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Home My WebLink About0028 BLACK VALLEY ROAD - Health 28 BLACK VALLEY RD., CENTERVILLE A= All oP�2-1� 0 N `a HASTINOY.MN Y BORTULOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD,MARSTONS MILLS, MA 02648 °� 000 508-771-9399 508-428-8926 FAX: 508-428-939 � �' ? 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM` PART A >_ CERTIFICATION Property Address Date Of Inspection ner's Name and Address:. Inspecto s Name: CERTIFI ATION STATEMENT I Certify that I have personally.Inspected the Sewage Disposal System at this address and that the informs- tion reported below is true,accurate and complete as of the time of Inspection.'The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maint posal Systems.Th, ystem: the of On-Site Sewage Dis- ___� Passes _Conditionally a es _Needs Fyrfher Val o y the Local Approving Authority �_R !In Inspector's Signature Date: ----------- Tile'System Inspector shall submit a copy of this Inspection Report to the Approving Ant I hority with Thirty (30)Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000c ty 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. EC I A) SYSTEIV,YPASSES: I have not found any Informatfion which indicates that the System violates any of the fail-. ure criteria as defined in 310 CMR 15.303. Any cated below. Failure Criteria not evaluated are inili- B) SYSTEM CONDITIONALLY PASSES: One or more System Components need..to be Replaced or Repaired. The System, u on completion of the Replacement or Repair,Passes Inspection. P Indicate yes, nor,or not determined (Y,N,OR ND). Describe bases of determination in all in determined",explain,why not. stances. If"not The Septic trat Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration orfl ex - ion,or Tank Failure is imminent. The System will Pass Sewage Backup Replaced with a confor Inspection if Existing Septic Tank ming Septic Tank as Approved by the Board Of Health. kup or Breakout or High Static Water Level observed in the Distribution Bo ' broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box.Box i due x�s clue to will pass Inspection if(With Approval of the Board Of Health): m 1 - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken'pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The System will pass inspection if(with approval of The Board Of Health): Broken pipe(s)are replaced Obstruction is removed. C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board Of Health in order to determine if the System is failing to protect the Public Health,Safety and the Environment.. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH 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 FUNCTION- ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a-Septic Tank and Soil.Absorption System and is within 100 Feet to a Surface. Water Su pply.or Tributary to a Surface Water Supply. The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public Water Supply Well. - The System has.a.Septic Tank and Soil Absorption System.and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and-Soil Absorption System and 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 from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: 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. Backup of sewage into facility or system component due town overload 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 clog- ged 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 - 2 - �,i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the.Soil Absorption System,cesspool or priv elevation. y is below the high groundwater Any portion of a cesspool or privy is within 100 Feet of a sur a surface water supply. face water supply or tributary to Any,portion•of a cesspool or privy is within a Zone 1 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 cotiform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd or greater(Large System)and the system is a igniticant threat:to public health and safety and the environment because one or more of the following conditions exist: The sF. ystem 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 area Interim,Wellhead Protection Area (IWPA)or a mapped Zone.II of a public water supply well.The owtrer or operator of any such system shall bring the system and facility into full compliance with the grom�dwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the f lowing have been done: Pumping information was requested of the owner,occupant,and Board of Health. /✓ None of the system components have been pumped for atleast 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. I _/—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. _4_The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System,have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-. depthspect o for condition of baffles or tees,material of construction,dimensions,depth of liquid, Ill— depth of sludge,depth of scum. ---L,—/The size and location of the Soil Absorption System on the site has been determined existing information or approximated by non-intrusive methods. based on - 3 - i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) V The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow:3130 gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use 42� Water Meter R,e ngs if.adi1 . il able. Last Date of Occupancyc z,as$x/kj .P t D/yif� COMMERCIAL/INDUSTRIAL Type*-of Establishment: .. ; Design Flow: gallons/day Grease Trap Present: .(Yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source of information: System Pumped as part of inspection: , � - I yes,volume p ped: gallons Reason for Pumping: . TYP F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain):. j APPROXIMATE AGE of all components,date installed(if known) and source of information: Sewagfmlors detected when arriving at the sited -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL.IN FORMATION (continued) SEPTIC TANK: dy Depth below grade: e g Material of Construction:_�concrete(explain) metal FRP Other Dimensions• ,,2'X(o'.Y� Sludge Depth: Distance from top of sludge to bottom of outlet tee or baffle; Scum Thickness: y Distance from bottom of scum to bottom of outlet tee or baffle: Comments:.(recommendation for pumping,conditioin of inlet and outlet tees o in relation to o u r baffles,depth of li quid tle 'nvert,structural integrity,evidence of lea age,etc. ` 9 level U.. GREASE TRAP:-z2Q1 Depth Below Grade:___Material of Construction: concrete(explain): metal FRP Other Dimensions: Scum Thickness: Distance ti'om top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level m relation to outlet invert,structural integrity,evidence of leakage,etc.) q TIGHT OR HOLDING TANK: . Depth-..Below Grade:___Material of Construction: concrete.(explain): metal FRP Other Dimensions: Ca acit Alarm Level: p y: gallons Design Flow: gallonslduy Comn.ients: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_V-/ Depth of liquid level above outlet invert: Comments: (not evel and distributior s „al ev�d „�* , 4011 out of box,etc.) y �` carryover,evidence of leakage into or fi ------------- PUMP CHAMBER:_ / Pump is in working order:.` Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) - 5 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS):. (Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers,number:'. Leaching galleries,number: Leacahing trenches,number,length: ; Leaching fields,number;dimensions: Overflow cesspool,number: Comments:(note.conidtion of soil,signs of hydraulic failure level of ponding,condition:-of vegetation,etc.)._ a CESSPOOLS: 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:, Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) . _ 6 _ r s ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. i 97 DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of Determination or Approximation: - 7 - THE COMMONWEALTH OF MASSACHUSETTS SOAR® 9F HE T w .............................. . ppfirFafion for Dhipvii al Workii Tomitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal syst •.......... . ...._ ................ �..� ..._._.._._........_.__...._._... ..... -ocatw.• ress � or Lot. ---------------------------- W r Address ..........- �'L e�e�f,e/`'..t.. -- Installer Address -,A. L U Type of Building p ( Size Lot.,_ __ feet ..............................Ex ansion Attic ---• Showers arb =Dwelling No. of Bedrooms____.______ age Grinder ( P4 Other—Type of Building __________________________ No. of persons._..-_..___..__. ( ) — Cafeteria ( ) a' Other.fk5ttures __.__. W Design Flow.............. -----------------gallons per person per day. Total daily flow-------7_3-;4._-e.4.... ........_._..__gallons. P4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter____-.__-___--_----_ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by-----------.............................................................. Date...........................------------ 14 Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................... a --- •----------------------------------------------------------- --------------------------- •-------------------------------------------------------------- 0 Description of Soil....................................................................................................................................................................... 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 i i T p 5 of the State Sanitary Code— The undersigned fur er agrees not to place the system in opera 'on un it erti- e ot.,,Com h ce has been i ed by the bid of he th. Q /G <S I ------------••---•------------- ............................... • ------- ........... ae Application Approved By------. � --j.. . -- - ate Application Disapproved for the following reasons:-•-----•--•-•--------------•---••-•------•-•----•••-------------------------•-•••-----••---•-------------•..._.. -----•••-----•---••------------••----•--••••-•-••---••------••--'-•-•••------•--•-••'------•--•--•----------•-•-•--•--•--------•------ ----------------•---•...-•••----------------...------•---_.._. Date PermitNo. ._. . _ Issued.--•---•-------••.........................•----••---_._ Date N�.............._�-.`-�'7 Lq Fps......-��.. _ THE COMMONWEALTH OF MASSACHUSETTS BOARD ,QF HEALTH ........................................r� � Appliration for Dispoiiai Workri Ton.striirtion jJrrufit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System-at: - 14. ................. ........................................................ p^�oca ron dress . 1 y w9�� or 0+�)5 1 Address ........ !' ................................... ...... n!'.�e_4!•_ta.--'....--•-•-----....'....................................... Insta.ier Address *^ e of Building Size Lot '- _ +°�' S feet d Type g ..n. !'----------------- q• r Dwelling—No. of Bedrooms....... _______________________________Expansion Attic (/Y)6s Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures.................................................................................................... d W Design Flow........ ___________________gallons per person per day. Total daily flow...........................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench.—No ____________________ Width.................... Total Length.................... Total leaching area--------------------Sq. ft. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.....................-------------•--- a Test Pit No. I................minutes per inch Depth of Test Pit--------_........... Depth to ground water_______________________- �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •--•---••-•-----------------•-•-------------•-----••----......-•-------...................--•------.....---•-----.....-----••-----------------•------•-••••-- DDescription of Soil..........................................................................................-------------------------•--------------------------------------------------- x U ---------------•---•-------------------.._..'--•---'•-------•--•------------------'------------'----.._..--------------------------•----•'----------------------•-------------------•---•--------'------ W UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------_...................... ----•----------------------------------------------------'--------------------------._........••-'------••------------•-------•---------•-•----•--------------------------------------'--------••-----• Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with `�I the provisions of ii E of the State Sanitary Code—The undersigned fu tier agrees not to place the system in operapon unti erti'• to of Com J�•a.nce has been issued.�by the board of heilth. �� •,� �s �.��,,� Application Approved B 1 1 �--- ` f`-� Date Application Disapproved for the following reasons:---- •-----------------'---••-------•------------------•--------•------------.---------....................... ------------=------------------------------'---'•-•-------------•---------•--------------••-----"-----•._......_...._...-------••--------------••-------------------------•----------------------'----- _„_,_„-_..�, ^' r`--._..� L{ Date Permit No. — —`� ' ... --_—�___! Date Permit Date THE COMMONWEALTH OF MASSACHUSETTS _�� ----' BOARD OF HEALTH �... ......v Y. ......OF............� L.'..'.C. ............................... �. .. %-Entifirtttr of Toutpliiinrr TH'S IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( } by....... "f-.__' .................................. _ •-------------.._...InstaUrx has been installed in accordance with size provisions of fiT" tom: j of T_he State Sanitary Code,a escribe, the application for Disposal Works Construction Permit No __.�-r�_______. dated_-..- �__ -� __� ...... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTIO SSATISFACTORY. J DATE._.. 2--------------- 8 -------------------------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �' �1" .............1..^.�,.i.r. ...OF.................... iii ��` ............................ FEE.^ r_.. ..._. --- Rspost [- orko Cnono#r ion Prrutit Permission is hereby granted.......... J .. • ...............��— __......................................................................... to Construct ( ,.or Repair- ) an Indivi ual Sewa a Disposal Syst • --- -••- ,�reet. r-{- r- as shown on the application for Disposal Works Construction Permit-N�D.-Q,__7.qDated___,_, Board of Health FORMA 1255 HOBBS & ARREN. INC.. PUBLISHERS �•:� it - \ TOWN OF BARNSTABLE // r LOCATION SEWAGE # - 009 7 )VILLAGE ASSESSOR'S MAP & LOT ® ' �..;�), NAME&PHONE N0. ~ SEPTIC TANK CAPACITY 1000,9d. :LEACHING FACILITY: (type) (size) NO.OF BEDROOMS._ BUILDER OR OWNS PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 feet of leaching facility) Feet Furnished by -, � .. ��U ;,. ... r 2�' ► �� ,, �� ° �`� � .. �° ' �� ' OWN OF BARNSTABLE LOCATIONLC'l 6 /`/ `:ow �4/14elf WSEWAGE #04 VILLAGE d �l'l l!� ASSESSOR'S MAP 6z LOT 1-70-222- INSTALLER'S NAME & PHONE NO.'/- , 'JCK X�J C`SEPTIC TANK CAPACITY LEACHING FACILITY:(type) -��^� %�/ter' _(size) � � NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: d �t DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No X �� e �� -� �� .� �+�1) �� ►��"' All, i /LTA - S 1116tLEI 1- L 3'43 --- I t o x 3 33a 6LYD L15E! IOC>Q C-r .LLnk.1 S�Yi1r--1a►aK 37 > _ N P1S'70SAL'Prr - USE )L>C)C-> GAL,.Oty7rT r � 7 'lot. v�lt-tH 1' GQ1j5{-FG'p STOf�l'� � j �' io'rntu SIDEYlAI�Lt. . . , . ._ a• � ' I � � `a"r n`rt �C �r�`ri 1 �} IDEA t 160 SFTIH )-O T 1 G(yALMA. irolbv L'kP�•Ctt`(�606 F MEI.p = SO TaT•aL- T>IG51 He" 'F4.o Aw s F- 425 C-z P7 s - r-c.O,LA-rko ��TC I�TZO 2r��u.cQl>45 1 MCHARD / Nra. 2'.If1A8 I Tq-ear Fti117 z tt ,sr. ScN� �� iDUo A1` O M�a � a'P�lL3 O ox �N� 4 F l.. CH INt/ R(T 1uv 1fJv TAUK TR �j 3q�011C CERTIFIED P1-aT F't_A'N EL ST 0 LC)CAT ION: ?LAX RF- Fr.-RIri-Acz �L 3'S I 13 ; _ 1-U H -- IJ if i. 1 2C1�d'S Im,t l�F::61511=:Zt1 W rTA 77 4F- 5IT-2s 1-1iA \N-Q Ski Av--K nF-r"E A WP IS iIA b?- —API_1 ANT: A 3.L J-f.1 '6 t,'t A L J— aG4ME13 4c/IT►A J -MF- "�'La�?pLht�, THis R.A,u 15 NOT-�3AStR. DNAN INSTRUMENT 5QKvEY r,ND 1 HE OFF5E75 5HOWN 5HZ)UL-D 144T V r3 E us ELi -'L) EST&13 L15 H Lz;>-' L 1 N J;S. I