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HomeMy WebLinkAbout0064 JONES ROAD - Health Irlarstons Mills A= Commonwealth bf Massachusetts Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form - Not for Voluntary Assessments 127 Blackthorn Road; Property Address Nancy Clark Owner Owner's Name information is Marstons Mills MA 02648 August 24 2009 required for — State Zip Code Date of Inspection every page. Cityfrown Inspection results lust be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Inf rmation When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Ccr ell cursor-do nol Name of Inspector use the return key. Septic Inspection' Services Co. Company Name r� 189 Cammett Ro d Company Address Marstons Mills MA 02648 rer� City/Town i State Zip Code 508-428-1779 Sl 12855 Telephone Number License Number i • B. Certificatio:h 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 sys ems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 151000). The system: cr+ Passes ❑ Conditionally Passes ❑ Fails ®' Needs Furthler Eva nation by the Local Approving Authority [V Ito Via_ t O '11. � August 24 2009 In ector's Signatur Date 0 � , :11 F" The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DE. ) 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 ito the buyer, if applicable, and the approving authority. ****This report onljri 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. �d Title 5 Official Inspection Form:Subsurface Sle DisposalIb Syslem•Pal 1 of 15 09-172 Clark.doc•08I06 I i Commonwealth,of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is required for Marstons Mills MA 02648 August 24, 2009 every page. Cityrrown ! State Zip Code Date of Inspection B. Certificatia, (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes ) ® I have not foil nd any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. i Comments: Tank is not in negd of pumping at this time. leaching pit had never been more than half full. i it i i B) System Conditionally Passes: ❑ One or more,)system components as described in the"Conditional Pass"section need to be replaced or r paired. The system, upon completion of the replacement or repair, as approved by the Board ofil ealth, will pass. i Answer yes, no dr not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic ta�tk 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 ithe Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Complian IIe Indicating that the tank is less than 20 years old is available. ND Explain: ❑ ObservationjPf sewage backup or breakout 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): ❑ broki n pipe(s) are replaced ❑ obstruction is removed 09-172 Clark.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 i r CommonwealtK of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 Blackthorn Road Property Address I Nancy Clark j Owner Owner's Name information is Marstons Mills MA 02648 August 24, 2009 required for every page. City/Town State Zip Code Date of Inspection i B. CertificaU cont. B) System Conditionally Passes (cont.): ,i ❑ distribution box is leveled or replaced ND Explain: 'I �i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will piss inspection if(with approval of the Board of Health): ❑ bro4n pipe(s) are replaced 1 ❑ obstr'luction is removed ND Explain: i 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 it failing to protect public health, safety or the environment. i 1. System ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(bjthat the system is not functioning in a manner which will protect public health, safety and the environment: +I ❑ 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: l l ❑ The!system has a septic tank and soil absorption system (SAS) and the SAS is within 100! eet 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 sup0.ly. ❑ The�6ystem has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 09.172 Clark.doc-C8/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealths of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �., 127 Blackthorn Road' Property Address Nancy Clark Owner Owner's Name information is required for Marstons Mills MA 02648 August 24, 2009 'i every page. Cityrrown State Zip Code Date of Inspection l �i B. Certificati6,6 (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system I1as 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 coliform bacteria indicate' 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. I 3. Other: i i u ,j D) System Failure iCriteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No i i Backup of sewage into facility or system component due to overloaded or ❑ ® i'; clogged SAS or cesspool ❑ ® ` Discharge or ponding of effluent to the surface of the ground or surface waters l due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ti Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ® than_day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. 09-172 Clark.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I Commonwea'Jth, of Massachusetts i, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 127 Blackthorn Road, Property Address Nancy Clark Owner Owner's Name information is required for Marstons Mills MA 02648 August 24, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® ! Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 ji 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. i} 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. 09.172 Clark.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth;of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is 9 required for Marstons Mills MA 02648 August 24, 2009 every page. Citylrown State Zip Code Date of Inspection C. Checklist 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 ❑ ® 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? ❑ ® 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? ® ❑ 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: ® ❑ 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 CMR 15.302(5)) it 09-172 Clark,doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is g required for Marstons Mills MA 02648 August 24, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: 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 ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Unknown Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (basted on 310 CMR 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: Last date of occupancy/use: Date Other(describe)` f 09-172 Clark.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is 9 required for Marstons Mills MA 02648 August 24 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped in 2004 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Ihnovative/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: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-172 Clark.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is Marstons Mills MA 02648 August 24, 2009 required for 9 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (or.condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below gra 1'de: feet Material of 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 ----------------------------- ---------------------------------------------------------------------------------------- Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Trace Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured 09-172 Clark.doc•08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is Marstons Mills MA 02648 24 2009 required for -August every page. Cityrrown State Zip Code Date of Inspection 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.): Tank is not in need of pumping at this time, liquid level was found at bottom of outlet invert and tees are intact and clear. 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 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: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 09-172 Clark.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewade Disposal System Form - Not for Voluntary Assessments 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is 9 required for Marstons Mills MA 02648 August 24, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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.): t *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): No solids or high stains present. Liquid level at bottom of single outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09.172 Clark.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 f Commonwealth of Massachusetts Title 5, Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is Marstons Mills MA 02648 August 24, 2009 required for 9 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ 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.): Leaching pit was found empty with a hig stain line indicating pit had never been more than half full while house was, 01,172 Clark.doc•111101 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is Marstons Mills MA 02648 August 24 2009 required for g , every page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) 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 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.): 09-172 Clark.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 | Commonwealth of Massachusetts ` ��°��N�� .�� ~�*~��N N����������������� ����0~0�� NN�N~� �� ���NNN�*N�wN Inspection 0—�.mmwm Subsurface Sgxva6e Disposal System Form ' Not for Voluntary Assessments 1%7 Blackthorn Road Property Address Na C| nk Owner Owner's Name information is required for �o����NN|�___________________ MA 02648 August 34 2009 every pace cup7own State Zip Code Date mInspection D. System Information (cont.) Sketch Of Sew \ge Disposal System.- Provide a sketch of the sewage disposal system including ties to at least two permanent rnfonanno landmarks or benchmarks. Locate all wells within 100h*at. Locate where public water supply enters the building. Blackthom Road � 25 3501 � � / � � 4u � | / Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 127 Blackthorn Road Property Address Nancy Clark Owner Owner's Name information is 9 required.or Marstons Mills MA 02648 August 24, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20+tee+ Please indicate,all methods used to determine the high ground water elevation: Obtained from Elo system design plans on record If checked, date of design plan reviewed: Date ❑ 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: USES topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 55 and topo map shows property above el. 100. 09.172 Clark.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 15 of 15 LOCATION SEWAGE PERMIT NO. . -VILLAGE i INSTALLER'S NAME i ADDRESS /-7, s U 1 L D E R OR OWNER /V/�/� �_ c--?G,�fir►C���l fps' DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED /� 'o�2 t 4 �s Ad TOWN OF BARNSTABLE LQCATION I L �" ' � WAGE # V?T.,LAGE M a Yh i I I S ASSESSOR'S MAP &LOT ® y6— 63 INSTALLER'S NAME&PHONE NO. 9;1'rbOn SPBiii- SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) L P 10 0 0 (size) NO.OF BEDROOMS 1 BUILDER OR OWNER 0 /►'1 D��.A s'1 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) lS Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by. Y \ r Al • © 0 3�b 00 4po v t� JOheS �, TOWN OF BARN TQBL�E LOCATION # �-✓+5 �WMLAGE (me �S ASSESSOR'S MAP&PARCEL R'S NAME&PHONE NO. t'tY--1- f O 2C I - 1°l'1 SEPTIC TANK CAPACITY 00 4 LEACHING FACILITY:(type) %'1 (size) NO.OF BEDROOMS 3 OWNER .,r k— PERMIT DATE: C®Mpi; iEF,DATE- P. Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility Of any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY \F\F \ f\ F � \f ! !\f f• •J\ f•I f f f F F f \ \ • • • • \ • J J J J J J ! f f J J J f F f f I f f f f I f l \ \ • \ \ \ \ el 25 1 5 35 53 46 0 No....J6.1IS-5. r Fi&$..... .,1�?.. ....... THE- COMMONWEALTH OF MASSACHUSETTS / �n BOAR® OF HEALTH OF....................................... ApplirFation for Di ipvii al Works Tunotrnrtiun Prrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at .l.Q�..7... � '��:�nb.!C ,! ................................... .................................................................................................. Locat pn-Address (� or Lot No. .. eL u t !�.N �.1.'t?..................... �!✓.�.._ll1 1 C?!5�.. .?' . � .� INS.J........ /� Owner A�dr a ........C_. .. . ?..--•....................................:......... ...........C� 7 l Ji_?. ............----•------•-•---............ Installer Address UU Type of Buildi Size Lot... a...Sq. feet U Dwelling—No. of Bedrooms................................ Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ....................................................................... W Design Flow.........................:..................gallons per person per day. Total daily flow............................................gallons. W -Septic Tank—Liquid capacity.j6Wgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.-/6........... Total leaching area..:..................sq. ft. Seepage Pit No--------------------- iameter.........&...... Depth below inlet.................... Total leaching area O._...sq. ft. Z Other Distribution box (✓ Dosing tank (' ) Percolation Test Results Performed by..WC6T------------------------------------ _----•---_--- Date........................................ a .Test Pit No. 1..... ......minutes per inch Depth of Test Pit....-ar------ Depth to ground water........................ LL, Test Pit No. 2-----1?-,,,..minutes per inch Depth of Test Pit..... ......... Depth to ground water........................ ------------ ......-----........ ----------•------•--------------------------- O Description of Soil-----�:=_;.,; .�.,� ._1�1� �.D!)'1..... W ••---•----------------•-----•-----••-•••--•-•••---•---.--•----•-----•-•-----•-•......•..----........................................................................................................... UNature of Repairs or Iterations—Answer/w en applicable............................................................................................... Agreement: ' The undersigned agrees to install the oredescribed Individual Sewage Disposal System in accordance with the provisions of iITI T-. 5 of the State Sa/hitiry Code—'I e undersigned further agrees not to place the system in operation until a Certificate of Compliaagn been i ued the board of health. -• ..... •............. ................................ D e. Application Approved By. ,�... .... ...... /D Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------•-----•-•-•--••-----.......... ------------------------•-•-••---•---------------------------------------.................----------._-•- Date PermitNo......................................................... Issued-....................................................... Date No.... :-.i .. Fps..... .�.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. .... .. .................O F.-.-.....-.-.--....--......_..--_-.__.._-._.-....----.....----...-._._..........._.....-_. Appliration for UispoiiFal Works Tnnstrnriinn amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............................................. --------------------•---•----------•---------------------------------................. ......_. Locat n-Address or Lot No. .............. fi -i 1 _ t , -- t.c� ac. ----•--- OwnerAdr ................................................... --•--•-•- �+t '. t .)...... ......................................... Installer Address �ff UType of Buildi Size Lot___ ..7..r� ...Sq. feet 4 Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building .............. No. of ersons.__..____._.__.___._..___._. Showers — Cafeteria a YP g --------•----• P ( ) ( ) Q' Other fixtures ----------------------------••-- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.)"gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No...................:. Width.. ................ Total Length__,/.b........... Total leaching area...................sq. ft. Seepage Pit No____________________ iameter._.__.__. _____ Depth below inlet____.__________.____ Total leaching area _ 0....s tt � - P g � 9• � _ z Other Distribution box ( Dosing tank ( ) a Percolation Test Results Performed by--WIC41 -------•-------•--_-_.._.. ---•--------... Date........................................ '� ..�. Test Pit No. 1_______________minutes per inch Depth of Test Pit------ _ ...__. Depth to ground water........................ (s, Test Pit No. 2____...2% _minutes per inch Depth of Test Pit____/,',lr._______._ Depth to ground water________________________ O Description of Soil..... "!-"-A- ---- ._ . ----`'�r _'"' _1 / !12 ?t'r -------------- V ........................................ t ...._ .iZI,21L, --- ��' ..................................... ------------------------------------------------•-•- ••. -- ----•-------•---•-----•--••••-••----•--••------------------------•••---••-•••--•••.................................................. V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ••••----------------••-••••--•-•--...__._._...••--•-•••••-•-•-•••••••••••-•--•--•-•----------------••-•-...••-•- ..................-•-•••......••••-•-•-•--•••-••••••••-•••••---•-•------•••---••- Agreement: The undersigned agrees to install the oredescribed .Individual Sewage Disposal System in accordance with the provisions of TiTl,;. 5 of the State Sand, pry Code—T�.e undersigned further agrees not to place the system in operation until a Certificate of Compliance' s been i ued. the board of health. STgn ,may. DD to Application Approved By.......... ..„. .. ,�.., ..- ....... . •_- = •--------•-------- r{` � `'6 ........... Date Application Disapproved for the following reasons__________________________________________________________________•________________________________._......_...._ --•------••----------•------•-----•-•-------•---._...----•--•--------------------------------•--••---_-•- Date PermitNo......................................................... Issued--•-----------•----•---••-----•----------. ....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (9rdifirtttr of Tnntplianrr IS IS TO CB IFFY, That the Individual Sewage Disposal System constructed ( or Repaireduk ( ) - by.... •0 -_--- --------� ------------ -------------- --- ------------------•••--•------------- --- • .................................... at....... -------&0....... ..... ...........ff ................... has been installed in accordance with the provisions of Tlj � j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-___i �__'f•=�'-..__._.____. dated---------------------------------_.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SAT)SFACTORY. DATE........................................ -- Inspector.----........ G''...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.__ :"'✓. ..........................................OF........_..........-••--------••-• FEE..._ . Dispo 1 ork nntrnriinn rrntit Permission is herebygranted t`V.W....__ _ .�•--••••-••••---•-----••--•-•----••••••-••-•---•••-.._.•••-•-•--••••................•-_..... g ��� to Construct ( _,�' r Re it ) an Indio ual Sewage }spos�j��y,,Stem /l � ,�, at No..... 1'7.......12!N:N_. .-}47111'�---- __._>_... 1 JF --------�- ................................ Street as shown on the application for Disposal Works Construction Permit No .. Dated..... ......................... -----------------••--•------•---- Board� e th DATE.................................... � FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 01�3 a (fir v Eli l^l1v ` 162X tl,� PRoPos2D 9ti4 Iwt� 4) 3ZiEattaa►ii � N U I '^ ICY.DiAM r,�ti+N�i to 0 s� a 14 , 3-AR N S-(A-5 L NAARIS O Ft t,,A ILLS VON OF Mq {C-Vr, L..A(-10/J�/ / 0 S pofST-AP-rR 0 C4TJ't i S� WALTER E. TH. )C�tR ASS/ANAL EZ �t I�- 104-1 + e. ,ow ` �7•a ?15 H 10 C — I D l 5T•.Bop( G� w o 0o CcFr DtoA4. p n 0o GoNc. IEAc.N;uc, Pir l000 Gwl. �c. AoA& Sap+i c- Ta.K k 98 0 4 a . d AAO one , u BoT• fl,T Env '' ES IG-1N DATA `> > • � ; 2Cot..ATt �N �AT� : 2M��J IINGJ-.l DROP zC) -op -C) Nf 4e , 9 i -7 3 [3p.pRoOMS K. I lO C-,PD = C PD LLCNItJC, ��� No C-7ARBIAC-4E DtSPOsAL U5E GAL-SEP icTA#4l CA,PAGtTy PR OVlCDED 730T�'oNj 7T 5'- x l !� - 78, 5 G p D S t DE" 5 TT/o K r x 2 = 47/• 2 G PP I OTP,L CA PA C I T`) 0 V( PeP ���r 1 , / C, Vol A QcLoRDAtJGE v`r ► T+4 �t�0�lfS1oNS ©F NI ASS . Et-lv !ROM MENTAL G o i7c . t t h1C! �1r'}F1✓, '�J?tCi '_ ,�C4yy� t'r�f �� 47 SOIL STR Ar,a r •S • Commonwealth of Massachusetts Cry Executive Office of Environmental Affairs`'---Department ®fEnvironmental Protection Wllllam F.Weld Governor Trudy Cox@ t»cM.ry,EOEA David S. Struhs Commoner SUBS FACE SEWAGE DIS P PART A SYSTEM INSPECTION FORM ERT C IFICATION ka Property Adres f�� 13ir1�k {+c .►� �C. Address of Owner: Date of Inspection: I t iy j (If different) Name of Inspector: t,\`Atr+:•k Company Name, Address and Telephone Number: h0��:lSc. SCrtPr� U I (ra►',r Al II45 L•+•ka Hvil.i-71J %►1W. d' Lic► CERTIFICATION STATEMENT 5C 71� 711 t I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: `' Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails / Inspector's Signature:(,k;,,,ULy4VVI V Date: -1-4 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: v I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) .AIL The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)SW1049 a Telephone(617)292-S1s00 0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: / B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static ter level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or un en distribution box. The system will pass inspection if(with approval of the Board of Health): brgk n pipe(s) are replaced �struction is removed // T distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. /� 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DET MINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AN AFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 fee f a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE B RD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONIN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT; _ The ,\,stem h . a septic tank and soil absorption system and is within 100 feet to a surface water supN:y Ur triLutery to e surface w r supply. The sy, n,, ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The s,stem has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ Tht+system hd� a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or�more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. I'll,� the failure. Board of Health should be contacted to determine what will be necessary to correct / _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or, onding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D)SYSTEM FAILS(continued): 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ' Any portion of the Soil Absorption Syst-e�m cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a ces fool or privy is within a Zone I of a public well. i Any portion of"a cesspool or privy is within 50 feet of a private water supply well. i — Any portidn of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greatejACarge System) and the system is a significant threat to public health and safety and the environment because one or more of,the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 t of a tributary to a surface drinking water supply the system is loiated in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public wa)er supply well) The owner or operator-of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: tv' m.ti; Owner: S„v.L.e •S',�r�G xa �r� Date of Inspection: 11. 14-15 Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. large volumes of water have not been introduced into the system recently or as part of this inspection. 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. _i/ The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. J The facility 0%'.nr ;an;? occupa^ts, if differe�- from owner? were provided v6th information on the proper maintenance of Sub• Surface Disposal System. (revised 8/15/95) q L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: RESIDENTIAL: FLOW CONDITIONS Design flow: •;jo ttallons Number of bedrooms: -1 Number of current residents:,_ Garbage grinder (yes or no): h;r Laundry connected to system (yes or no):4L!,_ Seasonal use (yes or no):j,;_ Water meter readings, if available: 4 5-• IA(kt2 Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy'__ GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) Nc If yes, volume pumped Qallons Reason for pumping. TYPE qF SYSTEM L// 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) and source of information: 0E.—Ind - I��ri•. Sewage odors detected when arriving at the site: (yes or no) Irevieed 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: la-1 6m,: t, -1►t ,c Q A I" t'',1 t,_ Owner: S"r,t,., Date of Inspection: _14. .;.,- SEPTIC TANK:_/ (locate on site plan) Depth below grade: i L, / Material of construction: _/concrete _metal _FRP —other(explain) Dimensions: Sludge depth: ;r Distance from top of sludge to bottom of outlet tee or baffle: L Scum thickness: &'- Distance from top of scum to top of outlet tee or baffle: L Distance from bottom of scum to bottom of outlet tee or baffle: P" Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concret _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scu to top of outlet tee or baffle: Distance from bottom i «Iv» to hnrmm of outlet tee or baffle• Comments. (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/i5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 01 i3t�►�1; �)' "� h�, tn,(ts Owner: S•"11C11 Date of Inspection: I.14.q 5- TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow Z gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: — Comments: (note if level and distribuii,c-- e�_:z!, e,,idc,.ce of solid, c2 raver evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes r no) Comments: (note condition of pu p chamber, condition of pumps and appurtenances, etc.) (revised B/15/95) 7 III SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: I I_ I y 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: I vp leaching pits, number: leaching chambers, number:, leaching galleries, 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,etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet in rt: Depth of solids layer: Depth of scum layer:_ Dimensions of cesspndl. Materials of construction: Indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of constru ' n: Dimensions: Depth of solids: Comments: (no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 o- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1A c Vd. Owner. Simpri S"71c '-fl- Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I I• it; I l J `1 l I �I �i t 1(\ t� DEPTH TO GROUNDWATER Depth to groundwater: ,7� feet method of determination or approximation: ;.1 1S ti (revised 8/15/95) 9