Loading...
HomeMy WebLinkAbout0015 COACHMAN LANE - Health 15 COACHMAN LANE, W. BARNSTABLE A= fr ° 1 n v v f P . *C)s-_ JD COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR OTECTION TITLEFORS OFFICIAL INSPECTION FORM-N T SUBSURFACE SEWAGE DISPOSAL VOLUNTARY SYSTEM FOESSMENTS PART A RM CERTIFICATION Property Address: /� C I'Kah �.aw� Owner's Name: r Owner's Address: 0. Date of Inspection; a $ Name of Inspector: Company Name• (PIe se print) 'G Mailing Address: r1.$PGC� Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that th below is true,accurate and complete as of the time of the inspection. The inspection was erf ? training and experience in the proper functign and a iformatton�reported approved system inspector pursuant to Section .534 e o Title 5 site CM p °emed based Pon my= sewage disposal systems. I am a�DEp r-3 R 15.000). The system: -jL Passes - Conditionally Passes ~' Needs Further Evaluation by the Local Approving ._ Ero Fails Pp ,Authority Inspector's Signature: Date: d The system inspector shall submit a copy of this inspection report to the Approving DEP)within 30 days of completing this inspection.If the system is a shareds system or has rity(Board of Health or gpd or greater,the inspector and the system owner shall submit the report to the a appropriate regional DEP.The original should be sent to the system owner and copies sent to the buyer, if a a design flow of 10,000 authority. Pp F g ona!office of the Y applicable,and the approving Notes and Comments ****This report only describes conditions at the time of inspection time. This inspection does not address how the system will per in the future and under the conditions of use at that conditions of use. under the same or different Title 5 Inspection Form 6/15/2000 Page 1 page 2 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSA.L`SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: S" CpGt6%�i Owner:_ Date of Inspection: 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have-not found any information which indicates that any of the failure criteria described in 310 CMR 15:3 3 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 ass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as proved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the Rowing statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or a septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank approved by the Board of Health. *A metal septic tank will pass inspection if it is stru ly sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is vailable. ND explain: Observation of sewage backup or out-or high static water level in the distribution box due to broken or obstructed pipe(s)or.due to a broken,se ed or uneven distribution box.System will pass inspection if(with. approval of Board of Health): Token pipes)aw replaced obsttucti(m isremoved distribution box is leveled or replaced. ND explain: The system re ed pumping more than 4 times 1.a year due to broken or obstructed pipe(s).The system will pass inspection if( approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSES SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TS PART A CERTIFICATION(continued) Property Address: O 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 order to determine if t is failing to protect public health,safety or the environment. he system J. System will pass unless Board of Health determines in accordan with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect publi health safety and the en vironment:onment: __._ Cesspool or privy is within 50 feet of a surface water. Cesspool or privy is within 50 feet of a bordering vege ted wetland or a salt marsh 2. System will fail unless the Board of Health d Public Water Supplier,if any)determines th system is functioning in a manner that protect the public health,safety and environment: at the The system has a septic tank and soi bsorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a s ace water supply. The system has a septic tank an SAS and the SAS is within a zone I of a public water supply. — The system has a septic d.SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is less than ]00 feet but 50 feet or more from a private water supply well** . ethod used to determine distance **This system passes if a well water analysis,performed at a DEP certified laboratory, for colifo rm bacteria and volatile or is compounds indicates that the well is free from pollution from that facility and the presence of amm is nitrogen and nitrate nitrogen is equal to or less than 5 pprn,provided that no other failure criteria are 'ggered.A copy of the analysis must be attached to this form. 3• Other: 3 Page 4 of 11 OFFICIAL,INSPECTION FORML NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PARTA, CERTIFICATION(continued) Property Address: C OwnerDate of Inspection: r-7 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for ill 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 an overloaded or clogged SAS or cesspool 0 Liquid depth in cesspool is less than 6"below invert or of times pumped available volume is less than''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number 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 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 z 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.twor less than 5 ppm,provided that no other.failure criteria are triggered.A copy of the analysis must be attached to.this form.] (Yes/No)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 desi gpd• ow of 10,000 gpd to 15,000 You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems:in.addition to the 'a above) yes no the system is within 400 feet of a surface g water supply the system is within 200 feet of a tary to a surface drinking water supply the system is located in a niu en sensitive area(Interim Wellhead Protection Area—IWPA)or'a mapped Zone II of a public water s ply well If you have answered"yes"to y question in Section E the significant system is considered a si Y gn� threat,or answered "yes"in Section D above th ge system has failed.The owner or operator of any large system considered a. significant threat under S 'on E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system o r should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: r Owner: Date of Inspection: 11(0-7 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? p—� 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) T 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 oflthe baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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 CUR 15.302(3)(b)J 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: / Owner: Date of Inspection: RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual):`�,3 DESIGN flow based on 310 CM1% 15.203 (for example: 110 gpd x#1 of bedrooms):. Number of current residents:Does residence have a garbage�r grinder(yes or no): Ilk? Is laundry on a separate sewage system(yes or no):—& [if yes separate inspection required] Laundry system inspected(ye or no):kV Seasonal.use: (yes or no):_ Water meter readings, if available(Iast 2 years usage(gpd)): Sump pump(yes or no):Sj6n4� Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishmeLin Design flow(based R 15.2 Basis of design flowson gft,etc. : °Pd Grease trap present( no ____ ) Industrial waste holdresent(yes or no): Non-sanitary waste to the Title 5 system(yes or no): Water meter readingble:Last date of occup OTHER(des ibe): Pumping Records GENERAL INFORMATION . Source of information: . Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _i 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 insta ed(if known)and source of information: 01 Were sewage odors detected when arriving at the site(yes or no): ` 6 Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: s'em t Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: _ Materials of construction:, cast iron f40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:x(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass__polyethylene —other(explain) r '-- If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or.no —(attach a copy of certificate) y� /� Dimensions: l Drxj qG,�`(i Sludge depth. Distance f om top of sWdge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ) a Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions determined: $d SV/Y� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relate o outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: concrete metal erglass polyethylene other (explain): T` Dimensions: Scum thickness: Distance from top of s m o top o utlet tee or baffle: Distance from bottom of scum t ottom of outlet tee or baffle: Date of last pumping: Comments(on pumping r ommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet inv ,evidence of leakage,etc.): 7 i Page8of1i OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: ,�3 Date of Inspection° TIGHT or]HOLDING TANK; (tank st be pumped at time of inspection)(locate on site plan) De pth below grade:: Material of construction:. con a metal fiberglass---Polyethylene other(explain): Dimensions: Capacity: allons Design Flow: allons/day Alarm present(yes or ): Alarm level: Alarm in working order(yes or no): Date of last pump' g: Comments(con tion of alarm and float switches,etc.): � DIST RIBUTION I ON BO X: X. ,., , � (if present must be openedxlocate on site plan ) ) Depth of liquid level above outlet invert: 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.): 0p t n PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in workingorder s o(ye r no Comments(note condition of p chamber,condition of pumps and appurtenances,etc.): - R f Page 9 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a� Owner: ., Date of Inspection:— SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching Pits,number: 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,etc.): damp soil,condition of vegetation, CESSPOOLS: (cesspool must be pumped as part spection)(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 i ow(yes or no): Comments(note conditi of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condi on of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: 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. G�C'iU dos/ 1� ro o?p 4 V V Page 1 l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Y'1 Surface water W Check cellar `!!ac Shallow wells 111b Estimated depth to ground water 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: 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 i database-exp lan. You must describe how you established the high ground water elevation: p i 11 _ v J t. Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection VAlliam F.Weld G" wr Trudy Cox* 8auetN,EOEA David B.Struhs ppmmbsioner v.' ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM o r` PART A �-ZZ CERTIFICATION - �_ OCT� 2 Property Address: w _&a4l,�Address of Owner: c° 0 199 5 Date of Inspection: /v _ /S- �j Of different) Name of Inspector: J Ma 12 1/U 49l Company Name, Address and Telephone Number: CERTIFICATIk 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: L4195-ses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fail Inspectors Signature: � w Date: 70 r The System Inspector shall submit a copy orthis inspection report to the Approving Authority within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"mot determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street a Boston,Massachusetts 02108 a FAX(617)556.1049 a Telephone(617)292-UW 0 vented on Rwyvied Papa SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution 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 The system req 'red pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection•if(wit approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED Y 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 environ t. t 1)' SYSTEM WILL PASS UNLESS BOARD O HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC H LTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet a surface water Cesspool or privy is within 50 feet o bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS HE BOARD OF H LTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIOfy'ING IN A MANNER AT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. j The system has isewic tank and soil absorpti n system and is within 100 feet to a surface water supply or tributary to a surface water s pply. _ The s\,ste r ha, a septic tank and soil absorption ystem and is within a Zone I of a public water supply well. _ The system his a septic tank and soil absorption s tem and is within 50 feet of a private water supply well. _ The system s a septic tank and soil absorption sys m and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform cteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. revised 8/15/95) 2 s 4� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: D]SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded o/clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is I than 112 day flow. Required pumping more than 4 times in the last year NOT due to cl or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool�or privy is low the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet o rface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone of a ublic well. Any portion of a cesspool or privy is within 50 eet of a priv a water supply well. Any portion of a cesspool or privy is less an 100 feet but gr er than 50 feet from a private water supply well with no acceptable water quality analysis. If th well has been analyzed o be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic cop6pounds, ammonia nitrogen nd nitrate nitrogen. f E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 3 ,000 gpd or greater (Large System) and the system is a si nificant threat to public health and safety and the environment because one or more of the following conditions exist: i the system is4ithin 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply t system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a blic water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6/15/95) 3 i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 157 r✓o c,,,�W v ' Oj w 134&A� Owner: Date of Inspection: 10 _ I Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. ✓The facility or dwelling was inspected for signs of sewage back-up. v The system does not receive non-sanitary or industrial waste flow Y � jZhe site was inspected for signs of breakout. ZAII system components, excluding the Soil Absorptio n System, have been located on the site. r%The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or _ P Pe tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _Zhe facility ov�ner (and occupants, if different from m%ner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 r Y i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: f S C u/-k-c-k Owner: Date.of Inspection: ic-) ` , 65- — 4 S FLOW CONDITIONS RESIDENTIAL: Design flow: *t.F b gallons Number of bedrooms: Number of current residents: O Garbage grinder (yes or no): a_V Laundry connected to system (yes or no): Seascnal use (yes or no): Wate• meter readings, if available: Last date of occupancy:'Ct� COM:4 ERCIAUINDUSTRIAL: Type of a ishment: Design flow: Ions/day f -- Grease trap present: (yes o - Industrial Waste Holding Tank prese es or no)_ es or no Non-sanitary waste discharged to the Title em: (y ) Water meter readings, if available: 77-1 Last date of occupancy: OTHER: (Describe) ----'` Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of in rmation: o /z 1 —QTtrvtQ.c System pumped as part of inspection: (yes or no) If yes, volume pumper! 4.r ' 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)V (revised 8/is/95) 5 I - l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / G�,q L /(J L-� IV'& Owner: Date of Inspection: /0- SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: �ncrete _metal _FRP other(explain) Dimensions: Sludge depth: bb �y ii ii Distance from top of sludge to bottom of outlet tee or baffle:_.,,, Scum thickness: O Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: f 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.) A1,. GREASE TRAP:_ (locate on site plan) Depth below grade: \. Material of construction: _concrete _metal FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outle or baffle: Distance from bottom n+ crom, t, m of outlet tee o,baffler Comments: (recommendatio or pumping, condition of inlet and outlet tees or baffles, dep of liquid level in relation to outlet invert, structural integrity, ence of leakage, etc.) (revised 8/15/95) 6 L - J° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Maternal of construction: concrete=metal _FRP—other(explain) Dimensions: Capacity: Lon Design flow:Alarm level: Comments: (condition of inletlarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: r Comments: (note if level and di ri uror. is e• ua�, evidence of co!i dc cargo er, a idence of le age into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order.(yes or no Comments: (note condition of pump chamber, condition o p d appurtenance�etcj (revieed 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 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, number: -21 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs Of hydraulic failure, level of pondi g, co ition of vegetation,etc.) AJ v 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 (ces of must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condi ' soil, Signs of hydraulic failure, ing, condition of��""i�onetcj�_..., (revised 8/15/95) 8 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6age /Yp).041 /,-V Owner: _ Date of Inspection: • V SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' C �1l 0. •v C - = -7 z DEPTH TO GROUNDWATER Depth to groundwater.__Lr feet method of determination or approximation: - (revised 8/15/95) 9 LO tCATION SEWAGE PERMIT NO. Lid l ZZ CCAc- zMAA.D i j V I L L A G E t►5C. n I N S T A LLER'S NAME & ADDRESS y UL (l A m S U I L D E R OR o OWN ER vF7ea4r IIA)O DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED ) ,�? � i+1csli a rJ T 33 20 .SL 60 $L THE COMMONWEALTH OF MASSACHUSETTS BOARD , O HEALTH . ...............oF . . ....... ... s'T�/.�e- c Appliratiun for Dhip sal Warku Tonotrurtiun ramit Application is hereby made for a Permit to Construct ( L-1/or Repair ( ) an Individual Sewage Disposal System at* 2 Z� ...................�' �1:'1 .....��'.�...... ..........----........—..........----...... .....................—......_..__.... •- Ewation•Address or Lot No. .... `. .._:�.rca.nt... j .. .....Ts .........1. .....l .�ai:_.us .r�....� ...�T W ownpr. — A dre s T g........C�.... 1��.4... ........ �.,� Installer Address Type of Building Size Lot... 1�.3.Sq. feet U Dwelling—No. of Bedrooms......................... .....Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures 640 --•-------------------•--.......-----..................................._......._.......... W Design Flow.................t!l.0.................gallons per person/�ear day. Total da�ly��low..._............ ---......----garllo��. WSeptic Tank—Liquid capacity/ gallons Length..f(..b..... Width.6. ...... Diameter................ Depth.!!�._�...... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area........._.. .._ .sq. ft. Seepage Pit No.......... . - __... iameter............ Z Depth below inlet....... 6...... Total leachingarea.. �� d� ft. Z Other Distribution box.(✓� Dosing tank ) Percolation Test Results Performed by... ....................................... te...... ....--•.--..... aTest Pit No. 1.L_�o.....minutes per inch Depth of Test Pit.....L�=....... Depth to ground water...,-;;,./?. ti Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x - �................. ...................................................... O Description of Soil.4-/z......��P Jo��� Z-/ f��' `yl�-,�r t/� f�✓p �a �•, ....................... .........--....---•-----.-.......--•--...........----..._.........----•--•--------•-•----.........••..................--•....................------•. •----•-••-••-------••-------•--•••••-•-•-•.......................••••---.....--------•---..._...•••-•-••-•••-••---...........•••...........--••--••-••-•-•-...---•--••••-•..................------...... 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 issu y the d•o ealth. / ed-----...... . ... ......--------•- f t° ...... ate Application Approved By.................. ......- ........ J.5- Date Application Disapproved for the foll n reasons:............................................. -......................................................................................-.....---_................_...................----••-••---...--...................................... .._ Date Permit No.............-.............._...-. - -- Issued.-_.....----•--- .. D ----------......._._. ...._ aft i r• � � � �� r. i°*'o}'r I?��tex.� 1�,�s;,. •t<„«tx,�"uw"'is,�,�. 17 ` V.__ THE COMMONWEALTH OF MASSACHUSETTS ; •BOARD OF H EA , T -i . s ! • ✓ • +. .J�• r �i ' - a y:*r` ;. f.t f-- C{� h./ / 1 Y `«• �,! i°7 a t ............ f�-�•./..�.. i.... yfig.(.a,G•- 1,..... g .,,'Alt j s L - rluttfibfi for is n tt1 Vvr+ks ,Cnnnstrur.#iun rdmit Application is.hereby,made foi:a Permit to Construct ( �✓) or Repair {, })r an:`Individual:rSewage'Disposalx ' •System at• r:. . „F <, . R .. ''1:, a• . .....»........»» ..p.»GGJ .................................. ..... �. .......... ........ ................................... �.. ...._ §.. Location Address y � . �-' �-�- or Lot No ....... l ,' f3 is 1 .. 6 �C1 tip f CX�D� .... ,��' f f t Owner r.�-(-• .. "p'• n �•� Addrerss C/......0 ..n a i a f +n /......t....CJ. j ! l7� X 1 r + ,.... Installer ... ... .... ....... Address .. :._ Type g Q Sq. feet•- of Building Size Lot;.......... ...• U r a Dwelling—No. of.Bedrooms................ ....._ ............Expansion Attic Garbage Grinder (� ) Other—T. a of Building'....... ' . No. of; ersons................ Showers Ctil yP g .... ..... .•---- — Cafeteria a P ( ) ( ) d Other fixtures - ....................................................... ...r:1 `ic .�» W Design Flow...: ......11_a.. '...gallons per person per day. Total•daily�flow............................................... ... `!.. Ions. W Septic..Tank"' Liquid capacity`:�gallons Length �..... Width..�_`�_.._ Diameter.:,.:' :..'Depth: x` Disposal Trench—No Width ...... Total Length, ._...... Total leaching'area...................... .............. sq. ft. 3 Seepage Pit No.......... Diameter.....:_............ Depth below inlet......... Total leaching area... -1� sq. ft. Z Other Distribution box (✓) Dosing tank 0-4 Percolation Test Results Performed.by.. � �" ��-. ..��........_ �` ........._------•. ate.. _ ............. $ Test Pit No. 1.eL minutes per inch Depth of Test:Pit L Depth-to'ground water.....:.�Z w Test Pit N.o. 2..... ....minutes per inch Depth of Test Pit .................. D.epth to,ground;water............ .......... .. 0 1 ---- O i . Description of Soil: .� ..%... . ......�+ ......... ........ -�. .� - .... (> ` ��' .............. .. .. ............................................ ................................................... ♦-- ----------------------------------------------- ..._.....................» ....... M } ._:{ --_--------------------- _ ......................... � Nature of Repairs or Alterations `"'Answer when applicable_____... ....:. ..............................:.-.--------------------......_.......... ..................................... �....- . ........................... •. ••-••---•---..... •................................................... Agreement: The undersigned agrees to install' the aforedescribed Individualr:Sewage DisposahSystem 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. �i ..� , ed_ ... {.1.. �J�A°.. ::».... ' ✓ - -- Date Application Approved, By.-••• .. 4 ). �_ . '� Application Disapproved for the f oll n reasons;::::`::..::: ................._ .......---- .. .............. »» - — _'�. ......................................-Date - -- Permit No............................»_....................... Issued.... � ..Y ....._.�_ A Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ ?���....�................OF....J -� ? S+ 4r '. �-........................ (alerfifirate of Tumplittnrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( or Repaired -•) r by ........................... !1_C.... .Ell ........G .N 7:2 't . .N........................................._-- •--.................... .. Installer at................................L&I.......... .. ? G l!'1 ='�t�V...-t_.. V:....... .12d314.f( Lr-- has been installed in accordance with the provisions of TI'ri, of The State Sanitary Code! de bribed in the application for Disposal Works Construction Permit No..............�5._- La(�. .... dated... .............. THE ISSUANCE OF THIS CERTIFICATE:''SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU CT I N SATISFACTORY. DATE............. E� !L�`Cf>a.. •-............. Inspectorf # ..... b G,V THE COMMONWEALTH OF MASSACHUSETTS 0 NJ 17 CJ t3,vILT c� R<!� ( BOARD OF HEALTH * 4 . C:Jr- 1\O.. ......... i�4 '')'431k'1+', 'k" ' r !nfi; cv y..s;. .. �� .e.+ F`kE..-4�.t✓ _.z. _. _ J is osttl for IV Tunstruution f prmit Permission is.hereby.granted:.... --....!'`..(r:.-. .: �- .......... i� :ta .!_Q. .......... ,........._...... ,. to Construct ( or.Repair ( ) an Individual Sewage Disposal System -. at No... •-----. ::.. �,_:.:. G©hc:t¢-1Me t�l ...4,,F,o_.K.r----------•---•-------------�t�'..'..`-1'a.�- 12'( _ Street S s� � - as shown on the application for Disposal ��'orks Construction Permit No......_._._. Dated.. .......... ......... .:......... .................................... �6 and of Health DATE................ :...: FORM 1255 HOBBS 6 WARREN. INC.. PUBLISHERS - X, LOCATON SEWAGE PERMIT NO. IS 0 c� VILLAGE L n ASSESSORS MAP NO INST A LLER'S. NAME ADDRESS BUILDER OR oW DATE PERMIT ISSUED J `� DATE COMPLIANCE ISSUED �f- f AGll l�J 6� Ilk Nol , 20 PT MIN. rr Top . OF Et- ` ice ► C NCRET1 r� �C A SAND 4 SCH. 40 PVC. P 'COVERSlPl> MIN. PITCH , :. � CONCRETE P fd8. t=PER T. COVER 2 LAYER OF CAST IRON i MAX. I 3 1/2„ WAS HEDPfRE_ MlN. Pt GN STONE i 4 PER FT o _ a w � � i.4W L NE z -.. 1 3 • _ r I f _ r _ MIN. _ F r. r, L EL .: ibo /� f p ,. 4 x t, ©O pfJ - 3 4 _!/2 16 r_ STONEWASHED4 4 W o n n,. <a n ff 6 w, �s r :R PRE: LEACHING x. - EL. BASIN OR EQUIV. , . f SEPTIC ` TANK 80TTQM OF TEST F0lE OR USCSPROBABLE WATER TABLE EL. rf , PROFILE 0 ..- T, . y GRfX1ND'WATER TABLE / ! EL._ 4w J DISPOSAL,LSYSTEM SEWAGE DES �� g , ., �• NOT TO SCALE � . ter. , ►. �® f�* r' .... .ILL.ti' �. !u:', , 01 ,. F D51GN CALCULATIONS :r. . , SOIL TEST NUMBER 4F BEDROOMS _ .. . :: . .. . .. . :. : . DATE Of SOIL TEST , _.,,, a w t- GARBAGE DISPOSAL UN1 ,. > . ; �, _ WITNESSED o . TOTAL FLOW _. . 0 L , s , . , . .. PERCOLATION RAT. MIN. ING PERCOL 0 N != l t-! ._.........,.,.... t d _ A SAL./D Y GAL./BR./DAY x BR. • .. r 4 E OBSERVATION_ HOLE 2 OBSERVATION HOLE c;P REQUIRED SEPTIC TANK CAPACITY. ,GAL. y , = ;' ATi � ,� �_ ,..�•:,, >f _ A ELEVA714N .-ELEVATION ON ACTUAL SIZE OF SEPTIC TANK......,.:: . . . .:. . . GAL. rr ? ea • ew, K .... ..- ° . LEACHING AREA REQUIREMENTS ., 1 s < 5(DEWALL AREA GAL./S.F. s., ! BOTTOM AREA 3 GAL./S.F. r� ,a , a /r �..: O EACHIN6 APAGtTY / 80TTOM + Slfl WALL , GAL. � \ t \ 14 ti ,. -. ...sew � � - r� i ti7-7 A ;,- RESERVE LEACHING`. CAPACITY ......:::.:......:...�._�_. GAL. i - NOTES , .. [' P A MATERIALS SHALL CONFORM .._ 1.ALL WORKMANSHIP AND M £ � ( � : : TITLE- AND THE TOWN Of TO D.E Q E L 5 . '. .,: 1 -... rt : T � R SUBSURFACE DISPOSAL , .- -,. ,- : . , RULES ANfl REGU�A IONS 0 U T SEWAGE Of SANITARY SE G ;H ,BR TO 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT 0 I � WITHIN 12 OF FINISHED GRADE:. ...,- :: t HA REMAIN ESSENTIALLY *. , .. 3. EXISTING AND FINAL CRAKES S LL E v . ' �, MIN. FRONT SETBACK µ - � THE SAME. , r ;E t .W MIN, REAR SETBACK _ - IC 'A TO 1 ATI N HAS BEEN MADE BY THIS OFFICE S - . '.. 4. NO DETERMINATION $ ,. » w -_ MIN. SIDE SETBACK APPLICA TCaMPLtA�CE WITH TOWN ZONING REGULATIONS. OWNER •,,. k _.♦ . � . BOARD OF HEALTH s< DETERMINATION F APPROPRIATE AUTHORITY. ,,. APPROVED IS TO OBTAIN,SUCH DETERMIN ON .ROM. ;.. t DATE AGENT , r „ _ •::� _ -_ ., PROJECT LOCATION -'- �E. yr C � �.. ,...._ .,♦. r;- n- .r ..< ... 7" :.-.,..1.-,::. ,✓ - :} ,. ,ry-., .1 .._.,fis'y 6.,,,.,. ..r., r •.r ,/ r J. a:Cr. v .,. GRICH, R ICHARDJAMES tt LEGEND '� t:i : .-�,. a .... � ARN , t--t k � , J T SALE , . DR. 81f DA E ,. . ,..... `... _ /rram� ((/�'.''�� ND. 594J. .. ,. i_ r r _ 4, r 0 0 ,. r t t T ELEVATIONS ,, 0 w T 1 EXISTING SPOT ELEV 0 0 ti .�`� x _. ,, � Y.,, _. PP Y. REV. EXISTING CONTOUR 00 /� . . _.. FINAL SPOT : ELEVATIONS : � .: DRAW IN_ HEARN Ifni DR tvG FINAL CONTOUR r � ' ,- URV Y R RFC. SAAI/1AR/ANSr .,: �_ �,, T LOCATION I O N KEG. LAND S E_© S t r ..,.� , . . .. SOIL L TEST L p �.�� — ' lV/T SITE PLA!!�,!! ,. .. .� RaurE i.�4 u 2 x , SC3UT,N vEnrNe s VA SS. OF