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HomeMy WebLinkAboutMiscellaneous - 71 LACONIA CIRCLE 4/30/2018 (2)N v 2 tT1 ' k 1 pn #_._..__ ljiA MAP # _ISS LOT .__.._ PARCEL # /So STREET CONSTRUCT I..QN___APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO It� PLAN APPROVAL: DATE ARP. BY.__. DESIGNER: �E� _ PLAN DATE _ CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT --44 - — ----- _ _ _ ..�_ DRILLER ,_.... _........ __.____._...._........_ .............. _. _.__. WELL TESTS: CHEMICAL DATE APPROVED BACTERIA I DATE APPROVED BACTERIA II DATE APPROVED COMMENTS: VA.% NeepeD FORM U APPROVAL: APPROVAL TO ISSUE (:;ES;D NO DATE ISSUED ls5oeo BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: NO YES YES YES NO YES NO DATE:_..� __gv._.....BY _.._.._._..... - - - r � SEPT I C_SySTEM..,. I NSTALLAT I.ON. IS THE INSTALLER LICENSED? TYPE OF CONSTRUCTION: NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW CONDITIONS OF APPROVAL (FROM FORM U) YES NO NEW REPAIR YES (g)- (jealD YES NO ISSUANCE OF DWC PERMIT YES NO// DWC PERMIT NO. _ DWC. 43 _ INSTALLER : __./�U� Q BEGIN INSPECTION ONO: .... ....... EXCAVATION INSPECTION: PASSED CONSTRUCTION INSPECTION: 1-11 A61 - AS BUILT u SATISFACTORY: APPROVAL TO BACKFILL: DAT FINAL GRADING APPROVAL: DAT FINAL CONSTRUCTION APPROVAL: DATE: '/ U Yd BY of wA► � .SL)PR7 C] F(9wt ► ❑ WELL AP ovrD C SS - 5 PT'I c SY STS VESt6�,) Ppl{ovev 1JPRWI1J6 /uTIioRiTy DI 54PPP4VED Re, 5o Js = DwL 3i`3 PC(AA) 9016A.) K Rq-E SAA' v4Tto/J 1NSf't:�6Tio&j FWAL 1U5PF�TIo�j M= 5ev1� C, (j TO = _ I -Ft� (-�«'Y P) e -A II►1 �r Ma(o��-+�� /"lit Oz' `�d' trPrc c SYSTEM t,USTA Q-A-Tio" 94rc UATC AVDIT101JAL, I�St .i (0�5 X11- A► ►Y) DISAPPRO\j6D I�C0,50 NS Dare- APPi)\J'NG AurHoRTy FVJ,QL /J PPR)VAL�- Dor APPRWV)G /M i Hog I +t/ W Idi PFEAZTH !r, Mass. i SUBSURFACE DISPOSAL DESIGN CHECK LIST APPROVED - DAB'S Provid6d: Title V I FM I OK Reg 2.5 DISAPPROVED DATE Reasons s Zq 1Q LOT # GQG©N4 Gl/� The submitted plan mist show as a mdnimu , (a) the lot to be served-area,dimensiors ),)t #,abutters >b location and log deep observation 'ji-v-distance to ties �c location and results percolation tests,iistance to ties �d design calculations do calculations shauiug required leaching area ,e) location and dimensions of system-incltding reserve area ;f) existing and proposed contours ,g) location any fret areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping ;h) surface and subsurfsice drains within 1001 of sewage disposal system or disclaimer :i) location any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Board files j) known sources of waiver supply within 2001 of sewage disposal d system or disclaimm, k) location of any proposed well to serve lot -1001 from leaching facility 1) location of water lines on property -10+ from leaching facility m) location of benchmark n) driveways o) garbage disposals P) no PVC to be used in construction q) profile of system -elevations of baseme%t, plumb, pipe, septic tank, distribution box inlets and outlets, d stribution field piping and Other elevations r) maximum ground water elevation in area sewage disposal system s) plan must be prepared by a Profese -na: Engineer or other professional authorized by law to ; .tp, re such plans Reg 6 Septic Tanks (a) capac t.es-150X of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground sw1midng pool (d) 251 from subsurface drains Reg 10.2 7 Distribution Boxes FI(a) slope greater U= 0.08 Reg 10.4 b) suM 107 F. ; -st Sr.- Middletoo, SAA 01949 (508)774-2772 1997 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: 1�--eaj / PROPERTY ADDRESS: ADDRESS OF OWNER: (if different) -- DATE OF INSPECTION: NAME OF INSPECTOR: Almj-� sols) c T (r_`k o 0 THE PROFESSIONAL EXPERTS IN THF SFPTIC AND !?RAIN !Nnlj';TRy 0 107 Forest St. Middleton, MA 01949 .(508) 774-2772 SEPTIC & DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM PART A CERTIFICATION FILE# /// 9'/i# Property Address: %/ Lq&0--71`q �/�" �/, i*ael el— Address of Owner: Date of Inspection: SP�ot 1999 (If different) SGm�_ Name of Inspector: o sSLC%1r,, '5u 1 am a DEP pproved system inspector ursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Mailing Address:. Telephone Number: 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: V Passes _ Conditionally Passes 'seeds Further Evaluation By the Local Approving Authority Fads Inspector's Signature: 1 '474 Date: %� 9�?1' The System Inspector shall submit a copy of.this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmenta! Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and tne. approving authority. INSPECTION SUMMARY: Check A,'l 8, C, or. D: A] SYSTEM PASSES: yesI 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: 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 yeq, po, 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) Paye 1 of 10 DEP on the World Wide Web: http.bwww.mapnet.state ma.us/dep 0 Printed on Recycled Pacer FILE# �11 M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /�rQ�%%/Q (Ir Owner: Date of Inspection: 97 61 SYSTEM CONDITIONALLY PASSES icontinued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box.,,The system will pass inspection if (with approval of the Board of Healt ). 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 pipets). 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 protea 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. z; 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: Al -The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or LV 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 supn!v'well. The system has aseptic 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 Al (revised 04/25/97) Page 2 of 10 .FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propertv Address: Owner: Feol ` Date of Inspection: 77 D) SYSTEM FAILS: You st indicate ether "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 C.MR 15.303. The oas for this determination is identified below. The Board of Health should -0e contacted to determine what will be necessary to corr6ri the failure. Yes NQ, Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. NDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS c• cesspool. Stant liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. AN Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flov,. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe's;. Humber of times :pumped _ Any portion of the. Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any porton of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. • �/4 Any ponion 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. _ Anv ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with r -o 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 ILarge 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: Yea 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 ll 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 0{/25/99) Papa D• of 10 FILE# 911974 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7//o� Owner: Pe4 / , Date of Inspection: 97 Check if the following have been done: You must indicate either "Yes" or "No" astoeach of the following: Yey No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have beenum for p ped o 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;q. The facility or dwelling was inspected forsigns of sewage back-up. tL _ 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. i _ 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 owneri 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) (15.3023)(b)] 0 (reviled 04/25/97) Page 4 of 20 3 p FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION N Property Address: /� 1'a0/i1'4 Owner: rtto k Date of Inspection: RESIDENTIAL: FLOW CONDITIONS , ,I ; Design tio% , i �g.p.d./bedroom for S.&S. Number of bedrooms: Number of current residents: Garbage g,r der (yes or no!: Laundry corrected to system tees or no):, Seasonal use !yes or no): } t_. Water meter readings, if available (last two (2) year usage (go): -i -4 C 9'r. majo � Sump Pump lues or no): Last date of occupancy: T or establishment: I. floH•:____gallons/da Grease ap present: tyes o of Industrial aste Holdi ank present: Ives or.nos Non -sanitary ste scharged to the -Title S system: (yes or no) Water meter re gs, if available- Last vailable last IER: (Describe: _ date of occupancy Ate. GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or noy If yes, volume pumped: A5210allon Reason for pumping _42 6;6 L* Q sysiew uoaS riewr , TY EyOF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool ; Overflow cesspool _ Nn 'Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) �dQ VA Technology -etc. Copy of up to date contract? Other APPROXI TE GE of all components date installed (if known) and source of information: f i d�� �o �q9� Sewage odors detected when arriving at the site: (yes or no) (=Ovised 04/2S/97) Z:ap� f of 10 - i I � I FILE# 91197t4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7/ 14and iq - C%. Owner: Date of Inspection:�Sp� J �} BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron _ 40 PVC _ other (explain) Distance from pr ivate water supply well or suction li-t Diameter /4 Comments: (condition f joints, venting, evidence of leak§ge, etc.) - I �T Jib/J LPQd/ns �LsP _ 9o1.7c lwl V "'.Pv r Sr -i) .-) i x..11„,.. -, SEPTIC TANK:$' (locate on site plan) Depth below grade: 6 Material of construction: concrete _metal _,Fiberglass _Polyethylene _other(explam) If tank- is metal, list age = Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions:, // X,S"WX /D rL /SCiD Qr4l T4ogk Sludge depth-—:?ir>_ Distance from top of sludge to bottom of outlet tee or baffle;—a Jjn &401e Qr 6q Scum thickness-_ A Distance from top of scum to top of outlet tee or baffle:_ r� Distance from bottom of scum to bonDrn of outlet teeor baffle: How dimensions were determined. /^ Qr rv/er Comments: (recommendation for pumping, condition oflnlet and outlet tees or baffles, depth of liq ' vel in relation to outlet integrity, evidgpSe,of leakage, etc.). �/iLar'� Gi✓QUT >�?� �i �a t.S" 4rie► ,//! Sat GREASE TRAP: *ate on site plan) below grade: kof construction: _Zcrete _metal _Fiberglass _Polyethylene _other(explain) Scum thickne Distance from t f scum to top of outlet tee or baffle: Distance from m of scum to bottom of outlet tee or baffle: Date of last umoin iendation for pumpIN , evidence of leakage, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural (revised 04/25/97) Rage 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Piopert,, Address: Owner: / Date of Inspecti6n: / n l TIGHT OR HOLDING TANK: Tank must be dumped prior to, or at time, of inspection.) (locate on site plan; D th below grade: R' Mat tial of construction: 'conciete ,_met Fiberglass _Polyethylene _other(explain) --, i Dimensions: Capacih gallon . Design flow: gal ns�?la' Alarm level. rm 1 working order _ Yes; No Date of previous pum g Comments: (condition of inle ee, co itior4f alarm and float switches,'etc.) DISTRIBUTION BOX:YPs (locate on site plan a. Depth of liquid level above outlet invert: Comments: . (ote if level and d stributio,p is equal evid nce of� s lid carryover, evidence of eakage into or out of t/ o �Cf' r/J' OW w e PUMP CHAMBER: (locate on site pian) Pumps in working order. (Yes CNo► r�s Alarms in working order (Yes o) Comments:, (note Condition of'oump sham :condition of numos.and annunananrat air l `" s►: (revised 0{/25/97) C• t Page 7-.ot 10 FILE# I If FILE# f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7� �Q �Q C//" Owner: Date of Inspection:l�S�p�l /7 SOIL ABSORPTION SYSTEM (SASAtio'n (locate on site plan, if possible; not regwred, but may be approximated by non -intrusive methods If not determined to be present xplain: ! �P Type: leaching pits, number# leaching chambers, number: leaching galleries, number: leaching trenches, number,length: 7ror_�PS � . leaching fields, number, dimensions: overflow cesspool, number: Alternative system: << Name of Technology: Comments: (n?tp_co9ition of soil�s�gns of iydraulic failure,. level of pondingi yonditjpn ofyegeta4n_etc.) , i A CESSPOOLS: 1�I% (locate on site plan) umber and configuration: D th-top of liquid to inlet Depof solids layer: Depthlat scum layer: Dimensi s of cesspo Materials o onstru n: Indication of ou water: ,inflow esspool i pumped as part of inspection) of soil, signs'sqQjdraulic failure, level of ponding, condition of vegetation, etc.) sma IVY: (I to on site plan/iorr Materia of const Depth of lids: -Comments: (note ccindjKbiNpf soil, signs *t I failure, level of poj ding; condition of vegewtion, etc.) (revised 04/23/97) page a of 10 Dimensions: FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM 1% -FORMATION (continue) Properly Address: O%ner: Ae4ll Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or berichnul, locate all wells within 100' (Locate. whore public water supply corm into 6use) ?&der Wnel y0trd U 114cenf-q (:wised 04/25/07) page Vof to eal9-er- T/ Tifo = 1-/ 7 -1 Drl -S— t — k, FILE# SUBSURFACE SEWAGE DISPUSAI SYSTEM INSPECTION FORM PART C nn SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: A I Depth to Groundwater Feet ' /41 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 f i Describe in your own words how you establishedthe High Groundwater Elevation. Mut be completed) hvvSP an S ST10 /.� e'lcw J CL z w coo r, Ludo r Z �f o� \J UZ Z- w O Q 2 W �¢ R]. FO . Z w 3� i I ,W, Z I I � IjJ e LL U �WfnfnQ(7W �a� a=OZW 2w20 MIO MEM Z U 3 m N a .1 4 , • 111 IF , K '�' • M. .•C ; .. '. f. .. ru ru 1 / m 00 Z a a r`l cD CC w W cr O W ' o m Lo J =Qa v Ln C U I', ! 0.0