HomeMy WebLinkAbout0111 REGENCY DRIVE - Health 11 I Regency Drive
Marstons Mills
- -- - - — - A=063,072
Commonwealth of Massachusetts
Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648
every page. City/Town St 10 a of Inspection
Zip Code Date of nspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A- General Information When filling out I
forms the 4
I
computer,
r,use 1. Inspector::
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return p
key. DOUGLAS A BROWN INC
Company Name
r� P.O. BOX: 145
Company Address
CENTERVILLE MA
2632
Cltylrown State ZipCode
508-420-4534 S14297 i
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was perTUrrriec based Uri my hairiiriy anei experience irr iite pruper iurru ion:arid:Inair ienanee Ui-Uri,5iie
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
E3 O
❑ Needs Further Evaluation by the Local Approving Authority r�
�-� CQ
-n
01-
10/4/09
is
4inspsSigna re Date
The system inspector shall submit a copy of this inspection report to the Approving A thority(B=d
of Health or nF=PI within'An Have of mrinnip. thiq incna�tinn If fkiR cvgfam it a qha ,n cvcfPm�r.
has a desig i flow of 10,000 gpd or greater, the inspector and'the systemowner shall submit theCp rrr
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
"'This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
. airc aan,c viwi ,1 cici a a.vnj.
Y.iiv.-10 viwac.
t5ins•09/08 Title 5 Official Ins pectlon Form:Subsurface Sewage Disposal System•Pape 1 or 17
I�
Commonwealth of Massachusetts -
'^�rn T.�•IA.0 ■ ■�t,A�AI INA MAA��AN. CA,MrN
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. Cdylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
Nj �7 43 nit r7d*.zC".:
® 1 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:
n .W,1 -s� nnnnrn I1TT1 un TI\Ar.nrl"1T1/'•T11 t.11Xn1 I/1\e(n T\/1"11/•.A 1 nl/��in �r^e%rnnr�nrr�(.r nrir
v,rv,(uvgi.nvvr_v.nr. rr.uv rurrc vu-._rry rnrvrc vr,rvvv,v, r rr r:yn-vivivv w.r.vvr�r.wvrvr:v-vvr_
TO ITS AGE
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for'Yes". "no"or"not determined"(Y. N. ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•09/D8
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
mm Ti�IA C �1#iAiwl INANAA��AN Cwr.rM
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. Cltyrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
LJ Observafi rn,orsewage oarckupwr.oreaK oui,or high.siabc,waierievei.m ine atstriouiion oox-due
to broken or obstructed pipe(s)or due Ito a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety.and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
t_t '4GJJr.lVVI.VI Nnvy w YYIU1111 VV Icci VI a vviUcnng vageAr cU vvcuarna VI a Jan��aiJn
t5lns I19W Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGEN3Y DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. Clty(rown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
aa`iv y.aIvu�ivr7vin7n ia:
❑ 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
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
rca5 urarr.r irr, �ii�Jivae uiai iry v`ura, ramie i�i��;a arc i�Iyy�eu.n wFiy vI ure ai-raryara ir�ii�i Ij
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
•tvu rrrusc;rrruteare"ies•yr "niu" iv�xc'rr vi lire iunvwrn�-livr�ii-irrs�rclrvrr�:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
❑ ® 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 Y2 day flow
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
T rn "r;4.1... C r1#:. ;,%1 INA MAA�IAN CAMN+�
ILDU v %0111%ojCj1 rlt�0Nc%.twj>t W1III
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4l09
every page. Cityrrown State Zip Cade Date of Inspection
B. Certification (cont.)
Yes No
Required pumping more than 4 times in the last vear NOT due to clopped 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® 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.
u 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.
For large systems,you must indicate either`yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
Ej 0 the system is within 2ou feet of a tributary to a surface drinking water suppiy
❑ ❑ 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.
t5ins•osoa
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
kl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
vlo
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is required for MARSTONS(MILLS MA 1 02648 10/4/09
every page. Citylrown State Zip Code Date of Inspection
C Chpr_kli-0
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?
® ❑ Vdere as buiii piafts uT irte bybiefn cbiaifted and exarftirted r to iney were ntri
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?
n n _n.�•�.,u �t�m,. ..,..,. ���� ,.i.,.�;, +tip ene
u u - . ...,..,.r„ ,. ...y ...
® ❑ 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 sewaae 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)]
D. System Information
Residential Flow Conditions:
f J rmher of be rQoms_Meeinnl• 4 nli imhar of ho'irnnmc for i toll- 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins•09AS
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
^•` (-n T761,. C AI INA NAA��AN 1_/1MN7
ILIc v v����.�a� 1I U0jJV%.LwI I I v1 III
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. Ctty/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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
senscna!UZZ, M V8 M KlC
Water meter readings, if available(last 2 years usage(gpd)): MINIMUM
Detail:
WATER COMPANY BILLED ONLY THE MINIMUM USAGE FOR THE PAST TWO YEARS
Sump pump?
❑ Yes ❑ No
Last date of occupancy: 10/09
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
tZ9¢IC of rlacinn flour tcon a/narennc/cn o olrr.I.
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 avaiiabie:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
mm T��IA C / '��A�AI INA NAA��AN CAM�i1r�
I IL"U V VIIIVIQI III0jJ1 %,LIVII I VI III
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'* 111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
' Date
vuiei(uc5i.iiu6 uci�itiJ):
[;anaral lnfnrma+inn
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
it yes, voiume 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)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09j08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
�'+ rn TC4.I/A C ` ■lI�AIAI INA MAA�IAM CAM/M
1 ILIG V VIIIVIAI 111�7rJGtr�IV11 1 V1111
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
SYSTEM INSTALLED IN 1982 ACCORDING TO ASBUILT CARD
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
coffiiiiivri of joll-16, verluriy, eviiieriiz vi leakage, eic.j.
Santis Tank(Innnta nn cites nlanl-
Depth below grade: .5
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age:
years
is ayr wrrlirrnCu by a%crtiiit;aia vi wrlrNiiantx%(diiaUt a wiry Ui ct IK;dic) a 'ram u 14u
Dimensions:
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
'^ rn T��•IA C r 1��A j�I INA NAA��AN CAM�1\
I ILM v vljiz.iaj n1aN�.riwjI g vj III
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. Cdyrrown State Zip Code
Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
viaiarm&irurn iup ur tiiudye iv buiium L;vuiiei iee v1 iraiiie
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
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK IS VERY CLEAN AT THIS TIME PUMPED EVERY THREE YRS ACCORDING TO OWNER
Grease Trap(locate on site plan):
Depth below grade:
feet
maienai of waw u6iivri.
❑concrete ❑metal ❑fiberglass ❑polyethylene
❑other(explain):
Dimensions:
oC:uri i ii`ricnrr665
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
-_ Ti11e F(NFw'al IrKnoN'v.n Cn.m bMimfaro Caueno ftiemed C.ic}em.Deno in of 47
Commonwealth
�o/f1 Massachusetts
T rn T��IA G • 17T�A�AI INA NAA��AN `AMMr\
v vI MPIaI Ins jJ1UU Pl l I Willi
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information MARSTONS MILLS required fo
ired for MA 02648 10/4/09
every page. City/Town 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.):
TA/.11
rnrvr%cwn/1%-/OrKv v�(1\/r�n\/nl rI141 AT TI II!\TI•Ir I'YI IT n�rn(�11/�\A/111/'41P /fir'/"•/fin n/1n1/'\\1
r�r vr.�nry n-1 r r nv-r-mr�uvl ww vr-rvvv vlvrv.a yr vvr�rwvr\nv
PROBABLY DUE TO ITS AGE
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
r-, r-,
LJ Ufrrii;ivie Lirrrciai L_I nuaryra�a U Frveyci�ryicric [�viiiai�exFriairi).
Dimensions:
Capacity:
gallons
Dew 9- -1 rtvw. gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
nano
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-osM
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
T®� I MEW v
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is
requiredfor MARSTONS MILLS MA 02648 10/4/09
every page. Cttyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depih ui iiquid ievei auuve uuiiei inveri
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 olan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Snil Ahcnrntinn Rvctam(SARI(InratP nn gita nlan Pxravatinn not rPnttirPrl)-
If SAS not located, explain why:
t5ins•agros
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Amm, Ti�lw C �1iw�wl INANwA��wN CAfi�NA
I ILI'U V VIIIVICII III0iJ1WVLIVII I V7III
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
Inl 2
1C"dGllll�tJ115 T ICIIr1UGI.
❑ leaching chambers number:
❑, leaching galleries - number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
i ypeiname of technoiogy:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation,etc.):
PITS HAVE RISERS CLOSE TO GRADE I OPENED ONE OF THE PITS IT WAS ALMOST EMPTY
AND APPEARED TO BE H-20 WITH NO VISIBLE STAIN LINE
Cesspools-(cesspool must be pumped as part of inspection)(locate on site plan):,
Number and configuration
Depth—top of liquid to inlet invert
Dupiit ui z5UNdb idyer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
T rn T.U.I/.. C / ■lI�A�AI INA NAA��AN CAM/M
r Icrc w vrrr�.rar rrrair�a,�rvrr r vrrrr
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
informationerequired
is MARSTONS MILLS re wired for MA 02648 10/4/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
vapi;i ui-su4iC6
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5ins•09MB
Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
— T:�T IA C ■ 1 �A�AI INA NAA��AN CAMM/\
I Iuc v WNINUIaI 111��✓c%.uv11 I v1 i1r
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r• 111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 10/4/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
. v Y.iwuv u•vr oupY7 "rn � ny. chcdh,vnv of vnvu .. '
❑ hand-sketch in the area below
® drawing attached separately
tsins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
mffamrn T;4.I.. C • 17T�A�AI INA NAAAN CAMYN
i 1L1c v v���a.�a� ���aNc�.��v�� I vjjjj
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°'Y a 111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Ip1 %iiec;K aivNe
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: GREATER THAN 5 FT
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
if checked, date of aesign pian 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:
Yrn 1 MUSt rlacrriha hrnu vni i a0mhlichorl fha hinh nrni rnrl wafar alAvafinn-
AUGERED TO @13 FT NO G.W.ENCOUNTERED
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
KMn-MnO
f
Commonwealth off Massachusetts
^ern TU.IA C • 177�A�AI INA NAA��AN CAMW�
ILM V VI1IVI4a1 III,01JIVL►LIVII I V1111
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
111 REGENCY DR
Property Address
PERRY
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 10/4/09
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
ILU inspection Summary D(System Faiiure Criteria Appiicabie to 'Ali Systems)compieted
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
LOCATION SEWAGE PERMIT NO.
V I L CAd E
arg l -s= ky��� I/Ae
INSTA LLER'S NAM i ADDRESS
® U l L DE R OR OWNER _
DATE PERMIT ISSUEDT4
DATE COMPLIANCE ISSUED
i
r
i
i + �
}
r, i
LOCATIONS SEWAGE PERMIT NO.
VIIIA 4 E
INSTA LLER'S NAM i ADDRESS
-Y
t UILDE R OR OWNER
DATE PERMIT ISSUED '/�ZlL
DATE COMPLIANCE ISSUED 5, � �
r .JO � � � ��1/ f? T
J� ii
o �� � ..
� �
��
�� �� f
t
f �
��:o �° ��
.� � � ��
No............. .�":3�� Fus..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..............�..o ._.....✓.....OF.....1,3411.01V S'7 ...............................
ApplirFation for Uhipaii al Works Tomitrnrtiun ami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......_.!_. G=. 1Y. ?.t... --.��1 1.G'1"------------------• .....................................
v. or t N.0.
er Address
a � �.:....... ... ............. ................. ..
Installer Address
Type of Building / Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms._.______?_______________________________Expansion Attic ( ) Garbage Grinder (reS)
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures ............................ .
W Design Flow........... .Jd�.....................gallons per person per day. Total daily flow.......... ! _....................gallons.
9 Septic Tank—Liquid'capacityZ� gallons Length%��=_G___ Width�=�__._ Diameter._�_._�•.._ Depth__z� _�_"
Disposal Trench—No.--_----___._---••- Width.................... Total Length.................... Total leaching ...sq. ft.
,.,Seepage Pit No../.v1'tZ...... Diameter............... Depth below inlet....g ........ Total leaching area..................sq. ft.
Percolation Test Results Performed by.`��i�>JlT1. =_...� �.<;1 9•�,S/=/C� c
z Other Distribution box (Yeti) Dosing tank ( )
,aa Test Pit No. 1....�f «^_'.__._minutes per inch Depth of Test Pit.... L............ Depth to ground water__/ y .
(i Test Pit No. 2........ ....minutes per inch Depth of Test Pit.... Depth to ground water..1k.0. ..
---------------------------------------------•-•-----•-------•---.._............-•------ I .................................
0 Description of ............................ '. r�ir?v1,� .0 ??-u"-=Sr✓�3 f�
U ..........................................
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 AiT12 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.
Sign/-------------------•----------•---..........------......._............----------....__
Date
Application Approved BY---- ----•.��`�-- -------------------------------------------•------------------... ...11 •��--'----•
Date
Application Disapproved for a following reasons:-----•-------------------------------------------.............................................................
.....--•-•---------------•--•--------•--......--•-••----------•--•---•-----------..............----•------••-------------•-••.-•---•-•--••------•-----•----•-•------•--------------••--••-••-•--••--•-.
Date
PermitNo....9 - -?....................•-----•--. Issued.......................................................
Date
No..........:. FEs...3�............_
4.
THE COMMONWEALTH OF MASSACHUSETTS
.y BOARD OF HEALTH
---.........�o-...LIJ.�/....OF....s�a. l�x �s�'/ •f � :.. -fir........................
ApplirFation for Diivuiittl Works Tonatrurtion "rani#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.. ._.�� F Z....... r�/. .. .................... ...............................4 T..----.a. .......................................
Location-Address or Lot No.
._. -----------------------------
-t� Address
-----------------•-----------------
• ............................................... ............................................-
I taller Address
Type of Building. Size Lot............................Sq. feet
Dwelling—No. of Bedrooms..........7`...............................Expansion Attic ( ) Garbage Grinder �eJ)
Other—Type of Building No. of persons............................ Showers
(-� YP g ----•----------------------- P ( ) — Cafeteria ( )
Q' Other fixtures .....................
--•-------------------------------•------------------•-------.------------------..----
W Design Flow........... ............................gallons per person per day. Total daily flow............////d.....................gallons.
h t gb
A: Septic Tank—Liquid ca,pac> gallons Lengtht!�."�___
W Di"' T `7
x sposal Trench—No. .................... Width___._._.._..._._._.. Total Length.._..._._._.___.___ Total leaching area ---sq. ft.
Seepage Pit No../.�:x?_...... Diameter.........4_...... Depth below inlet...A............. Total leaching area..................sq. ft.
z Other Distribution box (W) Dosing tank ( )
`_' Percolation Test Results Performed by4t.A�/7/, tr.....f '_��_-.._ : �_.��.. � .u. Date...05�r j� 1 �.
Test Pit No. 1...15��....minutes per inch Depth of Test Pit...,//........... Depth to ground water...!Z" F..
(s, -Test Pit No. 2... --q.....minutes per inch Depth of Test Pit---14.471-.. Depth to ground water._/V.V...A,.'.&', ..
All
O Description of Soil.Q_�_. 4.__'!AO_Zloev�ld_ 0 ' dui,oC� .CG�A•�1 say 45 ( �50/�
W ----------------------------- ---•-- i k 8:� � ' .C.4 S
- ----------------------------- ----------------------------.......................
UNature of Repairs or Alterations—Answer when applicable..................... ------..
...................................•..................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual SewageyDisposal 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.
igned...................................................................................... -- ----- -------------------
D
ate
Application Approved B
PP PP y- ----------------------------- ... ! vv,Date
Application Disapproved fong reasons':",,... _
----------------------•.....------•-------------------------...------------------•--------...-------•-------------•---••••••-••••---•••-•------•----•---------•••-•••......-•--••--•--------•••••---_---
Date
PermitNo......4L'_3_e------------------------------ Issued---------------•----------............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........;rP4 .........OF..../'�.,. ?1�177 ................
Trrtif irFa#r of TontpliFanrr
TH IS T CE FY Fh Individual Sewage Disposal System constructed ( �) or Repaired ( )
by. ''` .. �,�.. I stal
has been installed in accord a e wrth f e provisions of T I 1 L:. 5 of The State Sanitary Code de ribed in the
application for Disposal Wo Cons uction Permit No--------- `•, .. _.______ dated....... _ l... ". ".............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A G ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................................
................... Inspector____,,,a�//�.o:.A-. ?.. --------•-----•-•---•----•-••--------•-----.---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.---6,mr FEE........ ............
i n as r niA WIA prrmff
Permission is herebyg ranted --------------•••----•--•-•---------------.........-•--•...............---......
7
to Construct ( rj,.Irr Repair ( ) an Individu ewage Disposal System
atNo..---- = _ .... . ------.;-•--------•----- •-------------•-•••--•••----....-----••••-•••••----••---•-•-••---••------•--•---........
st-7 Street ,
as shown on the application for Di al orks Construction Permit No...�2_I Dated..........................................
s _ y t. Board of Health
DATE.......................---------._...--..�'-• •-----------•----•----------•----
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
I I
I
i D
f I I lam OS I
if
I k � ,• v
1 i
K.. a
•
-
j
r \ I% � I
1 l PQ
I� r,�h•,a --- - t
1AOfO
a - i <in
I
Ili
II
- � I
r . l
i
\
1 ,A. 42,
r.-I 4..S.
�54
� - ` 765T /+�s�C�" ( - T•C"`S'� /"/C74<5' L
VJ
J I
Alrj
T
49
7/Y-
% ` +
r�� lei
r
: /L.7
?�c 7�9^fJr4- OEM
1� �_
\ c ,
t�
OvN�aN7' ¢U' /"I//�'';, - Li/ '/ L> ! ' L/ir �j .:ems`
PnQpos�� �,JZST FLooT�
u0L� C�VF._ TC ��CTE_�tZ� T� , -� L/.UGH A.0 a M/ �2�r
24'D/A.Ccva \ > D/ter. F'!� a*'l
> � � Sox ,� 1
` / /MPS ✓i�'✓� G�'� r^
00 WA7Fe ��/rJiS�/ `P2E✓En/TGinIES F�O/�
IyiA! %4`/FrP!r�y __ M/�v —_ / f sr i/v�/,_re q ri/vG SrD,iI-
4; 6„MJJ\[. �//V.F� - � ,.��C 77s..::::c::7\� .terfi-ti
CAST/SON _ _Z M//v. -- '.•- Sl'lam/ I2 M/N.I "� 1"n
g1°.Sf
�1Jn/ � i/lN.P�rcti %q%fr/ vo o 2 /000 314"`I/�r
\sJ C> >� JSO+� `Ss 'o ` o STbv�;
/��✓ 7
/r✓✓E..�T - LEAC<1 P/75
�'�e ,ft?T % GALLON s . �.
GA,-Ae+/T 7' 4 M/ni. i S 3�
T � e 2riCl ,.- ( �`A eo Lj/,j
_ /.� TAA./t_ I E .—
,, /✓"er + (rVArE�TiGN7- i n/✓�T 3
L et
`'`L, Vie. 4/
("EPTiC SYSTEM /v'S T,2L/cT/Ofv 6•�
S ti`a L_ 0&,Fo c rl-.I Mass.
��'✓/�C%nit�SENT:-iL LODE T/T'/ c Y r
,2=✓,.SEL'7 7-/- 7?An/.C? Via, 5�071a� �...7 /
��.� ..
c` CRAIG �� &'CJA_�E3Ee O, OE 00 4
SEP7-/G 7-Ani4 D/ST,C/di_./TiO/v 1', x Rn.YMOND �
_ SHORT c / V 4 OlJ C GtiT = .
Tom? /�i/ ��G=[� CG/V C 2 7'� M/n/. � ��+j � 4 L e_A(f H//VCR
C�,V:=2 G T? S%f�`n.`Tr-/ 3 JJJ�' I °�SJf ,��.�'� L_-r=+E'f•-i CAA. G C7 O COAL_../�LjA Y
S54 .. .,
Dom/J_,c t1VA y I-vOT Tp E3E L_OC A7-�ED IiL
o✓"� sysTEMu Bess y 20
DES/G.�• �..=i D tn1 � /S US.=� �-.`-`
SIT
ALL ,r'/,4'5�5 T:-)*c3E i'V,cl TE E.�T/c /->'T '�� }�' a �G���. LOC.�T/ rJt\!: .����T�.3"•.mr���,� .�'.�vs�'r q
PLAN
F r f
7FFS C.157 /.E'On/O� CAST {F4t°� y" � rt_`f �'=/�.= /�/Ct� - Gca �''"L7, •�..C, �G, /� 4Z7�
BA YS iaf. S uleVEY CoRez=l
89 4t//'_L0W S7T YA r-'/,40L/7_1-/,z:'0.2T, `74_5S.
TigYa08 GO .2A7- e3 f
fy�
R