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Home My WebLink About0035 CATS PAW WAY - Health 35 Cats Paw Way,Centerville A=192-117 UPC 12534 ' No.2- 53LOR '�sr HASTINGS,MN BORTOLOTTI CONSTRUCTION, INC. ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop Date of Inspec} Map arcel Owner Q 7~ /7 PART A — CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: —.,,PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. ONE 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. 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 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. (/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 No of Current Residents Garbage Grinder LDS.... Laundry Connected to System 6 Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: , GALLONS Pumping Records and Source of Information: un1 e� may" 7`�'•n� �rL u /lr�� y/�� SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS Reason for Pumping: TYPE OF SYS EM: Septic tank/distribution box/soil absorption system � o� Single Cesspool Overnow Cesspool Iil vy Shared system (if yes,attach previous inspection records, if any) f Other(explain) Approximate age of.all components. Date installed,if known. Source of information. SSW SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTICAN : Depth below grade: Z Dimensions: Material of construction: oncrete Metal FRP Other} Sludge Depth O Distance from top of sludge to.bottom of outlet tee or baffle Scum Thickness O Distance from Top of Scum to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle C m.S Q /Ooo Cc ,� use a y- u e DISTRIBUTI N BOX: O'/' i hC' DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: ze . 0 PUMP HAMBER: / -----Pumps in working order? Comments: SOIL ABSORPTI N SYSTEWISAS IF NOT PRESENT,EXPLAIN: TYPE: - Ll Comments: v/ l T T. `l 4 V CESSPOOLS: A 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: SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' Y o DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: e 37, rd y wa 1i` i� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA pndlcabe Y—yes 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? Al 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? IV 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? 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 coliform 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. CHECK ONE V I HAVE NOT FOU ND 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 IF 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE ORIGINAL TO SYSTEM OWNER,COPIES:BUYER Cd applicable),APPROVING AUTHORITY 19,2_ !17 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Apphration for Bi-tipmial Worbi Tnnitrnrthin Vernfit Application is hereby made for a Permit to Construct ( ) or Repair 0<) an Individual Sewage Disposal System at .....�=�••-...----- .----•--• `bdb -•---....---•---•-------------- -�.. 1� .................................................. w I t _ Loc ii tjo i_:\ddres or Lot N f fib [-� `�C.. ess LA- ............................................. W ®2T c�Ua 17 ,�lS`i !U i GtlJ 7G� ( 1�gB y/ ✓U) i _0 t 6d.1 .--••----••••--•----- -•----.•--- ............................. Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............. -------..-..---.--_-_.Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow................. 2� ---------.-----..gallons per person per day. Total daily flow-.----..-.-� R�.IJ..................gallons. WSeptic Tank—Liquid capa6ty/f,Sal0--gallons Length---------------- Width.......-.------- Diameter................ Depth................ x Disposal Trench—No. .................... Width-.----------- ------ Total Length------------. Total leaching area....................sq. ft., > Seepage Pit No--------4........ Diameter....../Q------- Depth below inlet----- ---......... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date...................................... Test Pit No. I................minutes per inch Depth of Test Pit.----- ............. Depth to ground 'water....--_---------------. f14 Test Pit No. 2................minutes per inch Depth of Test Pit--.--------.-.------ Depth to ground water........--.............. 1:4 -------------................................................................................................................................................ 0 Description of Soil........................................................................................................................................................................ x U .....---••••••-•-•--•...-•••••••••-••--•--•--•••••••••--•-•-••--•••-•-•••---•--•-••-•••-•••--•-•-----••--•-•••--•--------------•-•••••---•--•---•••••----•-----••••••••••••..........-•••••--••••-•---••. w M. U Nature of Repairs or ?Iterations—Answer when applicable....-�fl..--....A---..--/.00.0I j-.-.----4:�.......... T ---------- /�_.�.-------- ------ ....... ................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate ofgCompliance s b n issued t oard of health.Signed ------.... I Da,e Application,Approved B PP PP Y - -................. - ........... .... .3-.�.a c .. C`eJ Application Disapproved for the ollowing reasons: ............ ...................... ........ .......... ........ .................... .............................................................. -- ---------------------------------------..................------. -- ----------- ---- Dace Permit No. �'57y Issued ---------- `a...c- ��'............... Dare I Mal In- 117 Ts ' No.... .:- ..?/ FE......:7G............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratilan for Divjipmttl Wor1w C owitrnrtion tiermit Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal System at: 3� C44'5 -t�D c �2v i Ul c .....................................••••---•----. ................................ -----------•••-----------.....-------------------•------...--------•••-•••...._.............•--•- 'P A LA- pCcatjon �o -:\ddrrsi/. T- �^ - / r or Lot No., , Owner C.l�,.iS—�.�I eel ,e rJ 7G J l�l�_ y ;� e55 , .v� �:1 a ------------•••---------------•---------•••-•--------------------------•----------• ------------------------------------- •-•------•-••--- •-----..---- Installer Address Type of Building Size Lot............................Sq. feet Dwell Other—Type T eoof Building oonls______________�____ No. of ersonsnsion Attic ( -)Showers Garbage Grinder ( j 44 Other fixtures ------- ------- --------------------- -------- -------- :--- -------------------(----)------•Cafeteria---------- a WDesign Flow.............._ __._____..._..____gallons per person per day. Total daily flow.-.__._....� _G..................gallons. WSeptic Tank—Liquid capa6tvAA.P---gallons Length---------------- Width---------------- Diameter..--..-__.--_-__ Depth................ x Disposal Trench—No_ ____________________ Width-------------------- Total Length------------ Total leaching area....................sq. ft. Seepage Pit No....__.._�......... Diameter....... 4.:-_--.- Depth below inlet----l2------------ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date......................................... ,4 Test Pit No. I________________minutes per inch Depth of Test Pit._.-----------__.___ Depth to ground water........................ fZ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.._-__.-_-____----__-- 1:: ............................... -------------------•--------•-......----•-------------------••----•--------•-------••--------•--•----•------•------•---...... 0 Description of Soil.................................................................................... ---------------------------------------------------.._._............--•-.-•-•- x V ...-••-•-••••••--•••-------------••-------•-•••--•••-•-••••••-•-•----•----•--••••••----------._.------•-------•-••......•-•-•--•••--------••--• •-•••••--•-----•---------------------•--•--------••----- W U Nature of Repairs or Alterations—Answer when applicable..__- _ f�..__.__ _-�_QG1.C1 __._.___ - ........... .......................... ...-!y ` ...... ...... ...=-.....-•-...........--•---.......-� ------ ....!Y4-------- ................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance i s b en issued t e board of health. Signed .........�..... _....... .............. -----------.-------- _.�/ ��...... F Dare ! Application.Approved By ---------- ------ --------- -�------------------------------------------------------ -- - c� 5 Dace �, Application Disapproved for the ollowing rearonr: ......._............................. ------------------------------------...._..-------------------------- ------------------------------------------- --------------------------------[J--------------...---------...--------- -------------.................---------------...------------------------.......... --------------------------------------- Permit No. -�� -d... � Issued ..........,,ram. .---:)- o..-..7..� ---Dare----- Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CIlEr#ifirate of C�omplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ^z ) by ----------------------- ------------------- -------- �G/ -lJ(A�---- ----�:w ST'/C--VG�--C �J `� Inualler �r at -------------------------------------- 3-5------------ 5-........`.�✓:' _ ` -F'` -------- ---� -�� -_----- - - -- ------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...- . -L/7� dated PP � P �� / - ... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRl7MAS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... �"`../ Y - Inspector ... _..... '—^ ———s————_—_,_,———_,.,-_� THE COMMONWEALTH OF MASSACHUSETTS /9L BOARD OF HEALTH , TOWN OF BARNSTABLE No.... v :.._ .7 FEE .......... Uthipinittl Worb Tonotrudi,on rrntit Permission is hereby granted--.--_----------------- Z�..(U�'"U��..-__._..C=-�!=J... U G'� - to Construct ( ) or Repair an Individual Sewage Disposal System atNo.----•-•-••-•.............•-••-•---• --- ----- Street as shown on the application for Disposal Works Construction Permit No. - � �---7 7!"�- Dated--------- -�- �_��5----..._.. .................................... ....................................................... ............... (�l Board of Health DATE----------------- � v FORM 36506 HOBBS 6 WARREN.INC..PUBLISHERS - , Q s 6 /3 OWN .gFBARNSTABLE LOCATION " G/I�LC SEWAGE # VILLAG )i L" ASSE OR'S MAr LOT ffiSMU�NAME&PHONE NO�r7QQA7 SEPTIC TANK CAPACITY IWO / �� — 0 � LEACHING FACIL=: I%V,--W lOe-D (size)/t�i�l.�, NO.OF BEDROOMS nn BUILDER OR O PERMIT DATE: 'cab"95 COMPLIANCE DATE: Separation Distance Between the: y 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 eet of le china hin faci ' ) / Feet Furnished b �('D`� 0 , �� ,�,, �C. a o � Np 5`�