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HomeMy WebLinkAbout0420 MARSTONS LANE - Health t 420 MARSTONS LANE,BARNSTABLE A= 348 020 o r i 1. Town of Barnstable • IMRxseaBM Board of Health P.O.Box 534,Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman Ralph A.Murphy,M.D. December 17, 1998 Ms Kate McCarthy-Martin and Heidi Pleso 3261 Main Street Barnstable, MA RE: Whistleberries/ 3261 Main Street Barnstable, Unit#3 Dear Ms. McCarthy-Martin and Ms. Pleso: On December 8, 1998, you appeared before the,Board of Health to request variances from the Board of Health Regulation PART`Il,°`Section 1.00, which requires inground grease traps at all food establishments (minimum 1,000 gallon capacity) and requires separate male and female toilet facilities at all food establishments for the employees and the`patroh"s.`Ihe requests for these variances were NOT granted. The variances were not granted due to the following: 1) The submitted menu contained various items to be cooked onsite which' are not authorized according to the written grease trap variance guide criteria established by the Board on July 15, 1993., 2) There is only one toilet facility provided at this food establishment proposed to be used by both male and female food establishment employees and for both male and female patrons. This toilet facility'is currently accessible only from . outdoors. The Board finds that this toilet facility is not conveniently located for the patrons nor for the employees. 3) The Board consistently requires all food"`establishrr ent,bperators.to,provide separate male and female toilet facilities for'empldyees and-for the patrons, which are conveniently located. Your proposal is i ofconsistent with"this requirement. Ic 'Earns. fie However, the Board of Health did offer you the following options: IG,:,1.4V I ;; • The proposed menu could be reduced to comply with the Board of Health criteria for food operations without 1,000 gallon grease traps (then the applicant could re-apply for the variance with the revised menu)•OR the applicant could purchase or lease a grease recovery,device.. • The seats and tables proposed to be used by the patrons shall be removed OR the applicant could construct a second restroom facility accessible from indoors in an area which will be conveniently located for the patrons. , Please feel free to telephone our Health Agent, Thomas McKean, if you should have any questions. His telephone number is 862-4644. Sincerely yours, Susan G. Rask, R.S. Chairman t: !d to :snniply with .j-,i, Board of `> Fe'--ith BOARD OF HEALTH '! � c; llc, E �7r;ss:y1:» f.�E,,i. ,� -ie revise (*'i menU) 1 the , recovery de'vico. ,1 .1 Xr.'.a'n, if °Cl`:. 5 i •t i'i` • A 1 III i •, 9 "TROY WILLIAMS SEPTIC Il4SPECTIONS Certified by MA DepartNsnt of Environmental Protection roy�N 99�f ) 385-1300 ®x�A 19 Hummel Drive -; ` � 'rydEE South Dennis, MA Q2660 .\ COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA� r r COPY DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617.292-5500 WILLIAM F.WELD TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: S �ah S �-to C v w �. d j Address of Owner: . G (,J�o.Gc f e.r Date of Inspection: S (If different) a err Name of Inspector: Troy Williams o ,ifi1ars4a S Lti. I am a DEP approved system inspector pursuant to Section 15.340 of Title S(310 CMR 1S.000) wr•- /Z/.�i�� �q . Company Name: Troy Williams Septic Insaections Mailing Address: 19 Hummel Drive, South Dennis , MA 02660 0�� Telephone Number: (508)-3 8 5-13 0 0 CERTIFICATION STATEMENT I certify that I have personally inspected the*ewage 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: ZPasses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: S /3 U / cy 7 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: V 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: B] SYSTEM CONDITIONALLY PASSES: A/4, 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 04/25/97) Page I of 10 DEP on the World Wide Web: httpJlwww.mapnet.state.ma.usldep SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: k t (i Date of Inspection: S 13 D �� 7 B] SYSTEM CONDITIONALLY PASSES (continued) /V 14- 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: IV/4 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) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES 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 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ya O 114 `` S `` 5 L-h Owner: w h k- L✓ Date of Inspection: D] SYSTEM FAILS: You must indicate ei;,,er "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 ioverloaded 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 6" 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 504eet from a private water supply wellwith 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:/W19 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 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 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 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /vi s L h Owner: ',,� k I c Date of Inspection: r /3 J / 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 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: yZ 0 114�`r f F° 1 L i, Owner: P ; ,, k—( e- Date of Inspection: S./3o /9 .� FLOW CONDITIONS RESIDENTIAL: Design flow: 350 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: o? Garbage grinder (yes or no): /✓? Laundry connected to system (yes or no): `LE S Seasonal use (yes or no): N6 Water meter readings, if available (last two (2)year usage (gpd): Sump Pump (yes or no):� Last date of occupancy: �-c—✓`o c c� COMMERCIAUINDUSTRIAL• /t 14 Type of establishment: Design flow: gallons/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: OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /✓° p u r.., .fp i It..6 ,r„ �v a✓4 (4 L, ( .- A- -<— 13. .., i 1L 6 /� Trc��—.�-e A- System pumped as part of inspection: (yes or no)_.&/o If yes, volume pumped: ttallons Reason for pumping: TYPE 9F SYSTEM - 1/ 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: d y ti µ. Q, Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / ^^ SYSTEM INFORMATION (continued) Property Address: '7 0 114 a rS S ti Owner: h /t J e ✓ Date 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) Depth below grade: Material of construction: _ki(oncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: A10A/1::F Distance from top of scum to top of outlet tee or baffle: /✓� s ""'� Distance from bottom of scum to bottom of outlet tee or baffle: A10 S 4- How dimensions were determined: d . Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)/j"�� s w� d ' I wo✓h . •, 5 o"ct.e A- S-i 4 s o c fit c� N a— a,_, cc GREASE TRAP: /y l�9 (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 pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/2S/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: C 13 O g 7 TIGHT OR HOLDING TANK:' "/(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 —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (cond.ition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_V. (locate on site plan) Depth of liquid level above outlet invert: l r'U ei Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) —✓���c := W A S � v. t! I G u— G-b. c.( � L. G �c�.r� Lt S G��J t✓ 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.) (revised 04/2S/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7,2_ 6 L' Owner: W I �_ / L✓ Date of Inspection: _C. Jq /9 7 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: 6A�- 6 /4 C Din e , leaching chambers, number:_ leaching galleries, number: . leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of.Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) o .. r' w••- S � v�. c/t � b�. S S.t �. �.�. � T�h t.- /V o S i c� ,S a tea✓ �: �✓r{ o�� Yc..) 6 c ✓J 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: Depth of solids: - Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc:) (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ^� SYSTEM INFORMATION (continued) Property Address: �� d`U Al a,— S /'c,s L�. 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) I r JS Tw'^k (reviaad 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t/ J) SYSTEM INFORMATION (continued) 7 Property Address: Owner: Date of Inspection: S a .�/3 Depth to Groundwater — Feet adjusted high groundwater level 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 Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) v L (revised 04/2S/97) Page 10 of 10 TOWN OF BARNSTABLE O LOCATION �°�" `"�S 5 SEWAGE # Z� VILLAGE_(e .�m�►.. ti u, .� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /p'5­"C. / LEACHING FACILITY: (type) / i (size) 6 NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe of leachi g fac' ' ) Feet Furnished by �, 5%�— �o� Z� z�, �S , ���� �� ?S � �'� 3� 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property �d Q M ar 6 s L t Cv w, ,i., � tcl o c� /lit a Owner's name Pam✓ 1 C�._ wCA&- d 0 h 9- -Date of Inspection PART A G�� CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. VNone 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. VAs 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. P The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. I/ 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. V The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. V/ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. f SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORM PART B SYSTEM INFORMATION FLAW CONDITIONS If residential .3 number of bedrooms 6 number of current residents .Lo _ garbage grinder, yes or no' YES laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: 9 7 ' q� 00 a�21 o yC ffo,, y VaC H¢ Last date of occupancy GENERAL INFORMATION Pumping records and source+ of information: A J 02 LJ kh YO I i t� Tb�- vt V 4.. a C.- 7 u ✓ n s rTi �-1 NO System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Typ of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) * Other (explain) Approximate age of all components. Date installed, if known. Source of information: / ��aOv c N v� s v, �r vc ✓ y�,a�� ,r �, a lta, NO Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: material of construction: concrete metal FRP other(explain) dimensions: / �� 1 X G I S 6 r/ sludge depth distance from top of sludge to bottom of outlet tee or baffle h-146' 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommenda ions for repairs, etc. ) Q) Gc, ` c. ,� 6, &J O, S la o 4 I e v C' 2 DISTRIBUTION BOX:, (locate on .site plan) 16'J ed w, -� depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, rec mmendation for r'e/�airs, etc.) ✓ -.0— c ro v PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leachingits and number O04 ` � L P leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition+ of vegetation, recommendations for maintenance or repairs,etc. ) zz o CESSPOOLS (locate on site plan) : f,,//14 number and configuration depth-top- of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Fro" i I GIs 9' p r--bo L ,s6o DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: HD J f e /0 LK 7' C V In 4 .L✓ J u r T LS h /� S I !�t'1�. TG pQ . 1. 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? _A Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below ,invert or available volume< 1/2 da} flow? NRequired pumping 4 times or more in the last year? number of times pumped 1V Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? IV within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? n/ 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 analy, . for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector' ) ra , l c^ 01 S Company Name r - f' / r07 - Company Address t_/ 0 0 0 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. !211, one: have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signatu e S Date S Original to system owner Copies to: Buyer (if applicable) Approving authority C �J►'144 � v, � , Mom . l LO CATION SEW C E PERMIT NO. i'57—4/V5 ,�C AIVY' VILLA4E INSTALLER'S NAME i ADDRESS UILDE IL Oft OWNER v - DATE PERMIT ISSUED lk ® DATE C.OMOLIRNCE ISSUE® /3a s' qa o r-R w� a � , i F'No..Y --/_1 Fps.��._... ........ a THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................OF.... c�rr�5��1�1 Applirathin for Ui_qpntiFal Works Cnnnatrnrthin Prrutit Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal System at -- ars�'ons l o,re Cum► ,a � L - - 8 --I-- Pi�n t3K_- �-' 7 3 --... ....................I..................... - ....1............. --•-- Location.Address or Lot No. . .( -!': �_ - ..._ 1 .. _t L9.:a.......W.,.I.----..._U.!.:..�1. ,�.� kid__ 1V�AsS, O �er Address a ................ .�... ._ ................................ .r..._................__...._..... ......._._.. ..................... .._..----•-----•-•--.. � 00 Installer Address d Type of Building Size Lot...41,.��_'_ISG_Sq. feet V Dwelling No. of Bedrooms._.._._.._..................................Ex ansion Attic g— p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.................:.......... Showers ( ) — Cafeteria ( ) dOther fixtures ...................................................................................... .............................................................. Design Flow____________SS________________________gallons per person per day. Total daily 4pow:_._.......3 3�..................... long. WSeptic Tank-Liquid capacity.-%a®•gallons Length.t©?�. _,Width.... Diameter________________ Depth-_- .0... x Disposal Trench—No..................... Width____...�..._.._._.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No—....1------------ Diameter.... ..... Depth below inlet._._.CEO:o..... Total leaching area.5Z :1:sF}� �•P.�. z Other Distribution box Dosingtank ( ) '-' Percolation Test Results Performed by..AC:.v`?_._. _.W eill er•-,..1 n G• 1 3 i 83 W Date -�•--------------•-•--.... a Test Pit No. 1.._..3.......minutes per inch Depth of Test Pit....)32:...... Depth to ground water. c,riccvr��-erec� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ -• O Description of Soil....... -- �e .-.a �.c e �`o`n V ....---••---••••-••--•-•-••--•--...._...-•-•---------•-•----•-•-•--•-•-•-•-----••-•-•---.......-••---....-•-•--•••------•-•----•--•-----••--••----•-•----------••••-•.............................•--••. W UNature of Repairs or Alterations—Answer when applicable.............................._................................................................ .. ---•••••-•••...-•-••---•••-•-----•••••---•-•••---••......-•--•...-••-••-...•... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in tion until a Certificate of Compliance has been is wed b// the boar of healt . Date plicationpproved B --- -- --------------- ............................................................ .................... Date Application Disap o or he following reasons------------------------------------•------------------------................................................... ............................................................................................................................................................. Date PermitNo......................................................... Issued....................................................... Date Nola a'"fo 1! F�s.!........................ THE COMMONWEALTH OF MASSACHUSETTS s BOARD OF HEALTH _ .n...................OF.... am ...........'t Applirattion for Disposal Works Tontrnrtion Urrutit Application is hereby made for a Permit to Construct 9,1110 or Repair ( ) an Individual Sewage Disposal System at: is .. ! r..._. ... ......... ; ......................� ................... --------------------•---. -----.......- ....... .._..-•••---• ....... -�` : -•------- Location Address or Lot No. a .......... •--•-----•-••-----------------------•••----•.......--••-•-••-----•........................._..... a. Ow3ar Address � ...................:. ..................................................................................................Installer Address Type of Building Size Lot...41,q�..Sq. feet aDwelling—No. of Bedrooms...........73.................................Expansion Attic ( ) Garbage Grinder (�) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ................................ . . W Design Flow............5.5........................gallons per person pgr day. Total dajly f ow.._..... 4.? d..................... Ions. WSeptic Tank—Liquid capacityl5�a•gallons Length.Aa' .... Width...5'$-_- Diameter---------------- Depth_..._ t.P_.. x Disposal Trench—No_____________________ Width_----_-7.... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No.__----1_____________ Diameter....1Q_ ...... Depth below inlet.... ? p..... Total leaching area.?.��•-__4t�.sq.. Z Other Distribution box (} ) Dosi tank ( � ) �`P 4 Percolation Test Results Performed by.........................................�""-.,-_A I'�!.._........ Date.._ �� $�............... a - _r ,..a Test Pit No. 1..._ minutes per inch Depth of Test Pit----�............... Depth to ground water. __.__ ,___.____ c�ca�rl'r�I P_n_J___._._. ere 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.--_•.-____---__ --___- ----------------------------------•-----------•......................................................... DDescription of Soil......-a^ . -.... ac.��.4....... ?rl-----••----------------•----------....--------•----------------------••-----..........--•------•-----• x --------------------------------------------------------------- •-------- •-•-------------------- •--------------- W ------•------------------- ----------------------------------------------------- ---•--------•••-••--•-•---•-----•-•••---•--••-----------------•-•••-•---••--•---••--...-•-•--•-••••-••-••......-----•••. UNature of Repairs or Alterations—Answer when applicable................................................................................................ •--------------------------------------------------------•-------------------------•--•--•----••---....----...----------------------------•--•---...---------._.._...--------------------•------••-... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in W,ation until a Certificate of Compliance has been issued by the board of health. All'!' 6 � Date Application LYpproved B -------------------•-•-•-----..........-•-------------------...--•-..---•-- f -- . •--------•----------- r Date Application Disa ro f or the following reasons-------------•-•-----•--•---------------------__............................................................... ............................. -•--- ------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................I..........OF..................................................................................... Trrtifiratr of fP�ont li�anrr THIS IS TO CERTIFY, That the Individual Sewage Disposal/��Sjjystem. constructed (o-j"or Repaired ( ) by_....._.... :.. ..... .. J_.._ Q 2=�c:_1, .__-,--' .[:.::,c---aw-----------•--- .---------------------------------- �, .-•' '' staller has been installed in accordance with the provisions of TITLE 5 of The.11.State Sanitary Code as described in the application for Disposal Works Construction Permit No.__•-_--•_____________________—" .._.. dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---•....................:� �'...... Inspector.......'`" -------------•--•- T E CO EALTH OF MASSACHUSETTS )4 BOARD OF HEALTH 7-0 ...................... Disposal W orks Ton it ion rrmit Permission is ereby granted `"=�`=="'=- ::...... e" .-------------------- to Constr ) r R��I� ) Indio a Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit No........ :... .. 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