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HomeMy WebLinkAbout0061 ANGUS WAY - Health 61 Angus Way, Centerville A= 251044 Slll J�,aa�►uEo UPC 12534 No.2_ 153LOR HASTINGS,.IYIN -"----- - ., _ :aria L� G I �` s' k ,;f _� �:; t BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop Date of Inspec} Map arcel Owner PART A — CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH, IZ 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 COLUMES 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 SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,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 SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED.BY NON—INTRUSIVE METHODS. C_-THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL —No of Bedrooms _ c;L No of Current Residents _ Garbage Grinder Laundry Connected to System A10 Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: GALLONS Pumping Records and Source of Information: SYSTEM PUMPED AS PART OF INSPECTION? U IF YES,VOLUME PUMPED A GALS Reason for Pumping: �� fe TYPE OF SYSTEM: ¢ Septic tank/distribution box/soil absorption system ��Lr Single Cesspool Overflow Cesspool Nd7 rivy Shared system (if yes,attach previous inspection records, if any) �y Other(explain) Approximate age of all components. Date Installed,if known. Source of information. 4 SEWAGE ODORS DETECTED WHEN ARRIVING AT THE,' D i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTE M INFORMATION (Continued) EP K: Depth below grade Dimensions: p , Material of construction: ncrete Metal FRP Other} Sludge Depth y Distance from top of sludgbe So bottom of outlet tee or baffle Scum Thickness _ //7 a Distance from Top of Scum to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffled Co ments: --�-- /000 omm en s:DI N BOX: Commerce: <Y2 DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT 4. xrl- 0 PU AMBER: Pumps in workin order? Comments: SOIL ABSORPTION SYSTEM SAS : IF NOT PRESENT,EXPLAIN: TYPE: Comments• CESSPOOLS: Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Materials of construction Dimensions Depth of solids Comments: f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — §ySTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' TA4c>; � o / 5`3 DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: rP S ulA e' G�.5. . S '�"U`to ma r' lto SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA / (Indicate Y—yea N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.) Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet. invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiftration? 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? Al Within a Zone I of a public well? Within 50 feet of a private water supply well? '.-4Z Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? 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 col form bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY. BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 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 RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS. C7HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 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 SIGNATURE: DATE: 7�d/ ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(d applicable),APPROVING AUTHORITY TOWN OF BARNSTABLE LOCATIONS t0 SEWAGE # / f �AGE. S �er i ASSESSO��' MAP/& LOT 6 6MVPMEBRUNAME&PHONE NO. Io - (lo j SEPTIC TANK CAPACITY Aoco /9 C LEACHING FACILITY: (type) 7 � (size) ZO 4(,' �S' NO.OF BEDROOMS BUILDE OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: I Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet f 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 feet of eaphin ra2',ty) Feet Furnished by ��/Otl IS Dl� ��2 `7/��'• II 2U o s� •� P JoJA WNN O�1��5� B.ARNSTABLE � G r- LOCATION SEWAGE # VILLAGE ��'�'``�"`�/i ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY / Goo 0 RIO � L/sJ ,fir L, LEACHING FACILITY:(type) O`�, (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER -pub 7ZAl .BUILDER OR OWNER ! / DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: Il- VARIANCE GRANTED: Yes No V NEW I . LWIN ��, C ASSESSORS MAP NO: PARCEL NO: H'I T14E COMMONWEALTH OF MASSACHUSETTS SOAR® OF HEALTH _-.............. -------- ---------OF........��..!9i@N!I"AQ Appa r atinn for MipatiFal Works Toustrur#inn 1hrutit Application is hereby made for a Permit to Construct ( y� or Repair ( ) an Individual Sewage Disposal System at: Loc tion-Address W / . Address In L 1 Ow ------------•• -... . �....YY'_____I_ Installer Y � Address UType of Building Size Lot._�.7.._�.9�'___..Sq. feet �-, Dwelling—No. of Bedrooms._......3................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) A4Other fixtures ------------------------------------------------•-•----•-----------•--•------•---------------•-----------------------•-•............................ W Design Flow...............................S- -gallons per person per day. Total daily flow._._........__._......_�3.4?.......gallons. WSeptic Tank—Liquid capacity./"©gallons Length:................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. r i Seepage Pit No------/------------ Diameter-----(0.. Depth below inlet......&......... Total leaching area---A 47 sq•..f._t • z Other Distribution box ( ) Dosing tank ( ) ; ... Date-••--•� x Percolation Test Results Performed by.....__��.h'd�____.. _ ./J� .,�_._.._.____. �,,�`_'._:��.I.�0 Test Pit No. lW.12-rninutes per inch Depth of Test Pit___ J.Y...._. Depth to ground waterh/OAl�.__i�� 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil s ._l.$ .. Gl :5.0 -------------------------------------------------------•------ --••-•----------••----------•---•d ...... ...•--..cjp& ----t.!.A'z:-............................................................--................... U 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 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. / Signed. = � ----�{ �` /. .... e Date Application Approved By...... .. Date Application Disapproved for the following reasons:-------•----------•-•-••-•-...•-•------------------•--••-------••--------------•---•-----•......------••------ ------------------------•----....---- ------. p u Date PermitNo.---....SJ..7._......(. --------------- Issued....................................................... Date �y� u 1 t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....­-w�------ ----- ---OF............i91.... Appfiration for Disposal Workii Tonitrurtion Prrutit Application is hereby made for a Permit to Construct (i/) or Repair ( ) an Individual Sewage Disposal System at: 5!0 C L/✓- CC V1ZL - Cam, c�ALocation-Address or Lot No. r CC �t . q� . /0 Q p p p Owner �fLL ddress a ��L-..-S-•-••-..3 .°s'------ NsTieu�T�iQ,J 3�¢• i �ns. AZ ..... �• /��enia�-r..... Installer Address /� Type of Building Size Lot_____.-,__.__g _._._Sq. feet ,. Dwelling—No. of Bedrooms..__...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ . WW Design Flow...............................!T! .r_...gallons per person .per day. Total daily flow....................__3©.......gallons. G� Septic Tank—Liquid capacity.10Oallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No. .................... Width....__.............. Total Length.................... Total leaching area.____-_-------___---sq. ft. Seepage Pit No------ ............. Diameter..._. _. ......... Depth below inlet......J67........ Total leaching area...�4 7.sq. ft. Z Other Distribution box ( off) Dosing tank ( ) ® aPercolation Test Re kks, Performed by.......................................................................... Date._l�6&- ...7..�.!$ ... Test Pit No. I.fofin.aminutes per inch Depth of Test Pit...1.1.4......_ Depth to ground waterNC--I�___F—���Dr 'D LX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------.................. a --------------- -----------------------------------------••---------•-••-•-----•---.........-•-•--•......................................................... 0 Description of Soil._P." Tt)- J." ..... .` o/L•-------------------•--•------------------ c.� ---. ---------............................................................. --------------------------------...2..----�®--•-. -D.------------------•----------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable..................................................................................._............ -------------------------------•---•-•----------------------------••----------------._.........---...----------•----------------•-------------••-----.....---------------------•--------•-----•--•-•---- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of T I Tt. 5 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. Signed.......... � � -7 !jZ 9 7 Date Application Approved BY---------- ------------------------------------- ----------•------ -------------- Date Application Disapproved for the following reasons:............................................................................................................. ---------------------------------•---••--•---------------•----------------•-•------------•-•--------...---------------------------------------------•-•------------------------•-----------------••--•-- _ Date PermitNo.--....�.7..:.--- .............................. Issued-------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OFOF HEALTH .........,,/c!{? :x,<�c6 OF....... ................................... r �rrtifiratr of Tompliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( } by--------------------------------- arc--.....A.1 t -------•-------••-•-----•-----------........----•-----•--------------•-•---•---------......---•-----•-------------•-•----•-- Installer at.......................••------------------------•----•-------•----------•-••--...•-••.._..---•----•--------------------------•----•-••-----....-------------------------•---•--------------------- has been installed in accordance with the provisions of TiTIE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------ :_-_�' .7..I?--- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... _' "- �..................-------•---•---• Inspector------•--•-•---- . t THE COMMONWEALTH OF MASSACHUSETTS .BOARD OF HEALTH 7- t� 1`y� .......OF........... ................................. No....5 ,?4�.0.O FEE. . :.. Disposal Vorkii Tonstrnrtion rrutit Permission is hereby granted ............... .....---......-------•--------•---••-•............................................... to Construct (136 or Repair ( ) an Individual Sewage Disposal System atNo......................... 7_ -------C--e-. te__ G'� =-.....C�.-�2u11) '-•-----------•------...-•--------------------------.............. Street �`I`�r �J as shown on th/alication for Disposal Works Construction P it No. Q ... Dat d. . .---- .. -----------------------------DATE. .C-L! . Board of Health FORM 1255 ,HOBBS & WARREN. INC.. PUBLISHERS LOCATION SCALE . ��=3n'. . . . DATE PLAN REFERENCE 5- LA/ �T � zs�9 I o �►sTi�/G D2 wE" i o� � o � 30• !1 1 i (� sEPric t v` y./6�yr,Q L/Nt � a TRNiG 1 A 40' . 0 7 too b� 7Z3r I _ —' P,r OF dRD 1 ♦ ,�' 3S, 03 ' b'1,1 KELLEY NO. 26100 p �Fs o 1p, ISTE 0n 4 s��NAL LAMo e�V TOP OF FOUNDATION -�- CONCRETE COVER CONCRETE COVERS 3,04' �0 4"CAST IRON MAX. 12"MAX. " "'�'"'• OR SCHEDULE 40 4"SCHEDULE 40 PV.C.(ONLY) P.V.C. PIPE PIPE- MIN. LEACH ' PITCH 1/4°PER. PITCH I/4"PER.FT. PIT PRECAST ° -� LEACHING o' INVERT o EL...47.•rJ¢. INVERT RT o . d. PIT OR SEPTIC TANK ¢z DIST. • z w we EQUIV. o INVERT EL...7: ., . . .' BOX %ILI�VIE ..1`... ' ; > b .... GAL. INVERT G 0 a 0 EL y,cl. INVERT w w p. :;�: 3/4"TO I I/2 � EL 66.40 LL a .\: WASHED w W STONE *-..AM.: DIA t:; PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE P- 3z 5/ SOIL LOG WITNESSED BY : DATE R.>�• 7 /9B¢ TIME.!!'oo! '� T'`;�B/• BOARD OF HEALTH TEST HOLE 1 TEST HOLE 2 �,2lfs//� CD^/�?� GS.�do . . . . . . . . . . . . . . . .y. . . . ENGINEER ELEV. . ELEV. .. .. . . . . . . /eN 7b4p DESIGN DATA PAF—ez- u•go Ca,%ZSC Ssr+�v NUMBER OF BEDROOMS 3. 4r� TOTAL ESTIMATED FLOW . . ' 30 . GALLONS/DAY 720' BOTTOM LEACHING AREA . 78 . . . . SQ.FT. /PITIC,R.A. Ez.LZ,¢o "yeD s,op/o SIDE LEACHING AREA . . �88:5 . . . SQ.FT./ PIT/¢7/ 6;P,2:>. $ GARBAGE DISPOSAL (50% AREA INCREASE) f3oN� TOTAL LEACHING AREA . 26.7 10 v . . SQ.FT PERCOLATION RATE 45 A5 y . MIN/INCH LEACHING AREA PER PERCOLATION RATE .5�P.. SQ.FT./C',P,D .J�!?. WATER ENCOUNTERED NUMBER OF LEACHING PITS APPROVED . . . . . . . . . BOARD OF HEALTH 7Wo DATE . . . . . . . . . . . . . . . . . . . . . . . . . AGENT OR INSPECTOR " OF fygs 10 . . . . . . .Z0T � 'u� C«rr�x v7/Y G 1 e,liu� r i < IST t"�fY.rJir'� � '_gRa74N0 AB\A� PETITIONER � � `rtj ,�t� '�'`�°~`r•