 1 GGtZTI *-( T�IA-r T14G_ t�wcl_(�WL S11oWIJ (;i,; PL41.!' QE�EiZE1.r}GE =}�;t • �-1F�C-�bIJ GCaN�Ph�(S W ITI�' TNT' �jIDE_Li�•IE t �; ':. , - = s ; r� AND SE•T AC4 VG4UIIZeAAa 1TS OF T64 33 ; 'to w►J of ' Al2 rJ 5`r►Q�3!.C� t DATE � �S Q , - - B�4XTGt� . uYE IBC. . REGls�rc-�h�, 1.A1.Ia 5t�evcYo24�j T141S VL-AW IS UOT BASEp 0" AN OSTE2V1l.LG : o IbtASS. I t o4,gr2uAAra�JT ScJcz�/C�( TILL- UFQr a�T�, Sl�oo�LD : aP6?.1..1.cA.P�B Llar @SI~ 4JSc� -To '��rceMl•�C:`•--�� :�LhIL.� _ .� � . . _ C�AM Mt!T :. t)cLbo2S r