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HomeMy WebLinkAbout0083 NELSON LANE - Health 83 l elson Lane;lVlarstons Mills ' I o �� TOWN OF BARNSTABLE LOCATION Qq w9E SOS — SEWAGE#ZO7.0- 290 VILLAGE in, no 115 ASSESSOR'S MAP&PARCEL 42 -R! INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �^—^----1 �l l,�_ (size) L3 x ZS is 7— NO.OF BEDROOMS .3 OWNER AlSinn PERMIT DATE: q-/S-ZO COMPLIANCE DATE: 1 l� Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility(If any wells exist on ;I site or within 200 feet of leaching facility) Feet Edge of wetland and Leaching Facility(If any wetlands exist within Feet 300 feet of leaching facility) FURNISHED BY Al. ZZ, 81- 14' � u AZ- Zs 2 13V t L 83" 851 A+ 64 ' 3 I No. 14 Fee !®0. J_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes applitation for lofsposal opstem. Construction permit Application for a Permit to Construct( ) Repair(✓) Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. VI NQISo n L ,,Q, Owner's Name,Address,and Tel.No.''(ri Goa. Vo,nJ Vr6)r mw&tons Wts Assessor'sMap/Parcel I1(, gf, �30t• LZco•1340 B3 Ngtso� LGne, Installer's Name,Address,and Tel.No.eA 6 ZUOA 00c k0n Inc. Designer's Name,Address,and Tel.No.1)6C C,nvirotytQ nb�s 11'i (�aoVL 130 Sundw'.o, (Sobs Wrf- 0coS3 (ZdS+ (so g)q 33' 21}q Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 3yq gpd Plan Date 9 l 4' 2 0 Z O Number of sheets Revision Date Title Size of Septic Tank 1000 000.\k40n Type of S.A.S. (2) S00 00,kkor% LI C'S Description of Soil S2a, pke nS Nature of Repairs or Alterations(Answer when applicable) &00,co- *p,teA !�NAS QSlgk (Z) 500 AcakkOn +- G1nap,►�II(S CAnnt-CA�nx Qotis'V%n% 1000 0-,a11or v V Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Cd ct E0 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. � �© Date Issued , 4 .s..,++'Y.. , 1 qt• �y, 4+* y 1 „v'JC-.. i....'in�;, —y, b'0.C••1, t•t ., 4" � � ��rPM+Fawq.Aak�* � f 4 No. Q '"' -L 111jjj Fee /0 0• THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Misposai 6pstern construction Permit Application for a Permit to Construct( ) , Repair(V) Upgrade(. ) Abandon( ) ❑Complete System ❑✓ Individual Components Location Address or Lot No. (63 N c!,a r, n c, Owner's Name,Address,and Tel.No. � Vc;.nvv�i- fy')O+ Sta<I s MA 15 Assessor'sMap/Parcel M(oj $ j3n' L7,(o•tSi►0 2�a 1�1e15a * a c Installer's Name,Address,and Tel.No. tb"F) c.xc auc son ins. Designeps Name,Address,and Tel.No. V)P,C r v ccom nar,N 31"1 (ioukt �So SCa 6k,,>-O,. C;SoZlWri• /S. d 0 0 7,).2?��' Type of Building: Dwelling No.of Bedrooms Lot`-Size l sq.ft. Garbage Grinder(g,lp) r Other Type of Building No.of Persons Showers( )�Cafeteria( ) Other Fixtures Design Flow(min.required) 'S 0 gpd �Design flow provided �LM gpd 0� t Plan Date c� w,a-Z,0 Number of sheets Revision Date � F Title Size of Septic Tank \000 Lea!\4n TypeofS.A.S. (1) 14OU nr~tlion ijL ,.) ,J e Description of Soil Sea talc n c, r Nature of Repairs or Alterations(Answer when applicable) '-,eta�ar4L - �N',I SAS; `U�ar�c_ �2�1 �0� a,kkor� ` 1 I. Q� 1 U s r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health.Signed R . -- , /_� {c Q'�c-� ` M Date q 1°iI,}! 20 Application Approved by y{� Date GJ Application Disapproved by r Date ' for the following reasons Permit No. r�.() , ,Yl Date Issued vL THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance °' THIS IS TO CERTIFY,that the On-site Sewage Disposal systemConstructed( ) Repaired(� Upgraded( ) Abandoned( )by Q)°� �� rC*X c n\jc�,4�or* ff;c . N at "'� !\ ��,c» osnc. `has.been constructed in accordance VY with the provisions of Title 5 and the for Disposal System Construction Permit No • dated Installer ' r.xCr~vr<-b0- ko . Designer n(;C �, no,tsIr+rnir�t ie"inns .y #bedrooms "�� Approved design�fiot """:� gpd The issuance of this permitishall not a construed as a guarantee that the system will //function as designed. Date / ,�, 'yo Inspector _ No. Ai. a t i—aho Fee b THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstern Construction Permit Permission is hereby granted to Construct( ) Repair(✓) Upgrade(., ) Abandon( ) System located at gi 3 k,�QA So rn U\nQ, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date _ 0 Approved by Town of Barnstable Regulatory Services Richard,V.Scali,.Interim Director = BnRNSTeBLE. 1®� Public Health Division f ; Thomas McKean,Director a, . 200 Main:Street;.Hyannis, MA 02601 - r` Officer 508-852-4644 Fax: 508-790-'6304 Installer &Designer.Certification Form Date; - r7 Sewage Permit# ua o --2y(% Assessor's MapTarcel Designer: M} rq. _ � Installer. � t -S.it Address: i ���i �7� �/ �t_.r1 Address:: �... 4 on +/ Was issued a permit to install a (date) (installer) septic stem at , P Y based on a design,drawn by (actdsess: dated (designer): TY.Vo certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such aS lateral relocation.of the distribution box and/or septic tank. Strip out (if required) was .inspected Arid the soils were.found.:sathsfactory.. I certify that,the septic system referenced above was installed.With major changes ( :e. greater than 10' lateral.relocation of the SAS or any vertical relocation of.any component of the septic system) but.in accordance with State &Local Regulations, Plan revision or certified as-built by.designer to follow. Strip out(if required) was inspected and the soils were.found.Wisfactory. I certlfy that the system referenced above was construct' a �liance With the terms Of the 11A approval letters (if applicable) ray oF�1gs�, 4v a DAVID 4 C. g MASO.C! m (Instal er's Signa a No.toes: (, ism.,-w+gn gn (Affix Designer-s Stamp Uere)Desi e s Si ature , PLEASk RETURN T:O_13ARNSTA.BLE PUBLIC HEALTH DIVISION.. CERTIFICATE OF ;COMPLIA:NCE WILL NOT, BE :ISSUED UNTIL BOTH HIS FORM AND AS- `BUILT CARD"ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.. THANK YOU: Q ASeptic\Des goer Cetditta&n Form Rev 8-14- 1doc Town of Barnstable P# ' ! Department of Regulatory Services B Public Health Division Date 19 lool >.MA8¢ 200 Main Street,Hyannis MA 02601 RFD�AA1 A Date Scheduled_ 1 ' / J/ Time Fee Pd. � Soil Suitability Assessment for Se`wa a D's osal 1� l Performed By: ( 1 9 MA/ Witnessed By: Y LOCATION&GENERAL INFORMATION Location Address fl W� U.J . . Owner's Name A bl\no �J)J Address � Assessor's Map/Parcel: `Z�/��j� / Telephone#��Le T •NEW CONSTRUCTION REPAHt j-�/ Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) j i 1 VV Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date Time Observation Hole# ` Time at 9" . Depth of Perc � Time at 6" Start Pre-soak Time @ .7 Time(9"-6") End Pre-soak - Rate MinAnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# '""► ' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel Los-IT"ITLI-1, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Graven DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) Flood Insurance Rate Mao: Above 500 year flood boundary, No• Yes v Within 500 year boundary No�V//Yes_ Within 100 year flood boundary No✓ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us terial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervi&us material? �414 — Certification G I certify that on jo "6 (date)I have passed the soil evaluator examination approved by the Department of Enviro ental rotection and that the above analysis was performed by me consistent with the re g,experti d e en e d scribed in 310 CMR 15.017. Signature Dat W 137 Q:\SEPTIC\PERCFORM.DOC f No. THE , ( � THE COMMONWEALTH OF M;ASSACHUSETTS FEE 6to BOARD OF HEALTH OF ('(1���L�� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT uct Application for a Permit to Constr (,Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components 3 5 ►-un-� to ;Location �� � wner's Name Map/Parcel# ')CA -42 _ 2,3 1 ,t..s t# Telephone# B+ (3 C, �ny i r-6.r�r� 1. Inst Iler's N � �•„ I ������)�esig��Named , dr ss �(a!� �Addi(ess `7 Jl"A� :7- �� 5bk-S33 -2177 Telephone# / n elephone# Type of Building: I Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min re .red) 33 U gpd Calculated design flow gpd Design flow provided gpd Jr Plan: Date 14 Number of sheets Revision Date —' Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluatio `� ^ DESCRIPTION OF REPAIRS OR ALTERATIONS r-&PTA�� ��GJ W�h l�r �s6 lrn.'�i, 4)rX� The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the sys m in operation until a Certificate of Compliance has been issued by the Board of Health. V'Sliani-d Date p s 0„ FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 NO. lJ ( THE COMMONWEALTH OF MASSACHUSETTS FEE ss rµ a BOARD OOF HEALTH f T� 4— �APPLIC�ATION FOR ISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora P.ermit t& 'gnstruct (% Repair-( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components 0 AL13 I K/) // V�L/cation �.O .,t!er's Nanie no— �, "1 H.5 Map/Parcel# .�' r. �,/^�(j �� — .'Address _ 15 f�b 3 �' L'ot# Telephone# - �L S'E�C al�/a (I7(1 _DG L /�'nV 1(r)n fYl 'rti c'I IT-Gt:tk�P�i �(sljII Na 1 t13 6& C.(n�t ���esignCrs Name' 'A lddre"ss Address Telephone# a Telephone# ,Type'of�Build ng. r �J M dip nU_ Lot Size Sq.feet . Dwelling—No.of Bedrooms '.' ccq Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures � 1 i. Design Flow(mini] rT[ired) *3 V -gpd Calculated design flow, gpd Design flow provided gpd Plan: Date J f t� Number of streets r Revision Date Title Description of Soil(s) _ Soil Evaluatof Form No. Name of Soil Evaluator QS C1 Date of Evaluation y 11141 0 DESCRIPTION OF REPAIRS OR ALTERATIONS (4 0IA L& e7 A Gi t�1 fi� !!�- l/�.� cvt� !IY/1 The undersigned cgrees to install the above,described Individual Sewage Disposal System in accordance with the provisions of .TITLE 5 and further agrees not-to place the sys m`in operation until a Certificate of Compliance has been issued by the Board of Health. < ZU . Med . .,rU V.;Q� � Date- " pecfionsG(1� FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ...-7�-.. -..a..>/11. No �^7'' � THE COMMONWEALTH OF MASSACHUSETTS FEE ,' n�n�. " (� BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DescriptionoJf Work: ❑ Individual Component(s) ❑Complete System t The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( '�Upgraded( ),Abandoned( ) at15D`1C1J?� has been installed in accordanc w t"theg ns of 310 CMR 15.00 (Title 5) and the approved desig 1 1 s-built plans relating,to.application NowGded Approved Design Flow (gpd) Installer ((�� // f j r m f �/� _ ��M/t Designer: D t""1,t.,,. �(IV V vM T_ nspector //�1'/,�iULC,% f�if( W DaWe r The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 -,CERTIFICATE OF;COMPLIANCE DEP APPROVeD�FORM 5/96 No. �'. THE COMMONWEALTH OF MASSACHUSETTS FEE »"-- _Rn(n,6f& . tC BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby _ranted o Construct ( Repair Upgrade ( ) Abandon ( ) an individual sewage disposal system at _ L,.PN "W1 / as described in the application for Disposal.System Construction Permit No. ID) dated Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date ! I.J Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W H08BS8 WARREN PUBLISHERS PUBLISHERS- BOSTON . 1 , Town of Barnstable BIKE rqy �� Regulatory Services ti 0 Thomas F. Geiler,Director B BLE, Public Health Division 9Q 1639. ,�g' ATF Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 I Office: 508 862 644 n� Fax: 08-790-6304 Date: Zoe Sewage Permit# Assessor's Map/Parcel Installer & Designer Certification Form Designer: "-11 Installer: Address: t7t ��`t Address: On � was issued a permit to install a (date) (installer) septic system at-4 based on a design drawn by 'n A y��, (address) 'Vl'�r 0 dated 5 201 (designer) Y 1 certi that the septic stem referenced above w certify p y o e as installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation.of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local u- `-tions. Plan revision or certified as-built by designer to follow. Stripout (if rP- cted and the soils were found satisfactory. H OF A4,,q o DAVID 9'I B vi'!' (Installer's . �Si e) MASON ,9 No.1066 esig s ignature) PLEASE RETURN TO BARNSTABLE PUB1.,._ fE OF COMPLIANCE WILL NOT BE ISSUED UN i flL gv Y ti i tuN t'URM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertification fonn.doc IRV Town of Barnstable Barnstable Regulatory Services Department AMMeftCft 41RN8TABLE, ' - MAftr Public Health Division Fc► °`� 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO i CERTIFIED MAIL#7012 1010 0000 2850 7688 April 22, 2013 Mr. & Mrs Edwin M. Albino 83 Nelson Lane Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located 83 Nelson Lane, Marstons Mills, MA was last inspected on 4/10//2013, by Patrick M. O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • System is in hydraulic failure. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace.the septic system within the deadline period will result in future enforcement action. h PER ORDER OF E BOARD OF HEALTH o . s cKean. R.S. C O Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\83 Nelson Ln MM Apr 2013.doc Commonwealth of Massachusetts w Titlie 5 Offtcia,l Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (� / f#ope�ddr. — ON ner t� er's Name information is required r)Yb�2'�► /h 2/-2 _ page. City/Town State Zip Code DateObf Inspection Inspection results must be submitted on tfifs form. Inspection forms may not be altered in any way. Please see co In etelnesWO'e.cklist at the end of the form,. to portant:When _ filling out forms A. General 'Inforrnati'OII on the computer, I use only the tab t Inspec710—�, key to move your / t cursor- et not l� /� ruse the return /11 (�n�,•,p key. Name of pector - — Co mean -- Company Address zz r w - State, Zip Code Gty/Fo -- Telephone Number. License Numtier "— B. Certification I certify that I have personally inspected the.,sewage,disposal system at this ao..t:•ess 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. Uraim, a POP approved system inspector pursuant to Section 15.340 of Title 5(310 CUR 15.000). The system: ❑ Passes ❑ Conditionally Passes Fai rD ❑ Needs Further Evaluation by the Local Approving Authority In ctor's Sgna tre DaC i The system inspector shall submit a copy of this inspection report to the Aj .rovi g Authorify:�(Boa of Health or DEP)within 30 days of completing thin inspection. If the system is a hared system or„- has a design flow of 1'0,000.gpd or greater, the inspector and the system owner shall submit he report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions a�tthe time of inspection and under the conditions of use at that time. This inspection does'n'ot address how thei system will perform in the future under the same or different conditionsof Use. t5ns•3113 4 Title 5offioal Inspection Form Subsurface Sevege Disposal System•Pagel of 17 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SysW : Form -Not for Voluntary Assessments 3 Rope dargis — Cw net Ow s Na — information is required for every a 4n, 6, page. 'Cltylfown tate Zip Code Oate d Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E /always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM:R 1&3`04 exist. Any failure criteria nc 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. Check the box for"yes", "no"or"not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): t5^s'3113 • ' Title 5 Official Ins pacfienForm Subsurface Sewage Disposal System-Page 2o'17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessmer..;; Roperty ildr — ? 441 Cw ner / i7 _ n :a information is F . ` required f or every w J ln.) � /�( L_. page. Cttyrrown State Zip Code t of nspedtioon� B. Certification (cont.) — ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below).- El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). lbe system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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. I. 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 mannerwhich 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 t5ns Y13 Title 50fftcial Inspection Form:Su Dsurfec.Sewage Disposal System-Page 3of1? 1 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessmet,is Property ddr ON ner O� rrle information is required for every , _ 6 �� �G page. !Town fate Zip Code 111ate 8f Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water ' ppplier, 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) a;;d 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 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 certif'�,d laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is e4ual to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis rnust be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ d Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 12 Liquid depth in cesspool is less than 6" below invert or x vailable volume is leas than day flow 15ns•3113 Title 50fficial Ire --peC bon Form Subsvface''vlogeDisposal System-Page4of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Propert7y- Ur UL Ow ner ON ner s Name A D information is n,�� �L , M for L� page.age. tylroG`i wn '� ta5 to Zip Code to bf Inspection B. Certification (cont.) Yes No ❑ [j Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or -,r tributary to a surface water supply. El �J Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ l� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, perfonr,,A at a DEP certified laboratory, for fecal collform bacteria indicates a6uient and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggerk ,. A copy of the analysis and chain of custody must be attached to this form.) ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00 Og pd. EA, ❑ The system it 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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 "yes" 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 con- rt the appropriate regional office of the Department. r t5 m•3h 3 •• t Title 5 Official lnspecbcn Form:Subsurtace Se waga Di sposalSystem•pag05 of 17 Y P Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Props A ress /� — ON ner f—i t7uv er s Name information is required for every V page. Gty/Town b ta to Zip Code V Datd of Inspection C. Checklist — Check if the following have been done. You must indicate"yes" or"no"as to each of the followings. Yes No El Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ tj Have large volumes of water been introduced to the system recently or as pain of this inspection? Rh ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 10 ❑ Was the facility or dwelling inspected for signs of sewage back up? 1 ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different 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: ❑ Existing information. For example, a plan at the Board c:'`Health. d ❑ Determined in the field (if any of the failure criteria related to Part C is.at issue approximation of distance is unacceptable) [310.CMR :5.302(5)] D. System Information -- Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): ry DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): t5ns-3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property M Ow ner Ldr� (A 1,) , Ow ner s Wrne — information is required for every 4t e A n) A r ` f I J , 9 7 page. Gtyrown State Zip Code Date Of Inspection D. System Information (cont.) Septic Tank (cont.) If Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — How were dimensions determined? fix' _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): L,i• 1ij �,tJe� W ootur `Z,nr/er — Grease Trap (locate on site plan). Dept h bel ow g ra de: feet '— 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: Date '— 19ns 3113 Title 5 Official Iris pecbcn F or[Suosulace Sewage Disposal System-page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments g 3 s� Ftoperty0dirpm /II •— Ow ner f i ) d� �-fl ( (to ON ner s Name — information is ++__ /►,, required for every AR 4i\n /`1 ib M; (� Z� page. 13 �ity/Town fate Zip Code '—"— Orate of Inspection f D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 ❑ polyethylOne ❑ other(explain): Dimensions: _ Capacity: gallons Design Flow: gallons per day -- Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date -- Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5i ns•3n 3 Title 5Offiolal Irspec lion Form Subeuf ace Sewage Disposal System-Page 11 at 1� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessmer, Property dd ess , ON ner rL information is s Fla7 required for every ({5(r)) /�1 Q / b 2 U , page' lfown State Zip Code �at�e of Inspection r D. System Information (cont.) — Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert b _ Comments (note if box is level and distribution to outlets equal, any evide,• a of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan).- Pumps in wonting order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SA a S not located, explain why: t5ins W 3 Title 5Ofrtcial ins pectlonForm Subsurface - vegeDisposal System-Page 12d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Roperty dr I^ Owner information is Owner's Name required for every itRiS--- page. GtylTown fate-1 L 0 �spetion Zip de Dat D. System Information (corn.) Type: leaching pits number: G LH '�. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): �Cj Cesspools (cesspool must be pumped as part of inspection) (locate on si, 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 ❑ No t9ns-3/13 Title 5Official Ins pecti on Form SUbsldface Savage Disposal System-Page 13 of 1; - 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syste Form - Not for Voluntary Assessments Roperty Pdr r. Ow ner ) information is s Rarrle required for every h S f}'> -) page City/Town to Zip de Da e o trlspectio- D. System Information (cont.) — Comments (note condition of soil, signs of hydraulic failure, level of ponding etc.): , condition of vegetation, 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.): 15ins•3n 3 Title 5 Of ficial fnspec6mForm.Su Dsurtace Sewageoisposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessmerts Rope drM Ow ner I i information is �/�n, s Na rn6 /1 `) p wired for every t y�Y� 5' - _CJ� 4 �—'LL-L page. uty/Town State Zlp Code to o Inspection _ D. System Information (cont.) Sketch Of Sewage Disposal System; Provide a view of the sewage disposal system, including ties; to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately LO t5ns•3113 Title 5 Official ins pectonFcrm Subeuface Sewage Disposal System-Page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessmeots It A— Property dd less Ow ner O v er's Name �` i ti-rN information is _ required for every page. Gty/Town t State ip� 4.,. Inspection D. System Information (cont.) Site Exam: L_�,/Check Slope L� Surface water V,Check cellar G Shallow wells Estimated depth to high ground water: feet --- Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date •— ❑ Observed site (abutting property/observation hole within 150 f(.at of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page, ' t5ns•3'13 - rifle 5Officlal InspectlonForm:Subsulace;`p;, WeDispow System-Page 1e or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. :Prope*rtyr ON ner Qv ner-s me— information information is -- required for every —ZilLIL /►�� t page !Town �L=L-L_ 0 !~ . 16 �d ,l State Zip Code Cbt, f Inspection E. Report Completeness Checklist -- U,Inspection Summary: A, B, C, D, or E checked 1 Inspection Summary D (System Failure Criteria Applicable to All Systems) completed l�J ystem Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ns-3113 Title 5 Official hu pecticn F orm Suosvface::,,',age Disposal S yslem-Pogo 17 01 17 ' COMMONWEALTH OF MASSACHUSETTS 12 i EXECUTIVE OFFICE OF ENVIRONMENT 1 DEPARTMENT OF ENVIRONMENTAL F']ELOTECTI(, jT e� ONE WINTER STREET,BOSTON MA 02108 (617)292-550�►4A C � e ro J O W GovemoM F.WELD w 19ys UDY ary c B. STRUHS ARGEO PAUL CELLUCCI Co Lt.Governor mmrrs+a®er SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO : Cj PART A 9 CERTIFICATION t;�SC Vl L►�• "'�Z�r`•tU,�l (`�I (5 ,r'IG of Owner: Property Address: 0 3 N Address l� e Date of Inspection: i I k (�i 7 (If different) Name of Inspector: I of, I am a DE proved system nspector pursuant to Section 15-W of Title 5 (310 CMR 15.000) Company Name: - t/ mt— Mailing Address: Telephone Number SZ�j _U.k-r y Oho CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal,systems. The system: �//Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: 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 t appropriate 1 office of the Department of Environmental Protection. The original should be sent to the system owner and copie's sent"io'ttte regions buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SY PASSES: 7ve 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. co1VAg.1vTs: S, S+e r>ti tk 2c o WC-0 o far F u/, Re �l u r urn ;n a r at I ea c h;nb 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. 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. tre.sed 04/2Stn PW 1 of 10 Pnnled on Recycled Paper • r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j^+' PART A CERTIFICATION (continued) . 05 Property Address:' ' �t ,, �R 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). Des rite observatto_ns: broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four titres 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 DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYS rEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERbIINES THAT THE SYSTEM IS FUNCTIONING 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 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04r25ron Page 2 of 10 A S - C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 4 CERTIFICATION (continued) property Address: Owner: Date of Inspection: D] SYSTEM FAEL S: You must indicate either 'Yes' or 'No' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than F below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. , E]LARGE SYSTEM FAILS: You must indicate either "Yes" or 'No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR'5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/n Page 3 of 10 • >i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B y CEIECKIdST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes' or'No' as to each of the following: Yes No — — Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04125/97) Page 4 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL' Design flow: ,�g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: NOYLP- Garbage grinder (yes or no):— Laundry connected to system (yes or no): � Seasonal use (yes or no): NO Water meter readings, if av ilable (last two(2) year usage (gpd): 1 CI Sump Pump (yes or no): Last date of occupancy: �1 COMMERCIALMI;DUSTRIAL: Type of establishment: Design flow: i:allons/day 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: b JTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_10 If yes, volume pumped: ¢allons Reason for pumping: TYPE F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology 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: (yes or no) .„ (revised 04/25/97) Page S of to t. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) property Address: Owner: Dote of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) I,,It Depth below grade: �✓ Material of construction: /concrete _metal_Fiberglass _Polyethylene—other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: —I I X 100 Q 0. L l(• ' ya✓1 Sludge depth: It Distance from top of sludge to bottom of outlet tee or baffle: ?J Scum thickness: ;W� ri Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 1 b How dimensions were determined: TneA 5urrl'n 4 Comments: recommendation for pumping, condition of inlet and outlet tees or baffles, depth of li uid 14ve1 in relation to outlet invert, structural integrity, evidence of leakage, a c.) �^ oyl 2 1 e 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: recommendation for condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, pumping, evidence of leakage, etc.) (revbW 041251n Page 6 of 10 I e 'I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TAA'K: (Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal_Fiberglass_Polyethylene od wr(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; _No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) r DISTRIBUTION BOX:y (locate on site plan) 11 Depth of liquid level above outlet invert: Comments: 0�( f n `(note if level d distribution is ual, evidence of solids carryover, evidence of leakage into or out of box, etc.) C U r emn 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.) wised 04/25/97) Page 7 of 10 ( - - ; - ,Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: / SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan, if possible. excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits, number:, leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: hydraulic failure level of ndin , co ition of vegetation, etc.) - (note condition of soil, sign of hyd Po g CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert.- Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, 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.) (revised 04rt5M7) Page I of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 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) C - 0 Zz v F 32 3 C7 G_ � C-0 { r t [revised O 25/97) Page 9 or 10 a i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM WFORMATION (continued) Property Address: Owner: Date of Inspection: i Depth to Groundwater a,'' _Feet Please indicate all the.methods used to determine High Groundwater Elevation: V/ Obtained from Design Plans on record Observation of Site (Abutting property, observation hole;basement sump etc.) It `-- Determine it from local conditions 1/ Check with local Board of health V Check FEMA Maps Check records � pumping V�Check local excavators, installers " Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) Co rrl ac- ek Lo c&I f )C c a vc---ham C h ec tY F em&, m&r chec�- wig Locoi R,C - H . (revised oans/n Page to or 10 e � c3 y 1 : � N .--•- ....... a Fps.... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF...... iS�.n..5: :....... ................................... Appliration for Bisvusa1 Workii Tongtrurtion thrutit Application is hereby made.for a Permit to Construct (,/) or Repair ( ) an Individual Sewage Disposal System at: wO s e - 3 P A S_CsrO e-- �.` r , .......��:....._...°�................................................._ x............... ... --n--...----... ..�z...........-------M - Location-Addres x 5 �� or Lot No. _ ....s r ... uf-- _ .....................................i Owner Address Installer Address d Type of Building Size Lot. _,_ .........Sq. feet Dwelling—No. of Bedrooms___..._3.............................:..Expansion Attic ( ) Garbage Grinder (Wo Other—Type of BuildingGLt�_.. No. of persons____________________________ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------------- - Design Flow_____________J1.0......__.........:___gallons per person per day. Total daily flow..........3._3_d-..................._gallons. W .W Septic Tank—Liquid'capacity.I.BP_._gallons Length---------------- Width•_____--___-__- Diameter................ Depth................ W Disposal Trench—No. -------------------- Width..?---------------- Total Length...........I........ Total leaching area--------------------sq. ft. Seepage Pit No....../-.._--_--__- Diameter----$------------ Depth below inlet...0............. Total leaching area....�....sq. ft. Z Other Distribution box ( Dosing tank ( ) a Percolation Test Results Performed by----Lca i...... �'�r�a��L--------________---- Date..$./.13//s��______._______.... Test Pit No. 1_._4Z_.__minutes per inch Depth of Test Pit---Z1 ........... Depth to ground water_.!L�_____________ GTq Test Pit No. 2................minutes per inch . Depth of Test Pit.................... Depth to ground water........................ ti -----------------------------------------••-- .......•--------------- . ...................................................... 0 Description of Soil......... _-_Z.______4 5..._.......�-- Z 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'T : p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si ne c_. .._. .._Y ....... �`�� UU / Dat Ji • Application Approved By..... s �F// f C 1 d1 ` = Date Application Disapproved for the following reasons:--.------------------------------------------------------------------ -----------------•--•----------•----- Date PermitNo......................................................... Issued-.... .... - ................... Date \ J No ....... Finc lie............ z: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,..<'— --------------------OF........ n s 1r. . ..................................... Appliration for Dhgp a al Workii Tomitrurffun ranfit Application;is;f-hereby made for a Permit to,,C-onst.uct (,,o) or Repair ( ) an Individual Sewage Disposal System at '".yr .: s.�... 7.3 - sari►' .... ,.acme...:.... Location-Address or Lot No. ................. -- ..._ ....._"' " + 5.'C".----•------••-- v i _Y......-a-t\\f is .x"�'�r- ...................................... Owner Address Installer Address d Type of Building Size Lotk-L S• a10:.........Sq. feet Dazveliing=No. of Bedrooms....... '................................Expansion Attic ( ) "' d1�' "w Garbage Grinder a Other—Type of Building-.. A C,...._______ No. of persons____________________________ Showers ( ) — Cafeteria ( ) Other fixtures _. ...___. W Desiv Flow....... ___ gallons per person per day. Total daily flow h--j__i5r_Q........................gallons. WSeptic Tank—Ligla da'p'a'cit/� _gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. _____________ _ Wi h�- __--_____ Total Length_ j Total leaching area.... _ _ sq. ft. See a e Pit No------ ._. Diameter :- Depth below inlet-6-- ---------- ......:.......... Total leachingarea__� sq. ft. Z Other Distribution box Dosing r}k ( ) Percolation`Test $` ults; Performed by...lfi_ _ Date�J l3 ------•---•- . 1 �. I't Test Pito. 1 ......minutes per Inch . Depth of Test Pit__ _______________ Depth to ground water______________________.- LT4 Test Pit No. 2.......K.......minutes pe, inch Depth of Test Pit____________________ Depth to ground water........................ o _- -----------------------------•---...............---••. Ie� Description of Soil :_{,�}• ---• .__.._..•------ A� i _---__- ___ _ ..................................................... V -------------- _____________rrY_._____. #__._____:_____________.___:�'.-________._.___.______...______________ __________:________.__.________________________._________.____._.__ ____.__ M _ _________ _?..-_..__._.._.. . ._ . _ -__ ----------- V Nature of Repairs or Alterations—Answer when applicable.______________________________________________________________________________________________ Agreement,- The undersigned agrees t install the aforedescribed Individual Sewage Disposal System in accordance with rq�isions of 1:.:�. 'the ; p r-IT _ 9of the to Sanitary Code— The undersigned further agrees not to place ill-b system in opera S`n until a Certificate of Compliance has been issued by the board of health. <�4. S e ------------ � - ^ f Date Application Approved BY e.. � !�,l +......................... Date Application Disapproved for the following reasons________________________________________________________________________________________ f i ......................................................................................-------------------__---------------•-------•----•-•------------•-----•---•------_----------•-----•----•-•-------- 1 Date t„ PermitNo..................................................... Issued....................................................... Date f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......:::........ G.4A.i�5' �rT`a +C..................................... THIS-IS TO- CFRTIFY, That the Individual Sewage Disposal System constructed ( V,�r or Repaired ( ) by...........:.... ..............----------------................._._.._....----------------------------------•'..--•-•-----•-•--------- Installer at....... •. ...... 96....... `\co.60'•----- � - ��► --••."Y{La. --------------------------------- has been installed in accordance with the provisions of T ` of The State Sanitary Code as de- ib�d in the application for Disposal Works Construction Permit No.___ _____ _---______- dated_- -�9 ..'__._________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. A * DATE__..........Z........./4.- -•------_----•--------- Inspector........ Ll-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH " tk1 n..:...........OF...........-. c. ........... -r--�' 7 �x+.�+ �a�c,..........:.............. No...:... -., FEE..._...._d........... , Permission is hereby granted.............. •--•••-•-- +' !"+---•--•--------------•-._._...--' ...__-----....... to Construct-( ) or Repair ( ) an Individual Sewage Disposal System 1 at No........L.•-o..k------} sv-•------_Tk .t. .......... .............. Q fir........ Street as shown on the application for Disposal Works Construction P t N .; �. -•--• --"- Band - --j: ........... .--.-- .. .__-.. -- DATE-------------•------••------•_ - -9.....a._..•-------------•----------- j FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS- r ' F DI E—_ lJ lu S [�AT'A Sl t.l Ca L1= 3 : D/K �. v 5 EPn G T At.14C * �jU>< l l/v USCG �C)00 1Dt S POSAL t?tT V$t_ ,000 t7�" l 91.7 Q RCQ �wt r1 S i t��,vALL AEEA = 1 SO 5 C J . _ +' PAS Soft- (,0 ToTA%- UE5►6 N Rz P62cot..o'rtc>w e,T1= t 1u T AUu oeLE65. ,sv � 111 LF r., -.<a + t. 'o 5�13�8o G= 99 + AIZ ,.• ToP Fuo /o/-o MW P6 • tuu 9 'S' SuaSo1L, 'got. 41 Sr.Prlc t TAutL i•. OPAL- 14.7 3 CEG Pt T i ! r WtT4b� ., vrasu� 12 EG=B�•$ +.lo Seeat� SGALE (l���DD UI�.T� ,����, � ! �o �/ar��. T�lzvPoS�� �a t,t 2��szr�.IGr✓ t GrA.Mi FY T"AT Tb4f_- TovNDATION 96wU t-{EtZE.ot.1 GoMP�-YS WtTN T4t1< zjveL.t►JF_- .� AWD StT$AGtC REc?JieL�.MEst.1T+j' of Tt7 wt-1 OF I 'B/�'CG.t�iTJs,R.�/;1.�' fl - - t�� 4 1�1►.� rr va-rE. 5 14 60 �m,t ,%.' � �Ja�� �a.x�-e Q u�t� ►Esc. tZ .ts'r-� tzt >LAI.,t> Sv¢Vr---Per, T41CP Pt_At•J (Ar UOT $ASED OU AU ttKT&WE"T OS.TE�`.!c�.-'mob A�cA.SrS. 'Sucvc! 4 T"Q ot=t=seT; iKouLD 'UOT 15E uSe> Av1LIGAuT To 'pETERatiNE t„oT UWE;. ASSESSORS MAP : N0'111'S: TEST HOLL: LOGS PARCEL: � �D - - G 1) The installation shall comply with*title V and 'Down of?�3oard of FLOOD ZONE: doT � �� SOIL EVALUATOR: ) 1 I leallh Regulations. ��!� WITNESS: v. O I Z 7 he installer skull verily the location ol'ulililics,sewer inverts feud septic -- REFERENCE: ) - � �/� DATE:'y components prior to installationand setting base elevations. PERCOLA11 U J It t-.- 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.The lit /2 "J�{, V two feet out of tine d-box to llte leaching steall be level. 1 -2 4) 'Fliis plan is not to be utilized for property line determination nor any other �. ! �� "q� purpose other than the proposed system installation. �t >D t A . 10 ` t 5) All septic components nnust tmeet'l'itle V specifications. q t G) Parking shall not be constructed over I I10 septic components. - 5 .� 7) 'Floe property is bounded by property corners and property lines. b l� ;1� � PJ ;�� 8 1•Ire property owner shall review design considerations to approve of total L OCA1 I O N MAP � � I ��'S �� ) design flow and number of bedrooms to be considered r6r design. Receipt of payment for the plan and installation based on the plan shall be deemed t1Q ,ylAt{/V - -- approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. 'Those within the proposed SAS shall 4 l be renioved along wilh contaminated soil and replaced with clean sand per - �� `__� � i ��l Title V specs. 10)System components to be 10 feet front water line. Sewer lines crossing the ay 'lj \ - � water line shall be sleeved with 4 inch SCI140 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service 1 line. The line is to be sleeved as aforementioned and maintained in place. 4$ _ [ 1 C SYSTEM DES I G C� 11) 1f a garbage grinder exists it is to be rentoved mid is the responsibility of the l owner to ensure such. . I FLOW 1:5T1 MATE 12)'I'he installer is to take caution in excavation around the gas line if such I-NO / `" exists. 81 1)HOOMS AT GAL/DAY/gEUROOM - GAL/DAY ✓ f l3)The installer shall,verify the location,quantity and elevation of the sewer lines exiling the dwelling prior to the installation. a .C l4 'llus Ian is re nreselnlative only that a system cane fit on a hrvperty meeting , SEPT 1 C TANK ) p I ----- 'Lille V requireutents. l J✓V-AL/DAY x 2 DAYS - i VU GAL JX USE O GALLON SEPTIC TANK(E�JT 501 L at3svRP f 10! sySTEM .__-- C4VIO - / 1 I �1 MASON �; F ND.1066 `~+ p �K 17,1 0^7 PTIC SYSTEM . SECT I Oil 109 NA J- o GAt SEPT I C TANK L�w�,wF1� 0 I' 20 A I YIO�PL k 6, L O CA IN��S��J 1LL t PlIE13AiIED FOR r . s aLE• w t o �)Av I u i3 . M/asol�I 7 DATE:r✓' o! 1 DBC Ei4V i R014MENYAL DES I GHS I v FAST SANDW i CI1 . MA DATE IIEALI N AGEIJ I' ( 508 ) 833-2 1 77 Yt_ �,�` ►0� {ems 5 Z � ---iii ASSESSORS MAP :____. * I� NOTES: _ -----. _ TEST I-I O L : LOG S � r L PARCEL : FLOOD ZONE: d-T SOIL EVALUATOR: I G 1) The installation shall comply with'l'itle V and 'Town of��3oard of L I lealtlt Kc �ulaltvns. WITNESS : 4�1 0 I 6 REFERENCE: DATE. l7 � C' - , / 2) 'I'lie installer shall verify the location of utililies, sewer inverts and septic 1 components prior to installation and setting; base elevations. PERCOLA'f I O J HP E: 1 , c3,4x7� 5 2 /9� 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per fool. 'f'he first - - - J �� two feet out or the d-box to the leaching shall be level. -2 4) '1'liis plan is not to be utilized for property line determination nor any other n tj YJ' w 5*•0 purpose other than the proposed system installation. 10 A , ID >L � I 5) All septic components must uteet'l'itle V specifications. g' G) Parking shall not be constructed over 1110 septic components. 7) 'Che property is bounded by property corners and property lines. L �J t a ;1� hag review design considerations t approve of total LOCAT ION MAP 3� .: .�� 8) 1 he properly owners l t b o o g p design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plait shall be deemed 5N1D 0. %, approval of the design flow by the owner. v 1 L1�p pt,11 9) The existing leaching or cesspools shall be pumped and filled with unalerial per Title V abandonment procedures. Those within the proposed SAS shall I 1 l P ,� tt be removed along with contaminated soil and replaced with clean sand per Z3 9.S O � ' �-t-"1`' I A�' 'Title V specs. - ,0 10)System components to be 10 feet from water line. Sewer lines crossing the 0 I 1 1 N (0 i D.E. 1 water line shall be sleeved with 4 inch SCI 140 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. ,Lz - S E P TIC SYSTEM DESIGN f a garbage grinder exists it is to be removed wid is the responsibility of the I 1 l) 1 g b b Po Y 1 owner to ensure such. I FLOW 1=ST I MATE 12)'I*he installer is to take caution in excavation around the gas line if such J exists. BEDROOMS AT GAL/DAY/BEDROOld -�GAL/DAY �13)Tlie installer sltallvedry the location,quantity and elevation of lire sewer lines exiting the dwelling prior to the installation. SEP7 I TAtJK 14)'1'his plan is representative only that a system cart lit on a property tweeting I Title V requirements. .4 V 3�rAL/DAY x 2 DAYS - �tw GAL l LT1�.1 I USE IMB GALLoN s 4-1 SoEP,TIC TANIcC I L SYSTEM N OF4f I DAVID P. SAD LA 100 F, X X 0 � 9 / 0. EL � a� `� PTI, C SYSTEM ' SECT 1011 J 1 II , ►� to ��� 00, . . f 1 D_ oX �1, 7E/a - ICCO GAL T 11 TANK �5 1067 S I TE AND SLVJAGL PLAIy WI5 �i5 PRLI'AIZED FOR :;_J �,� i ii 7 sALE • 1 = ° DAY I D B . MASON ?):�P DATE : �13 ° — DBC EIJV I RONMENt1 AL DES I GN5 b — (_AST SANDWICH . ILIA DATE ; IIEALIN AGENT t 508 ) 033- 2 177 i