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HomeMy WebLinkAbout0044 CHAPPAQUIDDICK ROAD - Health F44 CHAPPAQUIDDICK ROAD, A= 170 029 i UPC 12534 No.2_153LOR �.ro HASTINGS, MN I -7o - ©2 E® BORTOLOTTI.CONSTRUCTION,INC. D EC 1 3 1995 1 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 / 508-771-9399 5(18-428-8926 FAX: 5118428-9399 NOW SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO ' PART A 9 CERTIFICATION Property Address: Date of Inspection: 4t� 's Name. er's Name and Ad e r �• CERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal sys s. The System: Passes Conditionally Passes Needs Further Ev uationgh Local Aproving Authority Fails Inspector's Signature: The System Inspector hall submit copy of this inspection report to the Approving authority within thir- ty(30)days of compl�4g 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: A)SYSTEM PASSES: 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. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,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,cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): -1 - FO RM SUBSUR FACE E SEWAGE DISPOSAL SYSTEM INSPECT ION F PART A CERTIFICATION (continued) Broken pipe(s)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). y Board of Health): The system will pass inspection if(with approval of The B ` t; Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: s;kf al ^t Conditions exist which require further evaluation by The Board of Health in order to determine if Y, w dI health, safety and the environment. he public ea the system is failing to protect l p y 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 5 30r1�. SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT 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 wate�Lyply or tributary to a surface water supply. The system7has a septic tank and soil absorption system and is with a Zone I of a public47, water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private .' water supply well. yet 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 f }b bacteria and volatile organic compounds indicates that the well is free from pollution from Ayl ht,�a f the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. »try D)SYSTEM FAILS: ti � I have determined that the system violates one or more of the following failure criteria as defined x { 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 to an overloaded or clogged SAS ±s yy or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an fi7 ` G} 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. y #' Liquid depth in cesspool is less than Gn below invert or available volume is less than 1/2 t day flow. ! Required pumping more than 4 times in the last year NOT due to clogged or obstructed r : pipe(s). Number of times pumpedxti, -2- rddf ki, � 4 A ,ZwM Y tti it J" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 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,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 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: ..t, 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 (IW�P�k)or a mapped Zone 11 of a public water supply well. The owner or operatorp,f any such system shall bring the system and facility into full compliance with the groundwater treatment pogram requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. tY' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ` Check if the following have been done: r dumping 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. 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.site. T _-The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, pth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different front 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 Y� RESIDENTLA_L: Design Flow: gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected'ro System: Yes Seasonal Use: Allr Water Meter Readings,if ailable: Last Date of Occupancy: COMMER AiJINDLiSTRLAL: / r ;•,:, �� Type of Establishment: „ Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste.)$iacharged To The Title V System: Water Meter Readings,Ir'Available: Last Date of Occupancy: ts'n OTHER: Describe) Last Date of Occupancy: r GENERAL I.N RMATION PUMPINQ RECORDS and source of information: 4' rr System Pumped as part of inspection: If yes,volume pu gallons ' Reason for pumping: TYPES SYSTEM: V Septic Tank/Distribution Box/Soil Absorption System Single Cesspool yF'i Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) y h t Other(explain): APJ?R ATE AGE of all components,date installed(if known)and source of information: ;d h � Is Sewage odors dete ted when arriving at the site: AA T t•� -4- ;> 0 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: V Depth below grade: Material of Construction: V--C-oncrete metal FRP Other (explain) Dimisions: Sludge Depth: o Scum Thickness: U 1 e Distance from top of sludge to bottom 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,etc. laq A2re-(7 G 4 C'j � pL er h /) Lale GREASE TRAP: Mp Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other ;. . (explain) t Dimensions: Scum Thickness: Distance from 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 in relation to outlet invert,structural integrity,evidence of leakage,etc.) no TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: sallons/day '. Alarm Level: .Comments: (condition of inlet tee,condition of alarm and float-switches,etc.) -- •- ���' ;��,�r�'�� DISTRIBUTION BOX: Depth of liquid level above outlet invert:_WGr Comments: (no el and distribution is e 1 evidence of solids carryover,evidence of leakage into }y or out of box, t Y, PUMP CHAMBER:416 Pump is in working order: , Y Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) y -5- .i YA l 3; I k)5•4� t7: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): i(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: Leashing Pits,number: Leaching chambers number: Leaching galleries,n um er. Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil, si of h drau is failure level of ponding,condition of vegetation, etc.) a../y- wbd C tt�S CESSPOOLS: z Number and configuration: Depth-top of liquid to inlet invert: ry Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materiels of construction: Indication of groundwater: Inflow(cesspool musl�4,.puinped as part of inspection) i' Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, �x etc.) N PRIVY: Materials of construction: Dimensions: z Depth of Solids: Comments:.(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) V •e { i'Yiw �7 M kNi Ji d. -6- ait 3, 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. rJ d nx V Y "I DEPTH TO GROUNDWATER: Depth to groundwater: Feet Me od of Determinatio or Approximation: `d y.; f. 7 1 1f 2 %k J i. YSdi. Pp�i W.+4jyi� '.. h« C o �OWN OF BARNSTABLE L9�CATION �f� G ��i%cQ(1o1rJDlC�IC_. Sal SEWAGE # '73— -;�i4 VILLAGE CEAyT;'vX01Ut ASSESSOR'S MAP 6 LOT hQ-Qd-9 INSTALLER'S NAME & PHONE NO. C G7.® (EoA-L� �� k-9� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 7-54S 30'0 (size) -7 r-,,e-;9� NO. OF BEDROOMS PRIVATE WELL PUBLIC W� BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: a Li VARIANCE GRANTED: Yes No } 1 lA�� /' .. i A4\ � 7, ���J 3`1 ���, � -� �, / - -� TOWN OF BAWT LE 7 ` JCATIO i C SEWAGE # V'iLLAG V l ' I e ASSESSO S &.LOT //D a S AME&PHONE NO. �' C� M� 6 0 SEPTIC TANK CAPACITY X06 LEACHING FACILITY: (type �lG~C ✓(size) NO.OF BEDROOMS BUILDER OR OWNER < PERMTTDATE: COMPLIANCE DATE: /l G/,: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 1� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) IV � Feet Edge of Wetland and Leaching Facility If any wetlands exist fe within 300 t of lgachin$f/acili /t Feet Furnished b /�CIO D`�` JOICKbo YIC. � 0 . No.... "._aS Fizz .....�®J. THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH earnmWeccMservatian Oepartmemt TOWN OF BARNSTABLE -A- 8iq� Xpp tMftdvr 3 ifipwial Works Tomitrurtinit ramit Application is hereby made for a Permit to Construct ( ) or Repair (>e�_ an Individual Sewage Disposal System at 140.0 ICE or Lot ...............Lo N Owner d ess a tSTD c� rrraj. �o �Ir y j_. yJ Installer Address dType of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms-------------------_7-7 _Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- - - W Design Flow..................5} ............gallons per person per day. Total daily flow............W. ....................gallons. WSeptic Tank—Liquid capacity-,66.4?.galIons Length---------------- Width................ Diameter---.------------ Depth................ x Disposal Trench—No. ......../........ Width....__._........ .Total Length._.�9......--- Total leaching area....................sq. ft. 3Seepage Pit No.......... .. ._.._ Diameter-------------------- Depth below inlet.__......._..._.._.. Total leaching ng area_..__....._.__...sq t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..-....................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1x4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----••------- ---------•-----•-••--•----••-•--........••-•••---.....•••••-•-•••••••••--••••..................••---••....................----•---....._.•..... ODescription of Soil........................................................................................................................................................................ V -------------- ----------------------------------•--------------..........-----...--------------------------- ..............................................................__ U Nature of Repairs or Alterations—Answer whq.Vplicable.____/ -5 '�'L.. ........1 .Q._ 4-. 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 ComplianHT by t and of h alth. Signed -------- .. -- Application Approved By ............. �- ......................................................... ....... ; .- -- Application Disapproved for.the following reasons: ............. ................ . .............................................................................................. ............. ............................................................... .............................................................................. . ............................... . .. ........................................ �y Date Permit No. ....73-------- ....J-- ---------------------- Issued ................. :.'.. .a---- n............. Date No...9 3._._ Fps.....0® �.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH O 6 TOWN OF BARNSTABLE Appliratiott for UbjV oul Worko Tonotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (,_->4 an Individual Sewage Disposal System at: .............�y �PD.9c. �D 0%cox' �e�r%/1✓ 1_ = :. ........... ............... •.... ......... L s or 11 lo. -- ------------- Owner ress a = .... Installer Address UType of Building Size Lot............................Sq. feet i Dwelling— No. of Bedrooms.................. .............. -----_-Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building _-------------_--.-.-___ No. of persons-_----..-.-_____-_-__------- Showers ( ) Cafeteria 1 a Other fixtures ------------------------------------------------------ Desi n Flow-•••••-•-.......... ----- W g gal°Ions per person per day. Total daily flow..._........ ....................gallons. WSeptic Tank—Liquid capacity.-_D).galIons Length................ Width----_----------- Diameter................ Depth................ x Disposal Trench—No. --------/........ Width_.....7__.------- 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........................................ M Test Pit No.-I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ._...----•-------------------•-•--••-------•----•--•--•-•••---••-••--•-••-•--•-•-•---......_................................................................. .0 Description of Soil..............................................................................................f.-•---•-••....•••--••-•---••••••••••••-•••••---•-•--•--•......--------•-•- V -........ ------------------------------ -••--------------- ----------------------------------------------------------------- xt - ---• ----------------------------------------------------------------------------•----•-------•---------------------------- ------------------------------•------------------ U Nature of Repairs or Alterations—Answer when�aplicable /i S '�1...�i____....„/ - ••--••-••••-. l'� n .........A.4z i 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 CompliaLh2sen issue by the-board of health. G Signed ........ ...../ - i-....Application Approved By ...........�#� ,�.....------------------ Application Disapproved for the following reasons: ................ .. ... . -- -- .... --- .............._.. -- ............... ---.................. ....... .................... ................................. ...................... ................................................................. -• ............ ........................................ Permit No. .... ...-.....o .. ..h------------------- Issued _ Date .....-.. ....:�.a... �._�............. Dam THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE %Ce>r#tftctt#e of C�omyliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired ( ) by ........................................................... 1� =.... . ............ . .......................................... ,: h.,tauet at ..-------._------------------------------------------------yc ............._ .-sl..... +.v./ ��/'c ��C----- ............. 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. .._ .-. -..�6........---- dated ......._...............................__. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. q DATE .... .'.:,L ............. ...._..... ...... Inspector ..._._--------- .----- THE COMMONWEALTH OF MASSACHUSETTS f BOARD OF HEALTH TOWN OF BARNSTABLE No... FEE (........ Rapnoal Workii Tnnotrurtinn "rrntit Permission is hereby granted------------------------; ----('11 n .�_ �---------................. to Construct ( ) or Repair t�') an Individual Sewage Disposal System at No............................................. ... .... n - ._... ............ Street � )01 as shown on the application for Disposal Works Construction Permit No. _.�.. ._.4... .. Dated--_---.---4LI;..... .":�-..-.�.�.._ -------------•------•••--•-•-- ---------------------------------- ------•--- �} t y Board of Health DATE .- ^ ................................ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS