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HomeMy WebLinkAbout0231 ICE VALLEY ROAD - Health 231 Ice Valley Road Marstons Mills. '. ' A= 096,- 012 r 'J �Jd e=- •�s cal�� ..�;,�, G,y ���e 03—,2,20 c—rr e.,15. ` TOWN OF BARNSTABLE dVae"°� LOCATION 231 1 CE V A.LLG c� SEWAGE # VILLAGE C-3. �^ �— ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY lOM C-JACrLO"S LEACHING FACILITY:(type) UCA'L\ii'ofa.1ZOuCG (size) 4MS NO. OF BEDROOMS PRIVATE WELL OR PU�WATER BUILDER OR OWNER ZZOC G t- `'A fMC-0 )�-A DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED: VARIANCE GRANTED: Yes No Xy "be '��7IcsZ S�M�CpM(�/z No. EEE 2 5. 0 0 1[ �T�CIC 1f ® ®N - � _ �S Board of Health FTr; s a'_�J.cs_ . 3�_.w APPLICATION FOP, �� DISPA � ''MNSWCTI®N PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) AbandonXXX ❑Complete System 0 Individual Components e Location Owner's Name Map/Parcel# IN6 Ad ress i Lot# e ep one# Installer's Name Designer's Name J.P.Macom er & 8Ori Inc. Address Box 66 Address Box 66 Centerville,Mass. 02632 Telephone# 508-775-3338 Telephone# 508-775-3338 TypeofBuilding Residential Lot Size sq.ft. Dwelling-No. of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Omitting two cesspools in the front of house.F'illing in with fill. The undersigned agrees to' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not t pla, th tem in pera on until a Certificate of Compliance has been issued by the Board of Health. Signe Date 5 13 0 3 9 t-�- /o > Insp ions 4. No. c FEE$2 5. 00 Board-of Health,Rarnst�able �T MA. t P�LICATIO FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon!�7y ❑Complete System ❑Individual Components r Location 23 ce V llaeir Road Owner's Name e. �. Map/Parcel# _ Address �� , r SY4 Lot# j Y 1 Telephone# S Installer's Name T P far Designer's NameJ.P.MaCOm er & Son Inc. Add Address l Address Box 66 r� t� � � A �� Box CS .Centerville,Mass.02632 Telephone# 508-775-3338 Telephone# 608-775-3338 Type of Building Residential Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No.. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Omitting two cesspools in the front of house.Filling in with fill. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not t pla th stem in,opera on until a Certificate of Compliance has been issued by the Board of Health. Signe Date 5/1 3/0 3 Inspe,ctions 00 No. 4 a COMMONWEALTH EALTH OF MASSAl,14i SITIS FEE$25. Board of Health, Barnstable MA CERTIFICATE OF, - COMPLIANCE , Description of Work: ❑Individual Component(s) ❑Complete System F,41 i in two Cesspools The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),AbandonedK(K)X by: J.P.Macomber & Son Inc. N at 231 Ice Valley Road OsterviXle,,Mass. a � has been installed in accordance with the prpvisi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 200 dated �1 ( 0� Approved Design Flow (gpd) Installer J.P.Macomber & San nc. Designer:J.P.Macomber & Son TncLnspector: l Date: 0 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. FEE No. J f $25•Q0 COMMONWEALTH 'L,®tl�llMO WEALTH OF MASSACHtJSETTS Bo`a�d of Health, Barnstable h DISPOSA`L\SYST[M CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon(XXan individual sewage disposal system at 231 Ice Valley Road Osterville,Mass. as described in the application for Disposal System Construction Permit No. dated r Provided: Construction shall be completed �jwithin 1three years of the date—of this'.ermit. All local con 'do s must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date ✓/'-/C'-3 Board of Healt_11 05/05/1994 22:59 508-790-1578 J.P.MAMMBER & SON PAGE 02 — � i J A r.rrt t!`cJrX(,'TION FORM PART C SYSTEM TNFORM.ATI©N(continued) ProperrrAdd�'' IJJ 231 Ice Valley Road arst M ''s M R$ Owner: Shed Mattison ' 03te or lnspeefioo: 4 2 5K-E1'CH OF SEWACE DISPOSAL,SYSTEM provide tt tketch'orMe 1ew14t diIpottt Jyytcrn including tita !o t<1 least rwp permrtnsnf reference fel,d,,,erki or ocncrvnvkf.t.oer,te er!welts within t 00 feet. Locate where Q to It wtter supply enters the tt enct g. Z�l ,Q* :01 r � ...... LI r Te IQ { ,t � a ; OYST�2 REFd ESTATE o. > PWdNEr,NQ.,> .508•428 1623 Apr. 15 21602 10:MPI! p 1 Ilk '2 i � - - • ,•.•��T.+�.ry�Y�.w.1'/grl-'TR ` wY{1L11�!*�I RI Tw•rT��TTr.- .- , OR 'p,arnstabLe£ 'u{4AU;0F. 112ALT11 " SUBSURFACE SEWA(E'1)ISN, AL 9YSTFM INSRCTION FORM '-'PAPT D •- WIT I F I CAT I IDN •Tn-.�.!Mwmewr+�.•,fY11/MIM!'11raR�.w'�7''�—'�"Iwwnwa+��liTFo1�R� �' •r.�e+•.-�•+. ""r .``P�s ' � '��7111>L'DA'Pa1M? CLLAALY� .a S PROPERTY INSP�SC7'ED ��k� y�,pa 1 l;� � �_ . �(��;r,S�phS �l ���• STHET ADDRESS 231 Ice'61411'ley Road A---"' " ",mess . I ' 96/12 ASSESSORS MAPI' BLOCK AND PARCEL # v,r� h. OWN1:R' s NAM,B: Sheri .�'Kattison o.�.... x PAJ?r, D - CRUTIFICATXON { NAHF, OF IHSPBC70RJo®eph PMacomber; ,Jr',. � 1 COHPAN'Y NAME J �'p•Mac omber�&i�5oriInc:r! ' r9„ f ,. ,•, .,. ,: �fBox `•5b Ce'nteryille ,Mass, 02632 COf•IPl,N�v� ADDRESS I scroVc; •Town or City 7 CQHPANY.,.TELEPMONTr (50 ) 775 333$ t �."' PAX' {y508` � 790.. -1578 r. r.e rF..�O/I I,Y Y'�Ii�ii• I ,�fl� si6im� .v� o CURTIFICATION STAT1~MENT' E. .. w �°�f�' i 3;�4�a�+h'M�v $ .�.? u L ti..'A.' .L_•T.,4 p".t„ S I<:�I'= 5 z I certify that1 I h+,ve .per`s':naellyzlnapeetec� the sewage disposal system At this oddress And Chet the ;inT,or.mati`on, reportedr:is=-.tr>se� .aoourute i and cmplete as of the ,time af .inspeotlon ,..'The inspection Was Ferformed and an recommendatione•-re$orda`tig "upgr.ade,,::maIntennnee, and repair are cvnsisient . with my training and experlence• in the 'proper function ,and mainteiinnce or on- si a sewage"'d!spasoi gyStBh1J0 ,".^ ss. "c91' ;:7,`i: p,� Chec' ones . r' Systeai PASSED The Inspect_icn,,which,j, have conducted has not found anY information W111,ch Indic e►t`es ttl tl'the�-system fails to adequate.'.y protect public health or ths ,environment as defined in 310 CHR-.15 , 303 , Any failure criteria not evalunted are -as stated in 'the FAILURE CRIT$RIA eectlon o` r this r. System FAILED* The Inepeotion vhich Y�fhAve con ►coed, hss 'ound that the system fails tc ; protect the public=,het��.'th�eLn =:t�d' . he 'envi'r�nment:; in accordance with Title 6 ; 310 CHR 154303, and as specitical,ly noted o'n PART C - FAUUR : CRITERIA of this'"1n'.S ecti9n 'form r, r a � Inspector Signature €3 'I 4 Dat•; s>� f Mv nA copy of this rtificsstion mu9� .`be`#provid®d do .the OWNZRI the BUYSP. , vnere app?losbla) and rho DOARV OF 5H9ALT11-, r, r :t th• 1nagcctivn FA1LS0 thv owner or operator chall upgrsde ' the eyotem within o'ne yeazr oV the date cf tha inapection, unloss allowed or required otherwise to provided in 310 CHR 16 , 306 . ► portd.dvc t 200_ lU:d5 F.4n z.IUU� P 3 OYSTER REAL ESTATE PHCNIE NO, 508. 426 1623 Apr. 15 2002 10: p PROPERTY ADDRESS Q"sMass � ozbss I On the above date,`! Inspected +the septie ,system -at• tho above address.. Tttls system consists of the followln : r Y 9. ,. . 1 . 1-1000 gallon tank. 4 . 1-6.'X6' cesspool. ( kitchen ) Failed 2 . 1-Distribution box., "' �'5, 1L61X81 cesspool ( Laundry i 3 , 2-40' Lamchiag Based on my_ Ins pectlbn .1"ce'rIjfy:_thi�'fol fowl ng conditions: ' 5 . This is a split system.' " Year system is a titlew"f ve'"septgc 'Systev. #1 ' Kitchen cesspool #4 is, is hydraulic�_failure', Must bd bumped and filled ir. ,This can,. easily-tied into. -the septic system inthe ear of the house.:., , S . .The system, is condition'al.;ly pass.d.' Mill fuwl pass inspection once #4 cesspool' is' omitted', i SIGNATURE:.r mbar r Compan P^� y' Jose�h_ M.acomber A Snn Inc, ,. _--- ---- . , Address Box 65 ----------- Centerville, MaN_02632_0066 TM15 CERTIFIGAIT9ON DOES NOT CONSTITUTE A GUARANTY OR V/ARAANTY � I t f JOSEPH P. MACOMBER ru SON, INC< � Tan kv-0eispoesi-Loaoh fie Ids. a pumped &.Instahod 'Town Sower oonnec-dons P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 �.002 10:45 FAX CiYSTER REAL ESTRTE PHONE NO. 506 428 1623 Apr. 15 062 10:20AN PI) COMMONVISALTH OF MLASSACMTSE=S F - EXEGLITIVE OFFICE OF ENVIRONNTEN rAL DRPA*RTMENT OF ENYIRCNMENTAL PROTECTION TITLE S OFFICIAj.1NSPECTiON FORM—NOT FOR VOLUtNTAYy ASSESSM-ENTS SUBSURFACE SEWAGE DISPOSAL SYST M FORM PART X CERTIFICATION PrvAdd-ass237 I_ae Val e p�(y v aad A.M Owner's Nu rag"Sde Mar.tiaAtt Owner's Address: game Daty of faspcttforr rlamcGrinspector� 'plaese print)Joseph P.Macom r( Jr. Company Namc: h p �`Ar.^mbe_r & 4on Inc . Milling Addrtss: ntarvi e,_la .02632 Tcicphung Numbers $— CERTIFICATION STATEMENT I conify, that I hayo personally inspected the sewage disposal system at this addrese and that the informst4n rep-:)Rad bacW i5 r1,e,aecursie And complete a5 ortho time of the inspection.The inspection was perrorsrcd baser+ on my rrai.ning and experience in the pro"r Function and maintenance oron site sewage disposal systems. i a m s p t? Approved systcrn Inspector pursuant to Section 15,34o orTiclo S plo CMR 15.000). The system: passes conditionally passes Needs Ftrthcr Evaltuttlon by the 49041 Approving Authority Pall ll�spt:=r's Signature: Date.. T'he system inspe.otor she bmlt a copy of this ln;peotIon repcn to the Approving Authotity(3oatd of HeaITl or DEp)within )0 days orcomp!eting this inspeetlon.If the system is a shared system or has a design Flow or 10,000 j;pd or greater,chc ;nspcctor and the system owner shell submit the report to the appropriate regional ofTicc of the DEP.The original should bo sent to the system owner and topics sent to the buyet, if spplieel 1e, and the epproyLig ao!hori�-. *totes and Comtmcnts '•°'Thld repon only describes conditions at tbt time or Inspcctlon and under the conditions of use at thai tionc,Tbis inspection does not address how the syslcm wilt perfortn In the future under the same or ditYerra1 corditlons of usc, Title 5 Inspection Form 61l SfM0 page I f �1`2002 ?a:d3 FAX �l11Ut3 fT rr REAL ESTATE PHONE NO. 508 420 162a Apr, 15 2002. 10:2SrA-t'I -. a:a`�f• Page 2 of i i { OFFICIAL ItNSPECTION,I?ORM^NOT FOR VOLUNTARY ASSESSKEi' TS SUBSURFACE SEWAGE DISPOSAL,SYSTLM INSPECTION FORM PAwr A CERTMCATION (continued) 1?roperry dd bast 231 Ice galley Road Properry ddks. ass. Owner: h Mattison Date of lnspectidn; µr lnspeetloe Summary-, Check A,D,C,D or F./ALWAYS-complete all ol'S"Tioa D A, SystemPassest Canditionallp w 5. 1 have not fcLnd&-iy orm which'indlcates that any of the failwm eri:eria described ix. 310 CMR 303 vr' a�370R 15.30d exist.Any fYdl��re crfterla not es•aluated ere iradicssted belo,v. z Comment'. The1 c.esspoai has t o ba omitted <<.ttztd ti6d intorlhe. existing seutiic syst em. is _p001 i5 in hpdrAuii' c' a are. n0-4-1-d )�G num_por_ out; and 4i,'.ed in with clean perkabl,e sand Than t=he L, t i'ra insl e..0 ion will pass . At tllis time it rioniitio^ally Pauses- B. System Ooaditionally pu9sest One or more syst=components as described in the"C'ondiiionaJ Pass"section need to be replaced Or repaued.TThe system, upcn completion ofthe replacement or repai;';as approved by ih.L'oad of Health, will pass. answer yes, no or riot determined(Y N,Nb)in the ibr the following sea+emer,ts, If"not determined"please exola�r.. • 1 The septic tank Is metal and over20 years olds'or the septic w k(whether metal or noz) is structurally "nsourid,exhibits substantial infiltration or exflltration or tank-ikilure is imminent. System will pass inspeetlon if th e existing,tank is replazed with a complying septic tame as approved by the Board of Health. . •A metal septic ta-k will pass inspo';tion if it is stmetJ:111y Kurd,nos leaking sttd if a Cartificare of Corr:plianCc Indicating that th's ierk is less than 20 yeas old is avalleblo., ND explain; Obse,nation of sewage bloWp or break out or high static water level in the dis»ibulion hox doe to broi�:n or abstructed pipe(s)or due to a broken,sealed or unevstt distribution box, System will pasts lnspeciiOn If(wlth, ;approval of Board of Health): • ' ' broken pipes),are replaced abstrumion is removed �^ distrtibmion box is leveled or rrplaoea ND explain: The system required pwnpitta more than 4 tithes a.yew due to broken or obstnteted pipe(s),T1:e system will pass inspection if('rite,approval of the Beard.of Health): . I , . - . . broken pipc(s)ffi'4 rCplaccd obstruction is removed ND explain: 2 a i/�Ot7: 10;46 FAX Page 3 of 11 OFFICIAL INSPECTION.'FOI2M -NOT]FORYOLU'N'TARY ASSESSMENTS SUBSURYACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION(comituad) Prop" ,dd�ess:2 i3 Ice Valley= Road (n,�Y► ass. Owcert Sheri Meta:ia0ti 17ate of ins➢eoticn;_ 10 01' -__ C. Further Evaluation is Required by the Board of Health: Vb conditions exist w;tich require further evaluation by the Board of Health its ordar to dcterrnine if the system is failing to protect pQl Iit hoalth,_safery br the envlrotintent. 1. System will pass unless Board of Health determines in aocordancc with 310 CMR 15.363(l)(b)that the system is not Nccdoning in a manner which will protect public hevItb, safety aad the eaviruucrtent: .V6 Cesspool or privy is within 50 feet of a su'face water Cesspool or privy is within 50 feet or,bordering vegetated weriattd yr a salt marsh, 2. Systcrt rill fail unless th't Board orHealth�(aad Public Water Supplier,Uany) determines that tlho system is f11natlo11Lag in s manner ibttt protects the public health,safety and environment: VO The systgri has aseptic tank ind soli sbsorption sysieni(SAS)and the SAS is wlthir. 100 Peet ai'a surface water s tpply or tributary to a surface wmer,supply." The system has a septic tank and SAS and the SAS is wain a Zane I of a public water supply, L)2 T'ne eyst i has a septic tank and SAS and the SAS is whh tl$0 feet of a ptivatd water sul ply well. 7" te'he sysn has a septic tank and SAS and the SAS is less than 100 fe.,t hue. feet or more, is on a. privets water sspply NvelN'. .v%ethad usod to determine distance `tTr,13 5'�SteTri ASS"s iTl 1e yell wait:Wlaly�ls,performed at a aaEN eetttrlCd laboratory, for coliicrm bacteria and volatile organle=o:npounds indicbtes that.the.wtll is free hM;3'4'd0tl fl",1 Ghat fac"'i ! 11 the presence of Lmrnonia nitrogen 0rtd nitrate nit*oge:t is equal to pr loss than 5 ppm,provided'ehat no diner fitilure criteria arc triggered.A copy of the a.nmlysis roust be attached to this fann. 3. "Otharr { 3 d tlt�cv:�'f ZORE ST .idU 2Z9_� CZv SOS "JN ENOHC1 �J.Ltl59 -l��cf ci=11 D I,i0�� l y '1tFA 7/2002 10:46 FAX lif oog Pege 4 or]i — OFFICIA-L INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SIJBSURFACE SEWAGE DISPOSAL SYSTEM INSPEcriON ?CORM PART A CERTIFICATION(continued) properry,* dress: 231 lee Valley Road }� 'Mass, p„aer: hExa. Mattison Date of inspection; 4-1-10/02 D. system Fallure Cricerla applicable to all srstemsr You must Indicate"yes"or"no"to each of the following for bll inspections. Yes No ackvp of sewage into fzeiliry or,sy3iern component due to overloaded or clogged SAS or cesspool ischarge or pondirg of effluent to the surface of the ground or surfaec waters due to an overloaded or �IOgged SAS or cesspool static liquid level in the distribution box above outlet itnven due to an overloaded or clogged SAS or, / cesspool �/ lquld depth in cesspool is less than 6"below invert Qr avtulablo WhUne iC logs ehnn 'A day now Required pumping more than 4 tlmes in the last year NOT due to clogged or obstructed plpe(s;.Number 0f tunes plunped g, kny portion of the SAS,cesspool or privy is> elow high grour.d water elevation. ny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a st'.rface water supply. /jksty portion of a cesspool or privy is within 8 Zone 1 of a pubii!well, portion of a cesspool or privy is within 50 feet of a private water supply well. _ —4./Any portion of a cesspool or privy is less than 100 feet but greater then 50 feet from a private water supply well with no acceptable water quality analysis. (Tbts system passes it thr well vratcr analyai:., performed al a DEP eer-tllled laboratory,for eoliform bacteria and volatile of-genic compounds indicates that the well is free from pollution froth that facility and the prvsence of smmoria nitrogen and ❑itt'ate Oitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be Waehed to this form-1 (Yes!No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 CMR 15,303,therefore the system fails.The system owner should cart®et the Boar- Of Health to determine wh®t will be necessary to Correct the failure. E. Large Systemst To be considered a large system tht system must serves facility with a design flow or 10,000 gpd to 15,000 gpd• 1'ou muat indicate either`yes"at"no"to each Qf the following; (rne following eritsria apply 10 large Cyverns Ln.addition to the criteria above) yes nol a/the system is within 400 feet of a surface drinking water supply _ !/ th-system is within 200 feet of a tributary to 9 surface drinking water supply 1 the system is located in a nitrogen aengitive area(Interim wellhead Protection Area-JW-PA)or a mapped Zone 11 of a public water supply well If you have enswere- "yes"to any question in Section the aystern is considered a sipificant threat,cr an5wct:d 'yes" in Section D above the large system has failed.The owner or operator of any large System cansidere�a �;gniftcant threat under Section E or failed under Section D shall upgrade the system it,aecordEuice with 310 CMR J.70�1. The syslem owner should contact the appropriate regional office of the 0cpamren1. 4 t3eV 609 '17N 9N0Hd 7y;�j JD1;.J10 t zf/?002 10:47 FAX 10 � f . i t OYSTER REAL ESTATE. R-101 NO, SIDES4t8 1623 Apr. .- 2GJ�J 10: 5FIP1 P4 gyp, page 5 of 11 OF _.Y1�SPTr✓ SVBS S ux�Ae� � WAGE DISPOSAL S S'T`EM INSPECTION FORM suss PART.B CHECKLIST, Prop*r Ad Mir! 231 Tee Valley Road 1`M11� a aweer:Shpri• � att:isort .. _ ., Date of YnspeClio 0 Ch.zk if ttte followi l?Rave been done You meet indicet�` s"or"ro"as to each of the f'ollows,g: Yes NPumping information was provided by the owner,occupant,Or Fsvard of H:alth Wcre a of thi;system components pumped out io the previous y two weeks? 1 Y/14ss the system reaeivbd normal Vows it 00 pre OUS two week period? Have largo volumes of.wator been introduced to th®System recx,ttly or as Part vg�his inspection? _Z_ Were as built plans of the system obtained and examined?(If they were not available note as NlA) Was the fstciliy cr d.4illia3 inspected for signs of sewagR back cp 7 `,Vas the site inspected for sighs of break out? ; _ were all systern components, 'luding tr,e SAS,locatad ore.site? Werc the septi-c tank manholes uncovered,opened,and he interlor ofthe tank inspected for the condition of%ne baffles or tees, materiel of consrution,dlinensiens•1 depth cf liquid dgdt of sludge end depth of scum? .Was the facility owner(and tyccup-nts if different fronn owner)provided with information on the prv?v' mamiensce of subsurface sewage disposal sy51rcta 7' e The size and 19eAtloti of the Soil absorption System(SAS)on'ihe site]mot,been delermined based on; Yes/no .. ;� �• -. ,. .-�,;> Bxist ig information.For example,a plant at the Board of liealth, Demiralied in the Uld(if any of the failure criteria related to Pan C is at issue.approximation of dis:anee is unttaceptable)t310 CMR 15.302(7)(b)] , 5 ' v t. 2002 10:47 F-U t�lU11h Fy 1 LYSTER R=AL ESTATE PHQNE.NO. 508 428 1623 Rpr, 1S 253d 10:30F"i Pa • , Page 6 of 1 I °'- . OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSVRFACE S1WAGE DISPOSAL SYSTEM INSPECTION FORM �. PART C SYSTPM INFORMATION Property dr ,; 231 .Ice Vglley Road Owner:_ heri attlsvn Date orinspcc6n: FLOW COND]TIVNB RESMEN71AL , Number of bodrootas(design): Ntzmber orbedrorm's(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 Epd x it of bedrooms): `,/* ,.' Numbar of current residents! Does.residence have a garbage grih(ler(yes or no): is iaun'uy on a separate sewage systetri ens or no): (If yes separate inspection requircdI ,Laundry,system ImpocOW as or no):�7 x' Saesona!use:(yes orno): :. , . ryf 2001—.253 ;000 gal2on�=693 . 15 GAD Water meter readings,if available(lt>at 2 years usage(gpd)): 2 000—9 7 , 00t7 gallon 9®2 6 5. i 6 G p>] sump pump(yes or no): Last date of occupancy: Sprinkler system present . COMMERClAI..q"US'I PJAL 7y�e of escsblishmcnt: Design flow(based on 310 CMR M203): gpd Basis of design+now(slats emonslsgft,etc.): Grease trap present(yes or no): rflr/� Industrial avast:holding unk present(yes Or no): Non•sanitsry waste discharged to the Titic S sygkm(yes or no); Water meter read6i;$,if available; N Last date of Wcupancyluae:._ _ OTHER (describe); GENERAL INFORMATION Pumping Records Source0,infoTmmion: Was system Dumbed as pant of the inspection(Yes or no); .GP9 jryos,vQ1-m�pvm?cd: p �allOns--Hew was quantity purnped`determined? r Reason for pumping: . TY OE OF SYSTEM Saptic tan], c isroribution box,soil absorption system Single eesspvol�. Tm+R ?�;!I.I . Overflow cesspool MvY . . Shared system(yes or no)(if yes,attach previous inspection records,if any) s lnnovative]AlternatiYe technology:Attach s copy of the cuv'ant operation and maintenance contract(10 be obtained from system owner) y &Tignt tank i An:acb a copy QN11c DEP approval i1JU pt,5ar(describe), A roxlrnate ace of all mp nt5,date stalled if own). d sou a of SnPa ion: Were sewage odors detected when susiving ttt the sill(ues or no): 6 , r fix• , OYSTER REAL. ESTATE PHONE Ht7. 509 42$ 1623 Rpr. 15 :RK 1.G1:'_, f?f1 F=' i Page 7ofII OFFIC.IAL INSPECTION F'OXM NOT FOP.VOLUNTARY ASSF'SSNI&:T+TS SUBSUPSACE SEWAGE DISPOSAS, SYSTEM INSPLC XON FORM SYSTEM INFORMATION (:orit'.nued) PropertyAdd_rMeas: 231. ate ��a110 ey P,vad Owner:'Shbri Mattison Date of InsQection: 4 10 9UIL�ING S1;W)=1R(locate on sit~p'•tut} ''- . 37" ' De;t} below god et � Matcrtals orconsrmc;ian: cast iron _. 4u PvC", othFr tcxptain`,: Distance f;vm prlvatc water supply well or suction 1ine1 Comments(on condition ofjoints,vtrting,evidence of leakage, etc,): ?oint sb _ap�ar ti—, t hz_. evidence of leIkc . T11e .3 is vented through- t tie hcuse'°VQnt- SEPTIC TANK: 42,Oocace on site plan) Depth below materiLl of consavcticn:+ concrete.4,mctalc?,,,5 fib etglass0.PolyethYItne It rink is matal list age: is age confirmed by a Cercincate of Compliance(yes or no)id' (attach n capy of D:mensiont: r'�-.fiZ� S�•�°�1�. J•'��j,!°�- ;t. ;,, J . . Sludge depth: Distance&oro top of udge to bottom of outlet tee or bamet 5ct�thickness.,� Distance from cop of scum to top of outlet tee or bathe: Dir$nce from bottom of scum to bottorat of outl®t to o,,b3ffle: - HoW w•er:dlmensEon9 d®tercnintd:,;,:,���� °' - -- I Comments(on pumping recommendations,Wet and outlet tee or baX..e condition,structural t�:°ttepiry, liquid levels as related to outlet invert,evidence ofleakage,etc,): ?umA the Se tic e�.y tarak : v Z-3 years .Inlet_y u atlat _t9A5 are in lave The tRa.k ie structurally sounc! anu show Inc:eya nC2 of lea t�ge, GREASE TRAPA&Loocaie or.site plan) s f Depth bclow grade: &L41 '�iatettai other of construction:+ concrete. moral fibergl�5s-Apo i_' I (cxplaLn): /lam Dirncnsiotttl Scum thickness; Distance from;op of scum to top of outlet tea or baffle:' _ _ Distance from bottom of scum to bottom of outlet tee or baffle: Dace of fast pumping- A44 Cvmtnonz On pumping roeornmenda110M5,inlet and outlet tt:t oc baffle condition,strucnu~al inte$rity,"liquid lcveM_s as relatc3 to outlet inv:rc, evidence of leakage,etc.): Grease tr s not l r74` Ti2002 10:98 FAX [ j01:) rt di I OYSTER REAL ESTATEFH�NE,NO, ; ` eB 4231F�23 fir. 15 2fdC�2 1Q:�iArt P8. • . s' a? i 4''v Page 8 of OFFICIAL INSPECTION.FORM-NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSA'IL SYSTEM INSPE(:rION FOR'14 PART C SYSTEM INFORMATION(coniinued) j 6 Properll 6d r 231 Ice' Pall y Road Own-AlVi Ma tison Date of laspxctlont 10 0 2 ' TIGHT or HOLDING TAM(t"(twik must be pumped at time of in6pmction;(locate on,slits plan) Depth below grade: ?.latcriui of cons=ti n: 1,�Lcorcrctt 4.metal Aklitergtass olyCt7�icne�.�ot#tcr{oxptaii): Capacity: a)lons Dcaign Flow: Mons/day ' Alarm prescm Cye9 or.no): Alarm level:� Arta in workin8 order(yes or na): t1�9 Date of!asi ptimping: Cemrncnts(conditioa of alarm and float switches,ex.): ............. -- DISTRIBUTION DUX: (if present must be opened)(locate on site,plat) Depth of llquid level abave outlet inveztt 4)6 Comments(note if box is level and distribution to outlets equal, any eYidcnca of sclids carryover, any evideree of leakage into er out of box,ste.): etri ut;j box hag rwo laterals.No evidenee of solids a v r o �,3� aence of lea a e. Inin or out of_box PUMP CHAMa-E (locale on site plan) Pump:In Nwking order(yes or pq): AI%Ms 10 working order(yes or no): A Comments(note condition of ptunp chamber,condition of pumps ar:d appurteranccs,etc.): Ju_rnp chaatbe is n2r E ,p � �,�.; __-- ___ -- s...A..:.�..-..aa_n.•., fi:*s.•Px e�t a ..s t.-..a r ii In i . � ' �} , •. t F t � 8 t€ �0,C2 10:48 FAX ,# M' _. OYSTER REAL ESTATE PHONE .Na. 50SP428 .1623 Apr, 15 2002 10*-32AN P9 Page 9 of 1 1 OFFICL4.L INSPECTION FOPUM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SYSTEM INFOPO4ATION (continued) Property Addr s 2.31 Ice Valley Road � ffieffiffial Imam$ . Owner: Sreri Mattison Date of lospectign: G 10 < SOIL ABSORPTION'SYSTEM,(SAS): Ziocate on site plan,excavation not required) 2-6 ,X8 block cesspools 2- lgachinK t�•Pnehes C' 40 ' each if SAS not Iocated ©xplain why: a Locate , ee Page TYPe �_:eachng piu, number:,� /L` leaching chambers,number: 0 ; leaching galleries,number: en �. leaching trenches,number,length: 9 leaching fields,number,dimnsions: overflow cesspool, number:. `, :� a tnnova%ivc,'altcmati�•c system Typelnatne of tech,o'logy:f ' � t9,2 y 712e �� ,.nnalrinn of cnil tione of hvttranlir Pallure_ level of nondine., damn sell. co.,ldition'of vAgetition, , ge 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 231 Ice Valley Road 0wner:She i Mattison ,Mass Date of Inspection: 4/10/0 2 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to p ground water 3d feet Please indicate(check) used to determine the hi ,( )all methods high ground water elevation: Qbtained from. abuttin roe desi plans on record-If checked,date of designpl an reviewed.Observed site bservation hole within 150 feet of SAS) 1^�d.7 ecked with local Board of Health-explain: 01 Necked with local excavators, insta11 s- ttach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used ; Gahrety & Miller Model Gr o i,nd wate r con o irG ahnY.e saa � P�P1 Used ; Observation well data . June 1992 USGS Used ; USGS—Annual ranges of ground water elevations. Tec bulletin 92—Q001 Plate #2 hnical •uN ui vroun i�e�ak�s Groundwater;2fFeet Below Bottom of Pit • High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the botto i Of the leaching pit and the adjusted groundwater table is l �Zv feet. 11 f Pagc 10 of 1 I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTA.R SUBSURFACE SEWAGE DISPOSAL, ASSESSMENT SYSTEM y INSPECTION FORM S SYSTEM INFpART C RMATION(continued) ProperryAddr��ess: 231 Ice Valley Road Owner. Ae'ri , ass . Mattison Date of Inspection: 4 10 02 SKETCH OF SEWACE DISPOSAL SYSTEM Provide a sketch of the sewage al dispos system including ties to at least two permanent reference benchma.rks. Locate all wells within 'J feet. Locale where public water supply enters the building.landmarks or � II i �7 �ob mob' • ,�11 � ` • Imo. tYm'l-v-19 t Val 10 DA G A2, �n Vce �A 1 eAa% -d-U 3 23•yam 1S(Y �R4FtSi J' f/� h V S '. 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