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HomeMy WebLinkAbout0930 ROUTE 149 - Health 930 Route 149 j Marstons Mills P -� - - A = 102 047 No , /, ( Fee /06 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppliLation for 33isposal 6pstem Construction VrrmIt Application for a Permit to Construct( ) Repair(V� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.q30 ►4 MoG'6-S AM Owner's Name,Address,and Tel.No. IDq l%k o,AnGRenn Assessor's Map/Parcel MA oZ,fi`i►% /b d- C1 ��t. �'1,�1 Ntecs,�crc M.I�S Nk/} Installer's Name,Address,and Tel.No. / Designer's Name,Address,and Tel.No. A�a. & S�, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date //-L I-IL I Application Approved by Date L\ 5 Application Disapproved by Date for the following reasons Permit No. 4 5 ) Date Issued Fee v D THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pp4tation for Disposal *pstem (Construction Permit Application for a Permitito.Gonstruct( ) Repair(v� Upgrade( ) Abandon( ) []Complete System ❑Individual Components Location Address or Lot No.q3o (4t.. 01G Owner's Name,Address,and Tel.No. Zbcw dt \GUn c,ne _ CA�o CL�c �`I� Mc�s�c�s . , Mtk Assessor's Map/Parcel b2 � �o t"MtQ C"3 —Q y 7 Installer's Name,Address,and Tel.No. - Designer's Name,Address,and Tel.No. Mt(_L1 —r TA �l, _ S a (_« Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil At, Nature ofRepairs or Alterations(Answer when applicable) Q'�_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of t Compliance has been issued by this Board of Health. Sign ��.- Date I/-Z f-/Lt Application Approved by �, Date \ 15 F. Application Disapproved by Date for the following reasons Permit No. L` `► S Date Issued --------------------------------------------------------------------------------------------------------------------------------------- 7� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS O N L, Certificate of Compliance THIS IS TO CERTIFYthat the On-site Sewage osal system Construct d( Repaired) Upgraded( ) Abandoned( )by G Dis h , fi A� r at ciao ry4. \\&s� M« S�—,'A I AXhas been constructed in accordance., with the provisions of Title 5 and the for Disposal System Construction Permit No,�O;Y Zo 4a ed' 1 Installer Designer #bedrooms Approved des,gn flow „(� / gpd ' The issuance of this permits all of construed as a guarantee that the system wit nct� resigned. tf r Date Inspector pk_ 1 � --------------------------------- -------------------------------------------'--,-✓------- 0 No. �)O/LI ' / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Vermit Permission is hereby granted to Construct( ) Repair ) Upgrade( ) Abandon( ) System located at � � MGrSi.. /Vlllc and as described in the above Applicatiomfor Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must be c mpleted within three years of the date of this ermit. Date ���� �j L, Approved by r NLW L IM Scuti c- Scrvi cc 7 (508) 563-7433 j G (508) 548-3355 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 1 6 RT I" i M"SAA .n cfn t�\S -owner's name /'1emwiq -- Date of' Inspection PART A - - CHECKLIST C _ec 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. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank' was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper .maintenance of SSDS. :.urc.woray..i+s+vr'.w+•.;s u.�... _rw ., .....�. ....,,tea ... s ._ .. .,..... .... _ - n. .. ..-, .. ..... .,..... .t«a...... .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM : PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents - garbage grinder, yes or no laundry connected to system, yes or no e seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: S� � 1 Last date of occupancy GENERAL INFORMATION Pumping records and source of information: eve System pumped as part of inspection, yes or no if yes, volume pumped Reason for Pumping: C Typ of 'system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed if known. Source of information: l Sewage odors detected when arriving at the site, yes or no f. •YS"" 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM YNEORMATION continued SEPTIC TANK:,, - - (locate on site plan) 11 - - depth below grade: _ material of construction: concrete metal FRP _other(explain) -� dimensions: l� sludge depth i3 distance from top of sludge to bottom of outlet tee or baffle scum thickness - .5 distance 'from top of 'scum to top of outlet tee or baffle � _.t� distance from bottom of scum to bottom of outlet tee or baffle Comments:- (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in,xelation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site plan) +evE depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. )A4 ---PUMP!-CHAMBER: J V pumps in working order, yes or no Comments: W-,(note�:conditiori"of 'p"ump chamber, condition of pumps and .appurtenances, ---recommendations" for z aintenaiice- or .repairs,etc. ) •--..r w.wYM.lA'Tim'DYY4 .. ...a a� r .. ., r k..n.-.aaa+ ..e .... ..n........... u 'a..G-... ...y:v . ✓F.Nr-:: . N.:w{ ..i..?, a w•i- .x e -- a:� ' 1 L:F4eJi F.i:V,«^.''.. ��.�-"''�FL'Y y"(�.- _ i i ��fq,,.,,�..vik R+n�.cyti..�sse+'wYs�ear u4rer.n rrav Nrw wrs»n.+v.,,..r wm+i.w.,,.,.ua�-..u,R.....,...,w.,M.w.-•M-.....,.,,k..-._..w....»,....w.Nrr.....»->wn••.a...r•. .Tv s...,..,w.,..u.,.-wer.a..,. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORK , PART B SYSTEM I ORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, -if possible; excavation not required, but may be approximated by non-intrusive methods) If,not determined to be present, explain: Type leaching pits and number 0Af_ leaching chambers and number leaching galleries and -number- leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid .to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication .of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction A114 dimensions4 depth of solids Comments: TK (note condition-of soilsigns..of-hydraulic -failure -level o �- - ,�� ; �of p nding,- "condit on of vegetation,:-recommendations -for-.maintenance .or=-repairs;etc. ) 11 {1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B . SYSTEM INFORMATION continued SKETCH .OF. SEWAGE DISPOSAL SYSTEM:. include ties to at least two permanent references landmarks or-benchmarks locate all wells within 100' �vAk (� e 0 DEPTH TO GROUNDWATER depth to groundwater method of determination- or..-approximation: ' ....A.-.o en .w..i .if n d.a+:.M .. .•..:+.y'aw1-ia.l.,.. . . .4W ..r rh..!�M..... . <e... . ':.1 '[.x' S'.s�-.} i_.}# v3 A �M1 .'µiw u • x . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND -determination in all instances. If "not determined"Deecplainribeb why snoof t) Backup of sewage into facility?----- Discharge - . _ .� or - ponding_ of effluent to the surface of the ground or surface waters? Static liquid level in the distributi on box above outlet invert? Liquid depth in cesspool <611 below i flow? nvert or available volume< 1/2 day ARequired pumping 4 times or more in the last year? number of times pumped !� Septic tank � is metal . cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank. failure imminent? Is any portion of the SAS, cesspool or privy: below the roun high 9 groundwater elevation? Pf within 50 feet of a surface water? within 100 feet of water su 1 a surface water supply or tributary to a. surface PP Y• within a Zone I of a public well? ' within 50 feet of a borderingvegetated 9 ated wetland or salt marsh (cesspools and privies only, not the SAS)? within 50 feet o 3 ;f a Private •water=supply- well? less than100* feet but greater.,than :50..,feet from a X supply well„with .no ._acceptable .:water... private-water •has (been analyzeda,to,:_be.r.acceptable,, attachtcoanalysis? -If-the well for,coliformbacteria, _v.olatile organic 'compoundsf_®ammoniatnitanaly; wand ntrate.nitro en. �.. ro en- g ,� a.3 9 s mow' ^' w.- w..� ..... r.. +._ . w. .. ....v..u.....w.. ... -.. -v...uc*r T..-v MrKM --snuW.. .a•-ar.w..nt r.-.♦avrsr..WY.�- ..Q±+vLx'.fi.15' a -. Wiath.W.+1du{'✓1f.4+nu •. .. .+x.,...,. .....w .v..:a:-4'aW.. .r MHT.r...+ei.+e-wLwr m.... +n-...r..... ......,.L... ..xau.-r+•u.....r•L'•.w-t+saav..w......n,,..... 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name NEW LIFE SEPTIC SERVICE - - - RO. Box-2119 -- -- - Company Address Teaticket, MA 02536 (508) 548-3355 'Certification Statement I: certify that I have personally inspected the sewage disposal -system at this address and that the information reported is, true, accurate and complete as of the' time of inspection. The inspection was.performed and anyr.recommendations regarding upgrade, 'maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: �V/ I have not found any information which indicates .that the system fails to adequately protect public health or the environment as defined in 310 CMR •15.303. Any failure criteria ,not evaluated areas stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is prow de d the FAILURE CRITERIA section of this form. Inspector's Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority S ZC I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ` "i`�LE DEPARTMENT OF ENVIRONMENTAL PROTECTION LREED'2ARNSTABLE TITLE 5 DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION AP I uZ Property Address: 930 Route 149 r. „� Marstons Mills -'ARCEI. O q- Owner's Name: Eric Bengston LOT 20 Owner's Address: Date of Inspection: 12/8/2004 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 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 the inspection.The inspection was performed based on my training— d experience in the proper function and maintenance of on site 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 Needs Further Evaluation by the Local AuthorityFails Inspector's Signature: L/�✓S. Date: /,0 07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 to the buyer,if applicable,and the approving authority. Notes and Comments ""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 the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO N FO RM PART A CERTIFICATION(continued) Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: 12./8/2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: I 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: B. System Conditionally Passes: One or more system components as described in the"Conditional-Pass"section/ eed to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. l Answer yes,no or not determined (Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(wlether 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,Peaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out 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): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: 12/8/2004 C. Further Evaluation is Required by the Board of Health/ines Conditions exist which require further evad of Health in order to determine if the system is failing to protect public health,safety or the en 1. System will pass unless Board of Healtordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner wublic health,safety and the environment: _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 y)determines that the system is functioning in a manner that protects the public health,safety and a ironment: _The system has a septic tank and soil absorption system(SAS)and ther`SAS is within 100 feet of a surface water supply or tributary to a surface water supply. it —The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. /i —The system has a septic tank and SAS and the SAS is within/50 feet of a private water supply well. 1 _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,perforgied at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that thg'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,provided that no other failure criteria are triggered.A copy of the analysis m t be attached to this form. 3. Other: Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: I /8/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: 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 due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or cesspool — Liquid depth in cesspool is less than 6"below invert or available volume is less than%2 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 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 I of a public well. Any portion of a cesspool or privy is 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 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] t� Yes/No)The system fails. I have determined that one or more of the above 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 ith a design flow of 10,000 gpd to 15,000 gpd. 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) i yes no the system is within 400 feet of a surface dri mg water supply _ —the system is within 200 feet of a tributary o a surface drinking water supply —the system is located in a nitrogen sens. iv area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 0 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 syste as failed.The owner or operator of any large system considered a significant threat under Section E or fail d 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. Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: 12/8/2004 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? _ _�,X 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 than 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: Yes No _ 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(3)(b)] Page 6 of 11 - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: 12/8/2004 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): .2) Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):"3=3©, 6,i?Z> Number of current residents: 3 Does residence have a garbage grinder(yes or no):L22D Is laundry on a separate sewage system(yes or no):�4if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use: (yes or no): b Water meter readings,if available(last 2 years usage(gpd)): Q<nn& `cy y 6 Sump Pump(yes or no):A.)�D Last date of occupancy: C,, r � COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes no):— Non-sanitary waste discharged to the Ti e 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: s-- Was system pumped as part of the inspection(yes or no): N If yes,volume pumped: icpggallons--How was quantity pumped determined? Reason for pumping: TYPE ,,,OF SYSTEM _peptic 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) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): ADc> Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: 12/8/2004 BUILDING SEWER(locate on site plan) Depth below grade: /1/"' Materials of construction:_cast iron _�0 PVC other(explain): Distance from private water supply well or suction line:_,, ,g Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below,grade: Material of construction: concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: x Sludge depth: 3" Distance from the top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: 3 " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: (a " How were dimensions determined:s,,a ,�,� , Sa ` Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fibe lass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or affle: Distance from bottom of scum to bottom of ou et tee or baffle: Date of last pumping: Comments(on pumping recommendations let and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of le age,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: 12/8/2004 TIGHT or HOLDING TANK: (tank must be pumped _ me of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fib glass_polyethylene_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/d Alarm present(yes or no): Alarm level: Alarm in work' order(yes or no): Date of last pumping: Comments(condition of alarm and oat switches,etc.): DISTRIBUTION BOX:_Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: C_�O„ Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): n 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.): f /J I ' Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: 12/8/2004 TIGHT or HOLDING TANK: (tank must be pumped . me of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fib glass_polyethylene_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/d Alarm present(yes or no): Alarm level: Alarm in worki order(yes or no): Date of last pumping: Comments(condition of alarm and oat switches,etc.): DISTRIBUTION BOX:_Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: (-,)„ Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): n ^4 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,rndition of pumps and appurtenances,etc.): I I Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: 12/8/2004 SOIL ABSORPTION SYSTEM(SAS): t/(locate on site plan,excavation not required) If SAS not located explain why: Type ,Zleaching pits,number: X 4� 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.): r L—'k" r 1 I—Q, L���.` cam; 01 3�V+d Vim.,c�� cal/� G 4 IV,Avg, �'i o vP� V�S:��� - �• Sr�.r— a+� P'C" c.+�►`�k` c i � �3.�C. CESSPOOLS: (cesspool must be pumped as part of i pection)(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 or Comments(note condition of soil,signs bf hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) j Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of h draulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 930 Route 149 Mar stons Mills Owner: Eric Bengston Date of Inspection: 12/8/2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. � i a J r L{ S z t = QC C " ' i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 930 Route 149 Marstons Mills Owner: Eric Bengston Date of Inspection: 12/8/2004 SITE EXAM Slope Surface water Check cellar f Shallow wells Estimated depth to ground waterer feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record—If checked,date of design plan reviewed: 8 Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: ,�.^A,c_,�, . _ S®� S�S��g You must describe how you established the high ground water elevation: 4 _' �C�/�r'7 L'r J`�/v`�r � Iv C�J� C.� T�' •l� �nGC,.V f�.�„ �}Ll G.LE Flats I Lam! - V!; O *% DAI`K V--Lo..v is Itlp 41 - uSE 'm>ISPoSAL P1T V;E [coo STDfX.. S CEW O A eoT'TOM - A2aA I :Sfz - .. 1 :;:' '✓ # . :.. Aw f o Qi PE�c-.oL1i't'Ic►i'=Edit_ i7_Iu=2-A1�.1= rW 17 . A. } • y� t i.. '�'.''j�PE. � .' � � IVY•._-1�'r0 - VKT4A.L.TUUWL , r- -Q- - :-- i• vzl ;i��i--;��,'� ,,�.:: -� 1 ,-�• '-•-�'�C�R.TtFI'�a._r �.:oT 17 «- _ —P,QO t�t t...E -� 1 ---,ate + (_4-T;_._i_�• r�•�� G _ --+. T i { 1 1 '1 I i- %-� - i :, 7 }---�-+ 1: • - { . L• I, '1T . -_>•-iE2_E oi.t= Goi�iP_�-Y S i-i W ITN'-'RaG.'. ;t�E�:l ttesI + i� _' �� ' _._ .. --AND;-sSETB IL�R�QVI¢.�M6.uT; �.oF�tT'LIE 1_}� T. ri _,.,�.�fI,�� _;.., =��� ". . _ • OFF all t. _�L { �� ..:_._ 140 77 ' ? :_• ' .__ = - ---. r; " QtST� rt� Lin l svev�-�pe� TKIS "Qt-dN -t .--ILOT�--BASED Oil_::AU . lLKrTeOME$4T_. j .� OSTF�Vl t1� 1-A4JLGo S. Sur- T&1G OFF$w; .•'S4lOULD VOT aE Uieo.- . � , ,_. A?PLtGALiT'' Tc D�Tr_r_4oAWL --�-oT - -uuF,t:."- ,_. ..._ _ _. _ _• ' _ I14 NNO �'7 t► No..---......°1: .�.,... Fss..s .Q............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH��W_1A..-•-•--......OF........... M...OnT^A.l�-' ........................... , �irtttion for liopooa1 Works Tomitrurtiori ramit Application is hereby, made for a Permit to Construct (XX) or Repair ( ) an Individual Sewage Disposal System at: ny I .........Sand Shores,,.-l.,arstons__Mills........-•----•--•-•---•- -----••---......-- .... , 17.�- ---------------------- __.------ 20 "' Location-Address or Lot No. • Wianno Construction Inc. . ....9.50 Old Stake Road,__Centgrville___••••_-_-__ -_....... •--•.--•- Owner Address W AL_.......!e n- ' �--------------------- -------------------------------------- --...... .---............----•-......... Installer Address UType of Building Size Lot......11}0:. ..Sq. feet Dwelling—No. of Bedrooms........... ...............................Expansion Attic (no) Garbage Grinder (no) Other—T e of Building No. of persons............................ Showers a YP g ------=--------------------• P ( ) — Cafeteria-( ) dOther fixtures -------•----•---••------------------•--.......--------.••-•••••----•-••----•-•••••-••......-=•-•••-•-•••........ .... W Design Flow............... 15....._......•.----•gallons per person per day. Total daily flow................. B-0............... WSeptic Tank—Liquid capaciti6 .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.......f............ Total Length..........//_,�........Total leaching area....................sq. ft. Seepage Pit No.....--.-1.......... Diameter...........?..... Depth below inlet.......6......... Total leaching area._. ..sq. ft. Z Other Distribution box (✓) Dosing tank ( ) 0 j `" Percolation Test Results Performed by...uT�.. ..Ate.- �.... ,6.8C?T9 Date..... � .�............. ,.a Test Pit No. 1......Z...minutes per inch Depth of Test Pit------1` ....... Depth to ground water..-- ............ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......---............... a ......--• --...--•------•....... ..............•--•-•----•----•-••••-•.._........--... O � 2 - Descriptionof Soil - -•-•-----------------------•---•-------------.---------•------------------------------- cxj - --------------------- 2A.�1�. -------•--•------------------------•-....--•--•--...... 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 TI'L U 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. �ed ............................. ................................ DateAPPlication Approved BY ----- •. .....•- . --------=---•-Date Application Disapproved for the following reasons:................................................................................................................ ..............•--------•----•----•------------•.......--------...........---------••••--•----•......-•- te j -Date Permit No......................................................... Issued ..• _ •- ••• •- Da No.............. . Fzz... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF........................................1-1.1........................... Appliration for Uhipagal Workii Tongtrurtion Vvermit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ................................................................................................ ................................................................................................. Location-Address or Lot No. ...............I................................. ............................................. ............................................. ...........................................�wner �ress.................................................................................................. .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet U 1­4 Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) 04 Other fixtures ....................................................................................................................... < . ------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-____..._..... Depth....._......._.. Disposal Trench—No. .................... Width.........._.._._._.. Total Length......._..........._ Total leaching area....................sq. f t. Seepage Pit No--------------------- Diameter.................... Depth below inlet.........._......... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test-Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit..................__ Depth to ground water..__.................... (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.__............._._. Depth to ground water------------------------ 04 ...........I_ I ............. ................................... 0 ----------------------------------------------- Descriptionof Soil.........t....0.7.................................................................................................................................................. ..................................)........./ U .. .. .. .............................................................._.................................................................................... ........................................................................................................................................................ -------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable........................................................-....................................... ........................................................................................................................................................................................................ Agreement: The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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. Si ned- -- ---------­--------------"-----------­"----------------*------------- ..........D'"t.....**-------- aPApplication Approved ..... ................. .......................... ...... 6�z Date Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... IssuedL....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...................................................................................... Tntifirair jaf Tompliana TO R T Y, That the Individual Sewage Disposal System constructed ( I-ror Repaired Y'��.............by--- ------I-"L.=Y ........ ---------------­--- -------*-----------------------*--------- at., ..... ........................................................... ........J, . ...M... . A has been installed in accordance with the provisions of I T. 5 of he State Sanitary Code as described in the application for Disposal Works Construction Permit N ......... dated-47---- ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED At A GUARANTEE THAT THE 0 .....I SYSTEM WILL FUNCTION SATISFACTORY. DATE........ ................................................................. Inspector--- .................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH ...OF....... .......................................................4)n....... /S ....... No........................ FEE.. . ............. Permission/is eby granted.........6L.11V..... I���#rnr��inn ............................................................................................ to, Const (14 ) or e ir. Indivi W ual e Disposal, System C'at No .........12... .. L1111-1......------ ....................................... Street as shown on the application for Disposal Works Construction Per 0-------- Vated.... 7- ..... ............................... ................ -- ----­--- ........ ..................... DATE....... ........................................... Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS L 0 c ION S , W A/,G E PERMIT NO. VILLAGE `/� e� s INST, A LL R'S NA E i ADDRESS t U I L D E R OR OWNER `ZI t DATE PERMIT ISSUED ,� � �._ � DATE COMPLIANCE ISSUED a a )61 3 � _v