Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0039 NELSON LANE - Health
39 NELSON LANE, M•ki; TONS MALLS A= 126 084 III f COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF It PROTECTION V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:39 Nelson Lane Marstons Mills,MA 02648 Owner's Name. Hazel Rybicld Owner's Address 39 Nelson Lane = t Marstons Mills,MA 02648 Date of Inspection:April 19,2006 Name of Inspector:(please print) Victoria Waterhouse Company Name: Final Touch Construction Mailing Address: P.O.Box 1110 Forestdale,MA 02644 Telephone Number: 508-833-1128 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 and 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: x Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:A Date:April 23,2006 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: System is in fine working condition.The garbage disposal should be removed as soon as possible. System should be pumped on a regular basis,at least every three years R R"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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:39 Nelson Lane Marstons Mills,MA 02648 Owner's Name: Hazel Rybicki Owner's Address 39 Nelson Lane Marston Mills,MA 02648 Date of Inspection:April 19,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _x I have not found any information which indicates that any of the failure criteria described in 310 CUR 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 need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available_ 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:39 Nelson Lane Marston Mills,MA 02648 Owner's Name: Hazel Rybicki Owner's Address 39 Nelson Lane Marston Mills,MA 02648 Date of Inspection:April 19,2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria 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. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:39 Nelson Lane Marstons Mills,MA 02648 Owner's Name: Hazel Rybicld Owner's Address 39 Nelson Lane Marston Mills,MA 02648 Date of Inspection:April 19,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _x_ Backup of sewage into facility or system comment due to overloaded or clogged SAS or cesspool _x_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool x_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _x_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow x— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped —x_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _x_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _x_ Any portion of a cesspool or privy is within a Zone 1 of a public well. —x_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _x_ 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.] _No_(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 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) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes to any question in Section E the system is considered a significant threat,or answered eyes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:39 Nelson Lane Marstons Mills,MA 02648 Owner's Name: Hazel Rybicld Owner's Address 39 Nelson Lane Marstons Mills,MA 02648 Date of Inspection:April 19,2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No 1_ _ Pumping information was provided by the owner_occupant,or Board of Health 1 Were any of the system components pumped out in the previous two weeks'? 1 _ Has the system received normal flows in the previous two week period s Have large yoltunes of water been introduced to the system recently or as part of this inspection-9 1 _ 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'? 1 _ Was the site inspected for signs of break out? 1_ _ Were all system components,excluding the SAS,located on site'? _t_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffies or tees,material of construction,dimensions.depth of liquid_depth of sludge and depth of scum _t _ 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 _t_ _ Existing information.For example,a plan at the Board of Health. _t_ 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)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:39 Nelson Lane Marstons Mills,MA 02648 Owner's Name: Hazel Rybiela Owner's Address 39 Nelson Lane Marstons Mills,MA 02648 Date of Inspection:April 19,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_ DESIGN flo-,v based on 310 CMR 15.203(for example: 11.0 gpd x#of bedrooms):330 gpd Number of current residents: 1 Does residence have a garbage grinder(yes or no):Yes Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry-system inspected(yes or no):N/A Seasonal use: (yes or no):No Water meter readings,if available(last 2 years usage(gpd)):2005: 121 gpd 2006:8.5 gpd Sump pump(yes or no):No Last date of occupancy:Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Homeowner states system was pumped approximately 2 years ago. Was system pumped as part of the inspection(yes or no):No If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _x Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:Components are approximately 25 years old. Were sewage odors detected when arriving at the site(yes or no):No Title 5 Inspection Form 6/15/2000 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:39 Nelson Lane Marston Mills,MA 02648 Owner's Name: Hazel Rybicla Owner's Address 39 Nelson Lane Marston Mills,MA 02648 Date of Inspection:April 19,2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 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: 12" Material of construction:—x—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: 1500 gal. 10'6"x 5'8"x 5'8" Sludge depth:<I" Distance from top of sludge to bottom of outlet tee or baffle:3'2" Scum thickness:<1" Distance from top of scum to top of outlet tee or baffle:4" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined:measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):System is in beautiful functioning and physical condition.Continue to pump every 3 years.Remove garbage disposal immediately! GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc_): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:39 Nelson Lane Marstons Mills,MA 02648 Owner's Name: Hazel Rybicld Owner's Address 39 Nelson Lane Marston Mills,MA 02648 Date of Inspection:April 19,2006 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_x (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:0" 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.): Level and clean,functioning properly. 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.): Title 5 Inspection Form 6/15/2000 8 I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:39 Nelson Lane Marston Mills,MA 02648 Owner's Name: Hazel Rybicki Owner's Address 39 Nelson Lane Marstons Mills,MA 02648 Date of Inspection:April 19,2006 SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not located explain why: Type _x_leaching pits,number: 1 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.):No signs of ponding or hyrdraulic failure. CESSPOOLS: (cesspool must be pumped as part of inspection)(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 no): 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 condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:39 Nelson Lane Marstons Mills,MA 02648 Owner's Name: Hazel Rybicld Owner's Address 39 Nelson Lane Marstons Mills,MA 02648 Date of Inspection:April 19,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Proxide a sketch of the sen--age disposal system including ties to at least txvo permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 39 Nelson Lane Marstons Dills Fmrd N 3 2 'l A1=26' B1=21' 4 0 _23' B2=26' 0 =1 5' 03=36' A4-28' 9 4=56' Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:39 Nelson Lane Marston Mills,MA 02648 Owner's Name: Hazel Rybicld Owner's Address 39 Nelson Lane Marston Mills,MA 02648 Date of Inspection:April 19,2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 45.8'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: _z_Checked with local excavators,installers-(attach documentation)Previous"as built"stated+/-12' _x Accessed USGS database-explain:Frimpter Method You must describe how you established the high ground water elevation: 1. Depth to water table if applicable. N/A 2.a. Appropriate index well. SDW253 2.b. Water-level range zone B 3. Current Water Resources Condition 48.5' 4. Water-level adjustment 2.7' 5. Estimate depth to hi water 45.8' � Title 5 Inspection Form 6/15/2000 11 i TOWN OF BARNSTABLE LOCATION �3 5 V-�5©U'J I—KJ. SEWAGE # 'h VILLAGE tA —16V,+ \AMS ASSESSOR'S MAP &LOT 2L INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S C)C) g Vk LEACHING FACILITY: (type) (size) 1 NO. OF BEDROOMS BUILDER OR OWNER DATE: t y �% COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and BeMm-of-be -a cili_ _ �1 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) V,31 Lt& Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by T. � .k �� � ������ 8 �l-�6r V3\— �"�' e � .. .. (9�Z-a,3� �J2-�b � b��� ��E-��� �� e• c r COMMONWEALTH OF MASSACHUSETTS �, EXECUTIVE OFFICE OF ENVIRONMENTAL AIRS fCE/VC9 DEPARTMENT OF ENVIRONMENTAL PRO Of G ' ONE WINTER STREET, BOSTON MA 02108 (617) 292-550 cy r ��9� V 000FBARN HEALTH OEplABLE WILLIAM F. WELD TRUDY CORE Governor ,`o'm4 , Secreta ry ARGEO PAUL CELLUCCI _DAVID B. STRUHS Lt. Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1_ ow—\ CERTIFICATION Property Address: 39 N'tAsP"' `''�' �'tus `��\\� Address of Owner: �atltb�va C c� Date of Inspection: '711 y kc0o (If different) Name of Inspector: t:N, C" I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: r L Mailing Address: Telephone Number: ,—v�" CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage dispos systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: 1 The System Inspector shall submit a copy of this 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. COMMENTS: BJ SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04125/97) Page 1 of 10 kL , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 4 •� 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETEIL'1 MS THAT THE SYSTEM IS NOT FUNCTION'LtiG IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONLNG IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for colifonn 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 :r h SL28SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propertv Addr-ss: Owner: - 5. - n II Date of Inspection: 7 7y DI SYSTEM FAILS: You must indicate either -Yes- or 'No- a: to each of the folioWing: I ha a determined that the system, violates one or more of the following failure criteria as defined in 310 CMR 13.303 The oasis for th, determination is identified below. The Board of Health should be contacted to determine what will be necessary- to correct the failu Yes No � Badc p of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool. Dischar or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ciogge-' SA5 or cesspool. S:a:ic !ieutd vet in the distribition box above outlet invert due to an overloaded or clogged S15 or cesspoo; \ Licu:d depth in esspool is less than 6- below invert or available volume is less than 112 day floe: Recuirer pumping are than. 4 time<- in the last year NOT due to clogged or obstrucer pipe s . Numoer of time! pu pe-d _ An: portion t;'the Sort osorptien Svsterr, cesspool or pri%,,)• is below the high groundwate• e;eyatio- Am por::on o:a cesspool r privy is within. 100 fee: of a surface water supoly or tributal to a surface water supply An, portion of a cesspoo' or rt.)- is %dha-- a Zone I of a public well. An% pc-,o- e:a cesspool or prn within 50 fees of a private water supple well Any por,or. o'a ce<-spool or privy t less than 100 fe--t but greater than 50 Tee: from a private water sucoly well with no a:ceo:abie Ovate- cualir, analysis: If t e %veil has been analyzed to be accn,,zbie. attach c00% of we!I water analvs,s for coltiorm bacteria volatile organic Com unds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either -Yes- or -No- as to each of the following. The follow:ng criteria app;% to large systems in addition'to the criteria above: The system serves a facilin 'with a design flow of 10.000 gpd or greater (Large System: and the systern is a significant threat to public hea!th and safety and the environment because one or. more of the following conditions exist. Yes No the system is within 400 fe--t of a surface drinking wate supply the system is within 200 feet of a.tributary to a surface dr king water supply _ the system is located in a nitrogen sensitive area (Interim ilhe-ad Prote_tion Area - IWPA) or a mapped Zone II of a public 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 Surther.informatioa --- - - --- -- - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOti FORM PARTS CHECKLIST Property Addtess: Owner: Date of Inspection: !/ Check if the following have been done: You must indicate either 'Yes' or 'No' as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. Crone 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. RAs bull: places have been cmained and evarrined. Note if they are not available with WA. _ The fai:!IM or dwelling was mscw=ed for signs of sewage back-up. The si.stern do,-- not receive non-Sanitary- or industrial waste flow. The sue %%as insrected far signs of breakou:. All s%sten- co-nconenu. excludine the So-1 Aoscrpuon System. have been locate--' on the site. The septic tank r^..anho;e5 Nere uncovere,-J. opened. and the interior of the septic tank -as insae^.ec for condition of banies or tees. materna;. o:cons:rucuon. dimensions. deptn of liquid, death of sludge. depth of scum.. The size and locat,on cf the Soil Absorption System on the site has been determined based on ram_ _ The iac,laN a%%ne- .anc occupants. 1:diheren: tram owners were provided with iniorm oon on the prope• r..aante❑ante of Sub-Suriace Disposal System. _ Existing inior'^a:.on. Ea Plan at 6.0 H. , De:erm-ned in the meld u an% of the failure'Criteria related to Pan C is at issue. approximation ei dis:ante is unacceotabie 115 302:3+:bi! a 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.�t PART C SYSTEM INFORMATION Propert,* Address: /I/ S 6 �— Owner: Date of Inspection: I . z FLOW CONDITIONS RE51DENTIAI: Design flow Y4. oom A for S. S Number Of bearooms r Number o;current resioents Garbage g•. der (yes or no- Laundry co-•r•ected to syst (yes or no! Seasonal use Ives or no, Water meter readings. if a fable (last two i2 vear usage tgpdt: Sump Pump (ves or not Las: dare o=occupancy ert/— COMME IkUI!NDUSTRIAL: Type of est lishmen: Design fio,• allonsrca% Crease trap pre nt tves or no_ Indus:nal \taste olding Tani; oresen; ,ves or no Non-santta-% Mzste scnargec to the T!;ie s\,s;em ;ves or no_ \pater meter reading_ n a,ailabie Las:pate o: o OTHER. .De,cribe Last care or occ.:canc. GENERAL INFORMATION PUMPING RECORDS urce of iniormatior. System pum c as par, of inspection: *,ves or no O If ves, volume pumped _gallons Reason for pumping TYpF O� SYSTEM Septic tank,1distnbution box�soil absorption system Single cesspool Ove•flow cesspool Prt�y Shared system (yes or not (if yes, attach previous inspection records, if any) VA Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site. (ves or no)410 (revi.ed 04/25/9-77 sage 5 of 20 ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM PART C SYSTEM INFORMATION (continued) Property Address: �� ��t!Sv N A-"L Owner: Date of Inspection: BUILDIN SEWER: (locate on tte plan) Depth below ade. Material of con uclion. _cast iron _40 P�'C _ocher texplain` Distance from pr)v a water supply well or suction Ii-< Diameter Comments: (condato of joints, venting, evidence of leakage. etc.) SEPTIC TANK:_ locate on site plan Depth below grade material of construction _conc•e:r�5.me:a _F,oe•g)ass _Polyethylene _othertexplain If tani. is me:a:. Iis: age _ I; age cor.. rmec o\ Ce^•iica:e o. Compuance ,_(1res:',o Dimensions Sludge depth Disiance from top jj ge to bonorn o; ou:,e: tee o, ba�e Scum thickness Distance from top o: scum to top W outle: tee or ba- Distance irom bonorr o scuT to bo-o-n ow out)e: tee e• bar•••e _ how dimensions mere determines Comments trecommendation for pumping rond t on o in et and outlet tees or baffles. depth of liquid level )n relation to outlet invert, structural integrity, evidence of leakage. e:c i (CCO.Aw.� - L ;;Al. / -7 / GREASE P: (locate on s plan; Depth below gr e material of constru ion. _concrete _metal _Fiberglass _Polyethylene other(explain) Dimensions:_,_,_ Scum thickness: Distance from top of scum top of outlet tee or baffle. Distance from bottom of scu to bosom of outlet tee or baffle Date of last pumping Comments: (recommendation for pumping. condtti of isilet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc (ro�%*.d 04/75:97) lag• 6 of 30 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,, r / SYSTEM INFORMATION; (continued) q Propert% Address: 3 ( /V C�6-o ^- `�/l L 0%ner: Date of Inspection: `1," /s L TIGH OR HOLDING TANK: 'Tank must be pumped prior to. or at time, of inspecuont !locate o stte plan, Depth belo grade. Material of c struction _concrete _metal _Fiberglass _Polyethylene _other(explain! Dimensions: Capacit • gallons Deng^ floes galtarsoa. Alarm level A;arrnn ,n %%orking orde• _ Yes. _ No Date or previous punpin Comments (condition of inlet tee. card, or., a• a:a•rr and float switches. etc.! DISTRIBUTION BOX:_ tioca:e on site p-a- De_:h a: hould le%e' aoo,.e oune: in%e- V Corn-ne-ts mote :i leve! and d s:nb:;or js ee:,a• evidence of sofas carn•over. evidence of leakage into or out of boa. etc.) 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.) SUBSURFACE SEK'AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr-ss: 3 7 /IA(.Si:,t1 Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on stteplan, tf possible. exca%a:ion not required. but may be approximated by non-tntruswe methods. If not determined to be present, explain. Type: leaching pits. number. leaching chambers. number: leaching galleries.number: leaching trenches. number,tenph: leaching fields. number, ci.rr+ensiort; overflow cesspool, number Alterna�Name e system of Tecnnoicg%- Comments incite condi ion of soli, signs of hydraulic failure• leve` of ponds n . condition of ve Stat cn, etc �� c ✓J O �C r C 1 t o eT- e CESSP OLS: _ (locate o. site plar. Numbe• an config-ira:,or Depth-too of I uid to inlet Inver, Depth of solids ve•- Deoth of scum la er Dimensions of cess co; Materials of construchorr Indication of ground-ate- inflow tcesspoot must oe pumpec as par; of ,nspection� Comments: (note condition sail, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plant Materials of construction: Dimensions: Depth of solids: _ _. ... Comments _.._ (note condition of soil, signs of\h� auhc failure, level of ponding• condition of vegetation, etc.): SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C G SYSTEM INFORMATION (continued; Propert. Address: 1- 410L e— Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) o 1 _ �� � p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOI FORM PART C SYSTEM INFORMATION (continued) ��a Propem• Address• � � /V r:{�$UN e . Owner: Date of Inspenjon: Depth to Groundwater LaFeet Please indicate all the methods used to determine High Groundwater Elevation: . Obtained from Design Plans on record Observation of Site (Abutting properry. observation hole, basement sump etc.) Determine R from local conditions Cnec� with loca! Boarc o• nea!,r- Chec'k FE.NAA maps Check pumping records Check local excavaio,s ins:alle•s L.-se I-SCS Da'z r. o Describe in v0ur o.:-. %%oro= no- %o:. es:ao!tshed the �-igl+ Groundwater Elevation. (Must be completed! �t1�tI1���Cc�lydGu ��, -7-7 (zwioad :4.2519-. Page 10 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued; Propert% Address: �� �Gl Sd 44A Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) 0 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertv Address- _3 1L1e,1,5D1d- 44--z e Owner: Date of Inspection: c 171� // j � Depth to Groundwater la Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observation of Site (Abutting property. observation hole, basement sump etc.) Determine it from local conditions Cnec'K Hith loca! Board o• nea:t^ Chec'K FE.MA maps Check pumping records Check local eacavato,s installe•s L•se L SCS Data o Describe in voi, o%%,. r:oro5 no- %o:. es:abhshec the •`niigti GroundAate! Elevation. (Must be completed- u le 19 m et- -7-7 S ftav:.asd :4:1519 Pag• 10 of 10 i '•. �.+ COtiINIONWEALTH OF N ASSACHL'SETTS EXECUTIVE OFFICE OF E?`ti1R0tiNE\TAL AFFAIRS 1-�'IRO�:�IE�TAL PROTECT-1 . � DEPA RT. 1E. T OF E. ONE WINTER STREET. BOSTON. NIA 02106 617-242•S:OC� \ - TR_DY CC WILLIA"F.VELD 1g9(9 sc=: Govenlc' - 'Frl9BCF DA "ID�B STRL ARGEO PALL CELLL'CCi ommissic Lt Govnor SUBSURFACE SEWA GE DISPOSAL SYSTEM INSPECTION FORMyj PART A " CERTIFICATION Property Address; -aC�, N�`Sc;,� L4im� O'G9 1" l�s. Address of Owner. ,� Date of Inspection: 7//Y :(If different) Name of Inspector: er1 `C�� 1 am a DEP ap roved system inspector pursuant to Section 13.340 of Title S pt0 CMR 13.0001 Company Name:&/ o r 4-,'c 457A N'r #"e"` Mating Address: -2 o /;"c e_37� . H"Ke'00 L H 01-0 2—C4-47 Telephone Number: r -,f 44-;L 1;-- CERTIFICATIO% STATEMENT cer:tfl that I have pe•sonall} inspected the sewage disposal systern at this address and tha: the information reported below- is true. accura: and complete as o-the time of inspecoo,�. The inspection was performed based on my training and experience to the proper.funaion anc maintenance of on-sae sewage disposa; systems. The syszern: Passes _ Coricit-onaii% Passes _ I%eecs Further Eva!uaron Ev the Local A rovtng Autnortt} . — Fa.!s . Inspector's Signature: ate: T ! T:,e Svs:e^ Ins--%-o- sha!' submit a copy of this inspeaoon reoot. to the Approving A hariry within them (30. dais of completing this inspection. Ir the s).-stem is a share' system o• has a deslgrt flow of 10.000 gx or greater, the inspe:or and the systeT owner shall subn the repo-i to the appropriate reg-or office of the De;a-ment of Envirenmenta* Protection. The orig-na! should be sent to the system ow and copies .-nt to the buyer, if applicable. and the approving authorit%. INSPECTIO' SUMMARY: Check A, 8, C, or D: A] SYS7 PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.3C Any failure criteria not evaluated are indicated below. 7 COMMENTS: 61 SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, L completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined', explain why riot _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate o Compliance (attachedt indicating that the tank was installed within twenty (20) years prior to the date of the. inspection the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or t failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tar as approved by the Board of Health. r.va•d Paq• 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A J CERTIFICATION (continued) 21� Property a Addcgs s. ' Owner:) &I r.(,4.r.>_ �V Date of Inspecti n: / B SYSTEM COND OKLLY PZSES lconunj4d 1 �, Sew•ag ackup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or a to a broken, settled or uneven distribution bo::. The system will pass inspeaion if(with approval of the Board of Hea ). Describe observations: broken pipe(s) are replaced •_ _.: _ �: struction is removed - dis "bution box is levelled or replaced The system required pumpi more than four times a year due to broken or obstructed pipe!s).•The system will pass insoection if)with approval of Board of Health): - -- •- - - -- - broken pipetsi replaced obstructionis remo - C] FURTHER EVALI. TION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist •hich require furthe•evaluation by the Board of Health in order to determine if the ipstem is failing to protect th public health. sai -and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTE THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or prn is within 50 fee: of a surface water Cesspoo' or privy c within 50 fee: of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS T E BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THA THE SYSTEM IS FUNCTIO%Iti A MANNER THAT PROTECTS THE PUBLIC HEALTH AND WFETY AND THE ENVIRONMENT: The systems has a septic tank an soil absorption system (SAS) and the SAS is within 100 fee: to a surface water supply c tributary to a surface water supply. The systern has a septic tank and soi absorption system and the SAS is within a Zone I of a public water supri'y well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less thar. 100 feet but 50 feet or more from a private water supply well, uniess a well water analysis for coliform bacteria and volatile organic compounds indiates tl- the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to c less than 5 ppm. Method used to determine distance (approximation not valid). 3) _.OTHER tr.vii•d 04:2513-) Page 2 of 10 •a v , 51285URFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM PART A Z CERTIFICATION (continued) Property Addrrss: Owner: - j n Date of Inspection: � y DJ SYSTEM FAILS: You must indicate either -Yes- or 'No- as to each of the following: I ha determined that the system violates one or more of the following failure criteria as defined in 310 CMR 13.303 The oasts for thi determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failu Yes No Back p of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Dischar or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Sta:ic !iauid yei ran the distrib.,tion box above outlet invert due to an overloaded or clogger SAS or cesspoo. Liquid death in essocal is less than 6- below invert or available volume is less than 112 day rlov. 1 Required pumping ore than. 4 times in the last year NOT due to clogged or obstrueea pipe s . Numoer o;times pu pea Anv portion o'the Sod osorption System, cesspool or pno�• is below the high groundwzte• eieyanor. Ar% por::on of a cesspool r prn1• is wither. 100 fee, of a surface watef- sunoly or tributa-v to a surface water suppil Any portion of a cesspoo: or rivy is%,than a Zone I of a public well. An-, pe• o- o.,a cesspool or prt% • is within 50 feet of a private water supple well Am• por:.or o'a cesspool or privy i less than 100 feet but greater than 30 feet from a private Ovate• succiv well with no r i for - i h � f well water aria vsis o acceo:able mate• Qualm. analysis. It t e ��•elt has been analyzed to k acceot.Y e. ac;ac c�� � e cohiorm bacteria votarde organic corn \unds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either 'Yes- or "No- as to each of the following. The folioM:r.g criteria app;% to :urge systems in addition`to the criteria above: The system serves a facilim 'with a design flow of 10.000 g'pd or greater (Large System; and the system is a significant thre3: to public hea!th and safer} and the environment because one Of,more of the following conditions exist. Yes No . the system is within 400 feet of a surface drinking wate\drking y the system is within 200 feet of a tributary to a surface water supply the system is located iin a nitrogen sensitive area (Interihead Protection Area - IWPA) or a rrapped Zone 11 of a public water supply well) __... . The owner or operator of any such system shall bring the system and facility into full compliance with the groundwatec.treatment program _ requirements.of 31"* CMR.5.00 and 6.00. Please consult the local regional office of the Department for_funher.inforr-aaiioc}:--- -- _ •-- •- - 4 raw •d 0� S !' ]`nf LO'�"�- k . . '. SUSSC-RFACE SEWAGE DISPOSAL SYSTEM INSPECTIO-N' FORM PARTS CHECKLIST Property Addeess: Owner: /cv Date of Inspection: Check if the following have been done: You must indicate either 'Yes- or 'No' as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. - None of the system components have been pumped for at least two weeks and the system has been receiving rem-al flow rates during that period- Large volumes of water have not been introduced into the system rrterttf. or n as part of this inspection. RAs built plans have bee..^-- omained and examined- Note if they are not available with N.A. _ The farlll or dwelling %vas rnspec:ed for signs o-sewage back-up. Tne s-,•sten+ does not receive non-sanitary or industrial waste flow. The site %%as inspected for signs of breakout. All system co^toonent_. excluding the Sod Acsorptton System, have been locate: on the site. The septic tank rranhoies Nere uncovered. opened. and the interior of the septic tank was inspecied for conc-t.cn of baffies or tees. materta'. o'construction, dimensions, deptn of liquid,depth of sludge. depth of stunt. The size and locat-on of the Soil Absorption Svstern on the site has been determined base? an. The fac.la% o%%ne• .ana occupants. d dtaeren: from owners were provided with information on the pro pe• rra.r:erance et Sub-Surface Disposal Svsterr-. Existing mfo'rnatlon. Ex Plan at 6.0 H. Determined in the field !if an% of the failure criteria related to Part C is at issue, approximation of des:once is unacceotabie (15 302:31:b1! I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.tit PART C SYSTEM INFORMATION Propert,. Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design ilov. r. room for S..A S Number of becrooms Number o-'current residents Garbage g,.�der (yes or nog Laundry co-•^ected to $vst (yes or no` Seasonal use Ives or no.. "ater meter readings. if ava table (last two i2, Year usage tgpd): 4, r Sump Pump (ves or no 171 Las; date o;occupancy enl— COMME IAL'INDUSTRIIAL: Type of es, Irshmen: Design fio,. allons.da% Grease trap pre nt rues or no_ Indus;rra! 1%aste olding Tani present .Yes or no Non-sanitar% waste scnargec to the T!t,e 5 system ;Yes or no ater meter reading_ if a,ailabie Las:pare o: a OTHER: .Describe Last care or occ,:oanc. GENERAL INFORMATION PUMPI%C RECORDS urce of information System pum c a$ par, of inspection: ;Yes or no.1LO If yes, volume pumped gallons Reason for pumping TYKE 0�6 SYSTEM Septic tank,/distribution box�soiI absorption system Singe cesspool Overflow cesspool Prny Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: — c Sewage odors detected when arriving at the site. Ives or not 4b (revised 04/25/91; Page 5 of 20 SL:BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE.Ni INFORMAT10% (continued) Property Address: J F Alr tJd A) Owner: Date of Inspection: 61lG � . BUILDIN SEWER: z`/ ` (Locate on rte plan) Depth below ade. Material of con uetion. _cast iron _40 PVC _other (explain Distance from prty a water supply well or suction I1-� Diameter Comments: (condnio of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ 0 (locate on site plan i Depth below grade Iii material or construmon _concre:t:&-meta _F oe+glass _Polyethylene _othertexplam if tani is metal. Its: age _ Is age cor•.'.:rmec o\ Ce-taica:e o: Compitance Dimensions Sludge depth /`1 Disiance from top :j/dee to bonorn of outle: tee o• ba�e / Scum thickness _ Distance from top o: scum to top o' outle: tee or ba-�;Ie "t Distance from bonom of scu--� to bo-o^: of outle: tee e• bare _ how dimensions were determinec fYta�as�rc e. Comments trecommendation for pumping condition o� inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert. structural integrity, evidence of leaka e. e:c.1 ('�CO.ANn.t� 4- c j v A,n5ikkLl2 GREASE \constru (locate on Depth bel Material oto, _,concrete _metal _Fiberglass _Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum top of outlet tee or baffle. Distance from bottom of scu to bottom of outlet tee or baffle Date of last pumping Comments: (recommendation for pumping, conditi of inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural integrity• evidence of leakage. etc (to-load 04/75:9") Page 6 of 10 SLIESURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEy1 INFORMATION (continued) n q Propene Address: 3 f A CJO 'u- �i/L 2- 0%ner: Date of Inspection: TIGH OR HOLDING TANK: -Tank must be pumped prior to, or at time, of inspecttoni (locate -I. site plan, Depth belo grade. Material of c struction _concrete _metal _Fiberglass _Polyethylene _other(ezplain) Dimensions. Capacity gallons Deng^ floN gallons da. Alarm level A:arn in m orking orde' — Yes. _ No Date of previous pu:-+pin Comments (condition of inlet tee. condi or. a, a!a,n- and float switches. etc.) DISTRIBUTION BOX:_ tloca:e on site p•a- De::h o*liould le%e' a00%.e ouoe: in%e': V Comments mote :f leve! and dis:nbutoor is e'1ua' evidence of sofas carryover, e%idence of leakage into or out of boa, etc.) b �. P; y GI c> s�>l t —ram i-t, a;t '-1' 4'n 1 e PUMP CHAMBE (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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIA PART C SYSTEM INFORMATION (continued) Property Addr-ss: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on siteplan. if possible: exca%a:ron not required. but may be approximated by non-intrusive methods. If not determined to be present, explain. Type. leaching pits. number. . leaching chambers, number: leaching galleries, number. leaching trenches. number,length: leaching fields, number, ci.rnension: overflow cesspool, number Alterna ive system Name of Tecnnotogy Comments more condi iun of soli, s grs of hydraulic tailure, levei of pondin . and of ve tat ion etc 1 n 0 ✓lJs CESSP\ct (locatesite plan. Numbortiigjra:.ort Depth uid to inlet inver. Depths ve- Depth la er Dimef cess obi Materonstru or Indication of groundvate- inflow (cesspool must oe pumpeC a5 par, of inspection' Comments. (note condition 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 condition of soil, signs of by aulic failure, level of ponding, condition of vegetation, etc.): tre�aeeG 0�;23/9'•) Page a or 10 LOCATION SEWAGE PERMIT NO. .. k cTC k VILLAGE INSTALLER'S NAME \i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED � _ S RD- tSf 31 L 2� C1 1000&Kl- Ca2t P2E<Per svpnc ;moo No./ Fes$... ................ THE COMMONWEALTH OF MASSACHUSE'f'TS BOAR® OF HEALTH ..................................---....OF.......................I—.......... . Appliratinn for Disposal Works Toustrnr#inn runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System Location Ad ress or Lot o. .... `6. - ...... ter----......................... _ _ !�c..._ .✓._e lit Ow er Address a ........... .. -------•-------••------- ..� .�.G�.... C . Installer Address U Type of Building Size Lot__4*_Q.?___f...Sq. feet Dwelling—No. of Bedrooms........-3..............................Expansion Attic ( ) Garbage Grinder (140) Other—T e of Building No. of persons............................ Showers a —Type g --------•------------------- P ( ) — Cafeteria ( ) dOther fix•ures --------•-•-•----•--•-----•-------•------•-•----•------•----••--------•-------•-------- ----•--•-------••--------------- ........... Design Flow_._....__. i1_________________________gallons per person per day. Total dais flow...._.__._: _.' .................gallons. W rG' WSeptic Tank—Liquid capacity))A00gallons Length.-_�...... Width................ Diameter---------------- Depth.....G--_---_. W Disposal Trench—No..................... Width._.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------I----------- Diameter....f ........ Depth below inlet--_.�........... Total leaching area....�_?,�.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (74 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ....------•---••-•-•-------•-----••-----....-••-----------••-•-----•••----•-•---•-----------•-••-•••......................................................... 0 Description of Soil........................................................................................................................................................................ x U -•-----------•-------•-----••---------------•--....--------------•--•------•-------•----------------•----•-•---------------------....---------•--------------._.......-------------•--••-------•------ W U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. ...---------•--------------------------•---------•--------•----•----•---------•---.........._..-----.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.- 5 of the State Sanitary Code—The under igned further agrees not to place he syste in operation until a Certificate of Compliance ha e i sue by he b rd of lth. r n --------- --•-- =------ - --.................--....----------- ----- .---------------•--•-•-- Application Approved --•-- �---•• -----------------•-------•--.-•-- ....... ---- ------------------ Date Application Disapprove r e following reasons-----------------------------•--------------------------- .................................................. ............... .....• ---------...--•----------•--•------------•----------------------- ----------- ------- - ----------------------------•--- Date Permit No...... -•--a l.2--------------------• Issued_.......-7 1 Dat NoZ�-•--'Z.—--- q F�s..v�.......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................... -----------.....OF...................................... . ppliration for Disposal Works Tontrnrtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at _ ............f r ' �L - --•--...-••..................4 ............................................................ ----- � Location-Ad or Lot....o. L C . ...............•--...-•-•---• tip....... _...._._... ._... . �� c4 ..✓..... W Owner Address ........................................ r-' ••-----•------------------- -•-----•-'•-----................................................................................. Installer Address Type of Building Size Lot. WlC.a.0..�_---Sq. feet Dwelling—No. of Bedrooms..-------- ----------------------........Expansion Attic ( ) Garbage Grinder (.iG) a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow.........S—.S........................gallons per person per day. Total daffy flow----------3..... ?..................gallons. Septic Tank—Liquid'capacitylr.QoQ _._gallons Length. ....... Width................ Diameter-------......... Depth....r......... W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------t........... Diameter___/(�-__........ Depth below inlet....(p........... Total leaching area...<0 sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `" Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •... •-•--------------------------------------- ........... •••....... 0 Description of Soil........................... W V ._....••-•••••--'••••••---••-•....................'-_..........--..._.._.•-•--•--••••--•'-'••'----•-•-•••-•----...•••--••-'•-----••-•---•_....----•-......•-••'-•---•-•...........------...........'•'- W •--•••-•---•----------------•-•-•-------•••••-•-•-------------------•-•-•----------••--•''••.........•-••••-•------•--....-------••-••--•--•-----••••-•--•...•---•••--•-•--•••--•-•••............--'-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -••-----------------••------•---•---••----•-•••'-•--••••••---------•-•--••---•-•••.......---'._.....-•-•-'••••------••--••-•-----•-----'---••--•----...•-•----------•--••••--••••••••••-•-'--__.....•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI-E 5 of the State Sanitary Code— The under igned further agrees not to place the system in operation until a Certificate of Compliance haste n ' sue� rd of alth. - ---- ------ -- Application Approved y...... _ _%_ ----- -- .................. Date Application Disapprove .-o'r e following reasons:.................................................................................................................. ......'--•-•...........................................-••'•---••-•'••••••--•••-••-•----•-•••"--...................................................................................................... Date PermitNo......................................................... Issued-------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................I....OF........................... (Irrtifiratr of Tontphattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by--------- . .. -- --- ..... -•-•'----•-•.... ..-2--........................................................................................................ i ✓�� Installer has been installed in accordance with the provisions of TITL, f e State Sanitary Codeyas •e§cr' ed in the application for Disposal Works Construction Permit No.�'�� ._..`�................ dated_.. L:� THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CO STRUE® AS A GUARANTEE THAT THE SYSTEM WILL F CTI N SATISFACTORY. DATE. .._ :... .............•---•--'-•---••------. Inspector'-•-••.•.• .... --••--------...•---•-...._....••--•---••--••--•---••-•.._._.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `� ,''` ........................OF..................................................................................... No. •.--•......._-.— FEE .... ............ Disposal Works Tonst ion "Crrutit Permission�or, reby granted............................................. ---•-•'--•---"-•••...........---•...•---••--••---•-•-•......---•...............-•••----...._. to Construe, _ R pair,( � a ndividual rage Disposal System f at No.., !:_c Street as shown on the application for Disposal Works Construction Permit No ----------- Dated.......................................... -•-.......... " =-- • --•-•••--•-- ........................................................... Board of Health DATE-----•---y----- FORM 1255 q. . SULKIN, INC., BOSTON h 7- 0 r /7 ry l -06 f ` N o Q e. Lk �`XPgi✓Sio,✓��/�i x 7 ` A ; - 20, 4. l r 5,0 OF AU ' AL 0' ,g ll Y , x No.10 51 O ��FS.lONA1.�a�\ , 3 _ �t3 LEGEND I XlS>TING SPOT ELEVATION 0,10 `t� OF Mrs,, CERTIFIED PLOT PLAN ' s"EX9.S,TING ..CONTOUR — p _ _ �,<J' gfyG L.D 7- 58 Ec.So L•A4✓, i� z`FINI,SMD SPOT ELEVATION ROBERTBRUCE a FIKI,SHE,D, CONTOUR 0 N '3 o ELDREDG I N. APPROVED HOARD OF HEALTH SAJIAS fA.0.L9 �ASS* ND sv�� , t; AGENT SCALES J" 40 DATE 7 G11e¢ <, DREDGE ENGINEERING CO. IN . L,s Tip. CI.IENT._..�,._._,_._ I CERTIFY THAT THE PROPOSED ` diSTERE RE4ISTERED 4 D 6 3 x a>' J08 NO. _ BUILDING SHOWN, ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS DR.BY� ,4.A' M' E 0 ER R OF 8 RNSTABLE, MA39.�-, -712 MAIN :STREET . CH-'BY 7Z' 13• L' 6 g .- b HYANNIS, MASS. SHEET_/_OF TE REG. LAND SURVEYOR .4 rr^^a t nr:t i F f;•.i:+' .... 2 `i.ye xz n� •. '\ •' \' .. u --•�a h' ..F ,#. 'h. `a: '.S.-} ' ..�.. ks.'�Tc.a,d,, x ' �f''-„ .�1 ai"1. •—w`''" 4�*''^�: .,s .. +<' a«• ..X.. K`,. ,., ..ix:c...: !=. e_ -.ar+:.:... A..-. ,. . >�. .}..x „� ,.•-.., ... .. y. .LL `. -.+� t '....K...H .,.-...., ...#4' . " - t'a.... ..r -. ,� � �'? t^e.+• _... ..J4 v,,.., :M, vr�:' ram., n.a.. �.,.,r�.;� F� - C ..... .:, o... -�,._ t.�`• crs.:. :.:,y,. .,,.. ..�i.. ...<'�. .:. + r,-a.L: ✓. - f "-W - :,Et` a0 �^3':e. _ ar•v'*,`. s." •2` f- -,Y� - d �T �. �s �► i� ."t h.*-3 :r: e.. o.... f.. —u�-.�...• ;Y-r' .3 .._..-. .:.nt..,r. :<..:sx „-.. 'i"':!L :k Y'.-..e .i.e 9'rx�(,� y�7•...>;Fo* ,a��, i'.h.. �.�..w. -Wig A/ ...y+.w +s- 3' i �::: •f.?te-..::.LtC :,�ti.d -1:}yW?'.e ,�i-. r•^'.hli: . .. � Wo �� wA . G Yf.:P-4.Y" '!k, .- 'fi,._ �v�.�/-.;-•{•;.aw'�'r i ::�e.id-...Y.1 ..t(.., ,.,+.tiy...�• '� nc:*k:., ;.,�Q rI•.���I� w .-i �C .,[ 1x..5.� f• x 7 � ', i y S4 a�" •� ":S. �..�r .�- - <. Y,. 4 4 �4� i` tv TQ�r � y. �- c �ovR f/.�q BE SSG CG R- �L EAN 'SANG GQ(I/D LEYf'L. _ �� '�ST� - - - r •• ?LAYER oo v MIN PIS GAL. • �.o , . a a PAR PT. SEPTIC TANK /!OX • . • • • . •.# • , • • • • led zwprN• fee • .�. 'AlASXED STONE' lJVYERT,�LEI�ilT�C4Yd P1r.c�a p.4 � X�� :5`f, �/Dom %. : • �• a s • . •• •./• a • PI7 DR £VU/V. • • EL 3 INVERT AT d!/"IM5 !o b 3'FT. ti t sT_ --Am. IM ET . UD0.76 ^ Ti4NK. ' ,Pd©,l FT. : 1 fT. OIAJW. C�SES 7 ULATlGN� . 1 AW74,eT SEPTIC TANK. fT. . - = INLET DISTR/AI/T/ON BOX 19,7 FT. SECT/ON OF GRDuNo QTE/'�Till'", 007ZE7D1STRlAvr.#oN JoX 9.9.9 FT. - //VLFT LrACIllAW PIT 99 3 JT SEWAOR .O/SPIO�TAt SYSTEA�f 'AOMATIDN LF�4CHlNG .PIT � ' - DES/6/v CRITERIAscAL LF : %s' /_o. r O/MENJ/ON /1 * olly.�+rsrow a . . " *VvAfOER OF DED1RO&Y's DlMENSlON ri�_l=T.M�. : �RQ,tGED/SPOSAL UNIT Nyff€ SO/L LOG r.07A' EST!/�f�cT'EO F1AiV 3 3 y G,44.1,0AV SOIL TEST AEI, $OIL 717S7-,*Z - SOIL TEST NUMBER 4F t,�Ackl P/rs / f-F[EYtta Y, Lb4TE CF SOJL°TEST 7 �,� S/OE LEACHING PER P/T �Sf� FT. - �n�` 4oTTOM LE�1G'N/NG oER P/T Sq, ,tT. o- Z , - RESULTS JVITNESSSO dY. y� p'£' TOTA[ LEACH/NG AREA S PT. �p_5 <<- AW-4COIAT/ON MATE#/ 9'J 1y//1,S/IlVCI! ` Q 21 - - 4FW tCOLAT/G,V*4FATE*2 �— Ml/V flNCN �QESFRNELEA�'NlN6ARE^ Z� 6SQ. fT. yt9zc. 7�sr P-4�5u=:s.S 6'7i' emz `y'� Of MSS `' Gv/}�SF S/N✓o ; (t1 of w.-r t� PA cxLD L!�T�8 A67-L.5`0/✓ R08ERT MASS S$ G�z/�✓E-� BRucE AL EIDRE �0 0 MC-D.-v COpNPS -A WO No 10951 O U�A`' �' ` EL DREDGE EJVG1JVAVR1A9 CGt, ND 7!2 MAIN S rl- HYANNl9, M 45S S � S/ONAI�N6\� NG G/gOUND-�YATr`R JWCOI�NTfJeEG CL/.ENT: S L.5. TR D•LTE '�:2 : - �S G3 GRO uND kv.4TER AT EL,E✓. JOD Ao o 3 1I�lEET? f, z A4A%lPAcr- C.dAp../J3ow - )Skit Lo`v%s µ S v:R-Fax:. �c>,c, ) ��S s /�•U �,t 6wLw t t 1 . S`` Za SawA w 11N ((11 1 ��IQICcD .V��1►�r�•�..'f IZ. r�ce`C-A,.s�S�,Np ^�V�` r a 1. ,,., _,�'S. .,�['�'����`t�A::�l/•u • {/�'MM ti1 lIA1�1Ie1 .1.�• �'1 M f '.,,�r�uMr �t►AAl.�' . Sha/! cD�wAR'3C has. t P�ot�.� �-3 .S`-R-Sr►t; t SAwt7 et-' W E T 11 v A GK`cs7 �nAVW L- C,Sect:/i �P D I / S. -- O t To r ~�My�•�j•.4G ,'/2 1`�c.�.=C.�eSr �d�y,/.o � G ^A✓cl,,. . S S i rl AN IL • rc. l v. � 4 [f -, z. / r� S' �'�j ,'•Z,: � CO—C''Q�I,S� uj�C1(rr�. G ►�A v�``• j �' -�Z •� r�•- C o"�+�s � S nl.v� � C h�4-./L'- �,• - 1 . CovZ�j F rf, 1 W � LL w4 , vucrs 4 L ' f �. Au V, 4. r xr O' �-'1To.0.0 Z—S � c CaAnsl-' u 'Cicvv . 'V pA✓Vt.I S�Z.� ��0-C-Ap1vd S)"LIO `r!J'c�,ri.Fe �. ! S•Ff - .. �.,a '�"s�,.SD1t. ,� Z TX Ce�esr��o Gwn { Ls./Al. 94 F� 1 i 3 '• �r� �•' C• y ' ' a .... V. �,' c C�-►�t'a�.�.� r3 Y r1'4e ►a�S S w�`I �e� 1�ib o `tH OF M oHARRY _ Rr, y tAr ?per C'ST�R .." - _ - - FONAI ENG L-rJ 7 Zo M A , z r �p ^' ,tax,, N _ o P I ^y a g 1\ /o /s3 ' Io i �.q c1ti. '� N 74z•�p��O S� ��— ' 7-b sit ;o o 1 �q. U 7�, J\ y 1 O rq pxY t` z v+ 50''. ,eoi✓7��� T 57 �,N OF M+s off-, / ALNo 1p,51 - � 9 GISTE �? ��FSSIONAI h.x LEGEND � 31,XIATING SPOT , ELEVATION 0,t0 4AN Of M,, CERTIFIED PLOT PLAN f 06-tTINO CONTOUR -- 0 -. "�`'�• '+'lG L..D T- 'FINI;SHED : SPOT ELEVATION RoeLRT ,p , " FIKISHED; CONTOUR 0 BRUCE coo of y; i o ELDREDGIN tRPR;QVED BOARD OF HEALTH S AJU,S J,,,AJ0Li1 bJASS+ ,4 N p s AGENT SCALES = 4n DATE 1 76 8'¢ 5, DREDGE ENGINEER/NG CO. 'NOCLIENT.,,_..._ I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JJOB NO. 4 p d 3 BUILDING SHOWN ON THIS PLAN `v'CIVIL' LAND CONFORMS TO THE ZONING LAWS ` DR.BY A• M' f` E'NO N E RV V-7 RNSTABLE , MASS 712 MAIN 'STREET CH.,BY' 7Z. 3.MYANN 13 MA8S. Z' 9HEET..L.OF, REG. LAND SURVEYOR