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HomeMy WebLinkAbout0164 RIVER RIDGE DRIVE - Health 164 RIVER RIDGE, A = 059 007 TOWN OF BARNS TABLE VOCATION I��-I ZWE 30 Q..1 SEWAGE # VILLAGE 1 5 k4\�k& ASSESSOR'S MAP & LOT ' 00 006 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ca Q( 1 S (size) NO.OF BEDROOMS BUILDER OR OWNER T�IrJ PERMTTDAI-E: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 30 1 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) VJ Feet Edge of Wetland and Leaching Facility(If any wetlands exist N W Fe within 300 feet of leaching facility) et Furnished by IV i J� Z � d � 3 O � fl3 - ��'�°�� ,43' �� �`l- 33� `��1- 42.E �YS-S�� Q�S' 33� A CommoNwE.kLTH OF MASSaCHUSETTS EXECUTIVE OFFICE OF EN-VIRONMENTAL AFF S j� 0 DEPARTMENT OF ENviRONMENTAL PROTEC o,� ONE n71TER STREET. BOSTO\ '�L� 0210E (61i) 292-�:iOU d � 199 P 1 �XF 9 -'ecretan UHS ARGEO PALL CELLUCCI DA�'I , S-C - Governor ommiss:o ner Q ff SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM G J ` PART A .19 CERTIFICATION �o Property Address: 1 4 1-I ei V1ZK_4 y— Name of Owner �pnJo,,� y,> 0 ®� �Ms—kep5 `�� Address of Owner: spi , ,jam Date of Inspection: X\1eA15 �S Name of Inspector:(Please Pnl! I am a DEP approved system inspector pursuant to Section 15.340 of True 5 (310 CMR 15.00 Company Name: 1gZYG r? Ek r.A%''re u a..._ i,+1 1 - Mailing Address: An a z- Telephone Number: <�'Ca ) Lt 71X CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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: APasses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: I Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 ttte system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page IofII is Panted on Recycled Paper r y� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ►'��° PART A CERTIFICATION (contirxwed) 'roperty Address: 116y OwAt-S 44^4 . , Jwner: '" Date of Inspection: INSPECTION SUMMARY: Check A, B, C, of D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: Al B. -SYSTEM CONDITIONALLY PASSES: e — r. *One.or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon co'mpletion'of 4he'replacement or repair, as approved by the Board of Health, will pass. "-Z, .+". Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution Y ibution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced in more than four times a year due to broken or obstructed pipe(s). The system will pass _ The system required pumping Y inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page1of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 DETERMINES IN ACCORDANCE WITH 310,CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water 1/ 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 HEALT�'H.'AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system/SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption sysl m and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. — The system has a septic tank and soil absorption system and the SAS 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& presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine dista a (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that on or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified low. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage int facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of ffluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distri ution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less t an 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 time in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption Syst , cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is withi 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a one I of a public well. Any portion of a cesspool or privy is within 50 fe t of a private water supply well. Any portion of a cesspool or privy is less than 100 f t but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has bee analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia itrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above The system serves a facility with a design flow of 10,000 gpd or greater(Large ystem) and the system is a significant threat to public health and safety and the environment because one or more of the following con 'lions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304( ). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 • ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or 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. The system does not receive non-sanitary or industrial waste flow. X _ 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. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)I X - _ The facility owner land occupants,if differeru from owner) were provided with information on the propermaintananca.of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Oroperty Address: llc,t{ CUR-L Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow. g.p.d./bedroom. Number of bedrooms (design):03 Number of bedrooms (actual}:p3 Total DESIGN flow S-, Q Number of current residents: (� Garbage grinder(yes or no):�V Laundry(separate system) (yes or r If yes, separate inspection required Laundry system inspected 4!91r no) Seasonal use (yes or no):_Jh. Water meter readings, if available (last two year's usage (gpd): P-3 Sump Pump (yes or no): IJ Last date of occupancy:. v� COMMERCIALANDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 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: , Vo System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons 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) Attach co of u to date operation and maintenance contract � IIA Technology etc. Atta copy P P _ Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: \Zwfo3 Sewage odors detected when arriving at the site: (yes or no) 1� revised 9/2/98 Page 6ofII r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: J-wcv-s „ Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site pl n) A Depth below grader Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 10 oi1a�� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: ki- Distance from bottom of scum to bottom of out t tee or baffle:_ How dimensions were determined: 'omments: (recommendation for pumping, con itio o inlet nd o tlet tees or�affles, de lvith 9t li uid level i r latio to outVt i vct ent, structural integrity, evide �e of leaks e,etc ) i �� `1 GREASE TRAP:�I (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplainl 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: 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 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: �Ir etJ(.(q Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal_Fiberglass_Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: 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: WIOVIV�TW ✓t-If Comments: (note if level and distri uti n is equal, evidence of solid carryover evid ce of leakage into or out of box, etc.) C A! PUMP CHAMBER: (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,-condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) property Address: L I U6 09194c,(� Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excav ion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: 01 (pl( leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note c ndition of soil, signs of h draulic failure, level of ponding, da ,soil, co itio f vegetation, etc.l rt, a CESSPOOLS:-iD (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth 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, etc.) PRIVY:4 (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.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: )wner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) -S" ` Z , 3 O C 9-3 33 revised 9/2/98 Page 10of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: '�o�� C P Owner: Date of Inspection: NRCS Report name PD Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope t-r.) Surface water t-o Check Cellar dJ Shallow wells f Estimated Depth to Groundwater}Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers y Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 3 v S, ,�o��c�Px�� rk{dtco Io5 cuUes77q� revised 9/2/98 Page 11of11 f ASSESSOR'S MAP N .007--,f-o PARCEL b q(m LOCATION 1(�y SEWAGE PER IT NO. -LoT � LvFti A/ &r: � VILLAGE 041 /-1/L 14ILC S 0 I N S T A LLEfR/'S NAME a ADDRESS V T� e/P© l3/Z OS Z,A � R UILDER OR OWNER J,,SM�TtI DATE PERMIT ISSUED DATE COMPLIANCE ISSUED lb ppol , No ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F................ 0........... ........................ Apphration for Disposal- Works Tomitrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at ..................... ..............A6 41.................................. ................................ 0 Lot 10. .......... ed, ................... ....... t�............................................. Owner A ress ......... ................... .......... .................................................. M 1.4 Installer Address 6 Type of Building Size Lot....WI..................Sq. feet Dwelling—No. of Bedrooms.................. ........................Expansion Attic Garbage Grinder Other—Type of Building ............................. No. of persons............................ Showers Cafeteria A4Other fixtures ..................................................................................................... Design Flow...............rs�.....................gallons per person per day. Total daily flow------ -----------Z&.*...... WSeptic Tank—Liquid capacityf .gallons Length................ Width.........._..... Diameter..._............ Depth................ Disposal Trench—No..................... Width.................... Total Length............... Total leaching area....................sq. ft. Seepage Pit No..........**- Diameter.........i.0..... Depth below inlet......Z.!.!i..... Total leaching area...:�5:245?�.sq. ft. Z Other Distribution ---- X) Dosing tank 0-4 Q,77 Percolation Test Results Performed by.. VT+:-JYQ............................... Date.....62-4.1..... ............ Test Pit No. I......OL...minutes per inch Depth of Test Pit.._..... Depth to ground water________________________ w Test Pit No. 2................minutes per inch Depth of Test Pit.__................. Depth to ground water.......____........._.._ M ............................................................................................................................................................. 0 Description of Soil------------41....................... . ..... .. ................................................... I ...... W 1�. .. ..EZ1.0 -----------------I>---------------------------- C,L.eAQ........�im. V;�.. ...AA ..Vv-x..........S.0�.w. ................................... ------------------- ----------- .. ........................................................................................................................................................................................................ 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'JI'112 5 of the State Sanitary Code—The undersigned further agrees not to place the system in opera ntil a C rtifi to of P!AW 11 e has been issued by the board obhealth. 4igned.."—... . .... L............... ............. ate pplication Approved By...... . ..... . ---------------------------------- .......... Date Application,Dizlpproce%fq� tfilgjollowing reasons:.............................................................................................................. ............ ..................................................................................................................................... Date Permit No-2.7.4.1 6......................... Issued....................................................... 4f Date No.U. .... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..._•--..... .. . OF.........``? lI ... ......................7 Appliration for Disposal Works Tonstrudiun rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - _N / .......... ...... Via.t±� :2 �°r is�^ ....�.. . .......... 1�I/�. ........... ........ � ..f ........- ----....... Location-Address J or Lot No. OWner ! _ Address W Installer Address Type of Building j Size Lot... ..................Sq. feet U I,{•' ,.� Dwelling—No. of Bedrooms...........................................Expansion Attic Garbage Grinder `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures .........--•••-•----•---•......... ...... W Design Flow..............!g.._......._._...__-..gallons per person per day. Total daily flow... �.___...�.......gallons. WSeptic Tank—Liquid capacity`{1?.gallons Length................ Width................ Diameter................ Depth................ 1x Disposal Trench—No..................... Width.................... Total Length........__...... Total leaching area................_...sq. ft. Seepage Pit No._......_....r_..._../Diameter.........1-0..... Depth below inlet...... ?'_________ Total leaching area...�D........sq. ft. Z Other Distribution box Dosing tank ( ) r a `Percolation'Test Results Performed by.. kr1 I ¢:._k Q Date....(!� � '� i- ---- --y----- a Test/Pit No. 1...... r ...minutes per inch Depth of Test Pit........f_2�>_ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ -----------------------------------------------•----------•-.......-•--------•---------------.---•--......................................................... 0 Description of Soil............-==........................:....•--•-••--•----------••--•--•-•-----•--•------•------•--------------/^ .................................................. _ 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 TIT LE 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. f igned 1 = 1 to Application Approved By..... .' ---------�tJ 4te Application i pprrd)f�o�ollowing Permit No.-- -,. ....-�-.1 e i---------------------•--. Issued..-•------------....-- ...-----•----..._...at EJ ...... Date THE COMMONWEALTH OF MASSACHUSETTS --` BOARD OF HEALTH ....................t. )�.............OF........�... ...."'.:.......................................................... Trrtifiratr of Toutpliatnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( `�or Repaired ( ) by -�:...... .......... f� Installer_...ti ) j.....................••------ at.............. ............... .. .....:..........:.:.. .`: ...........:........................=`............................................. has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as descri ed i the 1-7 application for Disposal Works Construction Permit No._..-_I0 �-.�_9 --•---- dated.......��J? ... ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THA THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................... ............................ Inspector.............------ f ............................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (lC — f ��. l:i!,-........OF............ ::�.���1 (l I�I`?�..d Lt:....... !, �,.... No.Q........ %..�� FEE........................ Disposal Vorho Tunstratrtinn unit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo..................................•---------------.......----•-----............................._..-----Street-••----.............,... - ............ 7 as shown on the application for Disposal Works Construction Permit N _________ _______ ated.._.__..................... _..... ..... ....................... ..... .......................................................... DATE............ ................................... 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