HomeMy WebLinkAbout0136 CLIFTON LANE - Health 1.36 CLIFTON LANE, CENTERVILLE
A= 247 014
UPC 12534
No. 2_153LOR �
HASTINGS, MN
BORTOLOTTI CONSTRUCTION, INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Prop
Date of Inspec Ma arc I Ownero- /e "0
PART A — CHECKLIST E 47
CHECK IF THE FOLLOWING HAVE BEEN DONE:
Vo"PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH._ e
i !/ NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS kffiN_
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCEDD I�IJTO
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.
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, e�
oL_ No of Bedrooms No of Current Residents /V d Garbage Grinder
Laundry Connected to System _X
KS—Seasonal Use
NON RESIDENTIAL: —
Calculated flow
WATER METER READINGS,IF AVAILABLE:
i
GALLONS
Pumping Records end Source of Information:
SYSTEM.PUMPED AS PART OF INSPECTION?/6 IF YES,VOLUME PUMPED = GALS
-Reason for Pumping:: .
TYPE OF SYSTEM
Septic tank/distiibution box/soil absorption system
Single;Cessppgl Overflow Cesspool Privy
Share&system (if yes,attach previous inspection records, if any)
OtherT(explaln)',
Appr xlmate age of all components. Date installed,if known. Source of information.
g
t, °r`� r ir✓*F � kr
yt' Uri
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE?
OUTLET INVERT
Comments:
e o
pISac eso�b77.
Oe
PUMP,CHAMBERVV 0 Pumps in working order?
Comments:
IL AB RPTI N Y TEM (SAS):
IF NOT PRESENT,EXPLAIN:
TYPE Com
f rpSnQ
CESSPOOLS' '!�' Number and configuration
Depth-top of liquid to Inlet invert Depth of solids layer Depth of scum layer
Dimension of.cesspooF. Materials of construction
Indication of groundwaterinfiow(cesspool must be pumped)
Comments: ..
.' PRIVY:
Materials construction
Dimensions Depth of solids
Comments
.'f
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
IM ^ �
DATA
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
` PART B — SYSTEM INFORMATION (Continued)
SEPTIC TANK:
Depth below grade: Dimensions: S
Material of.constructlon: Concrete Metal FRP Other}
Sludge Depth y Distance from top of slud�e to bottom of outlet tee or baffle
a 3
Scum Thickness- , `�e Distance from Top of Scum to top of outlet tee or baffle
/l/U Q
Distance from bottom of Scum to bottom of outlet tee or baffle
omments:
obi �e� oG
O
/00
)(o f
, .
Q $
} e ,
DEPTH�T 1 11 .. I DWA R
"5 DEPTH TO GROUNDWATER
METHOD OFD AI�IATIO�I;ORi4PPFfOXiMATION:
is{.• 11'{�� �:fy� �W,^ii*4 .' - - -
r �
{.
kx pt w.' �� �'F`f+r. �a 2��``I•yt ��Fpl yr .. -•
r
'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
A .
fi . .PART B — SYSTEM INFORMATION (Continued)
SKETCH OFLSEWAQEIDISPOSAL SYSTEM:
,7n1 INCLUDE' TO AT<LEAST:TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL.'WELLS;W: ITHIN.100'
Within,50 feet of a surtace water?
✓ 'Within 100 feet of a surface water supply or tributary to a surface water supply?
Within alone l of a public well?
Al Withim, 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-than100 feet but greater than 50 feet from a private water supply well with no acceptable water
qualityanalysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for
co6form;bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen.
PART D — CERTIFICATION
r INSPECTOR ROBERT J:'BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS
COMPANY; k �BOR,TOLOTTI'CONSTRUCTION INC. MA 02648 (508)771-9399
CERTIFICATION STATEMENT
1 CERTIFYTHAT I`HAVE=PERSONALLY.INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION
' -:REPORTEDIS;'TRUE ACCURATE`AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
RECOMMENDATIONREGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
IN THEkPRsJER FU�NCkTIs�N AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS.
CHECK.ONE�.
'V ;`I HAVE':NOT FOUND ANY INFORMATION WHIC
H INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC
:.HEALTHxOH:THE.EWIRONMENTAS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS
STATE DIN THE;y`FAILURE CRITERIA".SECTION OF THIS FORM.
.I HAVE'-DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
310 0MR16,303 THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS
c�
i.. r
s,> INSPECTOR 3 SIGNATURE'.
DATE,
ORIGINAL;TO SYSTEMyOWNER,COPIE$'BUYER(H applicable),APPROVING AUTHORITY
r. - J
$UB.SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Sty. V d..t,a..+.
PART C — FAILURE CRITERIA
^'(Indic
sde Y-yea N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.)
/ Backup of Sewage into Facility?
Discharge or ponding of effluent to the surface of the ground or surface waters?
Static liquid,level in the districution box above outlet invert?
Liquid°depth'in cesspool, 6"below invert or available volume, 1/2 day flow?
Al Required pumping 4 times or more in the last year? Number of times pumped
Septic.tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiftration? yt
tank-failure imminent?
V Is any portion of the SAS,cesspool or privy, below the high groundwater elevation?
316-
TOWN OF BARNSTABLE
LOCATION-X2—��146Q SEWAGE #
VILLAGE ASSESSO ' MAP&LOT o/C/- 00b2
.z7VS�ct,���s NAME&PHONE N . Ar C) n// -'/
SEPTIC TANK CAPACITY V�,
LEACHING FACILITY: (type) ,GrOz2C A P'Z (size) IL900 cq ,,
NO.OF BEDROOMS. z/
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 t of jeachinn lfac' ' ) Feet
Furnished b ✓�h�
,� . ,
���
6� �a��"
o
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may,
�,- ft� ��
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1
Fss....... .... .D.b.....
DTHE COMMONWEALTH OF MASSACHUSETTS
n a - BOA LTH
L,-------------_--....OTF. a.$LU_ ............I.........................
, ppliratiun for Disposal orks' Tonstrurtiun ratnit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
1'i•-.-�:t 1+�... s �-.... .....-. .........................................
5. .. of No.
Lac ddres or Lot No.
Y
cm 0. _ Addicts& n
W ........... A. . --• .......
►-a Installer Address
QType of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms__________________________ ---•----
Expansion Attic ( ) Garbage Grinder
Other—Type of Building ............................ No. of persons.........----------------- Showers — Cafeteria ( )
G" Other fixtures -------------------------------- -
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 to"iPit
. O
Percolation Test Results Performed by.... -.•-----_...... -•- Date.. •..................................
minutes er inch Depth ...'_`�u_._____. De th to round water........................
Test Pit No. 1`Z...... p p g
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-----------------_......
O s:
Descriptionof Soil-------�-------.--------------------------------------•-------•-----------------------------------------------------------------------------------------------------
x
U
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 iITL L 5 of the State Sanitary Code—The de signed further agrees not to place the system in
operation until a Certificate of ComplianYhasnued by e b and of health. Z/45
Si =---- -•-• --------------- --•------------•---•--••-•-•--...... ------•-------•-----
•---.--
Application Approved By--------------•-••- -• ....
Date
Application Disapproved for the following reasons---------------------------------------------------------------•------------------------------- -----------------
...........-•------------•-----------•-••••-•--•------------••--------••---------------------•---------...-•----------------•----••••-------------------------•------•-------•-----••--------•--......_..
Date
PermitNo....................................................... Issued-.......................................................
Date
r
n
• . k
No.....46_3=15_6;> Flms.......�t.Q.s ..
..vim
THE COMMONWEALTH OF MASSACHUSETTS +
BOAR F LTH
- ------------------oF........ .�...AJ �.-:
t
Appliration for DhipmFal lVork.5 Tonarnrtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
...... -••-- ..........................................................
address r or Lot No.
t tjJ fs `(X
OVF
Addr
W ._. ....:.................................... .................................I _
�.,
Installer Address
dType of Building ? Size Lot__� �.......Sq. feet
U Dwelling—No. of Bedrooms________________________________ Expansion ttic ( ) Garbage Grinder
pa, Other—Type of Building ____________________________ No. of persons.........rl-ti ........ Showers ( — Cafeteria ( )
Q' Other fixtures __________________________________ ______
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 ( )
'-' Percolation Test Results- Performed by. 2_. ___....____ J" ____.. Date___
Test Pit No. 1___.•-______minutes per inch De th of TPit________•----------- De th to ground water........................
P P P
Gx, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -7............................. ........................•----•-----•-----•-•-••••-•-------•..._...........................................................
O Description of Soil....... --. .....................................................
x
U
W -------------------------- --------•-------••--•--------------•-••--•-•-•---•......-•--....•--•---------•-----•--•-••-----••--•---------•--•-•--•----•-•------•••--•••-•-------••---•••-----------------
U Nature 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 TITIZ, 5 of the State Sanitary,Co e— The de signed further agrees not to place the system in
operation until a Certificate of Compliance has 'en, • sued by e b and of health.
Signed_. r
Application Approved By................... ' �. i .
Date
Application Disapproved for the following reasons______________________________
-----------•-----------------•---•-•-----•-•------•----------- -----------•--
---•-----••----------•-----------------------------•-----._...-------------------._..........-------_•--_..
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
---^� BOA �OF .TE LT
."` ,era-•...............OF... ... .l....... .................._.........._.......
v
CIrr#ifirFatr laf utpliFanrr
THIS IS TO C FYI That thrdividua Sewa Disposal System constructed ) or Repaired ( )
... ......4 r ---• ---------------••---•-•._.._....---••••-------••------•-•---•--_••--•-
at -•- � /r/Jli taller r �,..
has been installed in accordance with the provisions of TI i r > f The Stflte Sanitary Code as described in the
application for Disposal Works Construction Permit No.___._ ___".____tpvl.......... dated-...............................................
THE ISSIJANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE
SYSTEM V!I F TION SATISFACTORY.
DATE. - ------•• ................................................ Inspector------ -- --- •--•-•-----•••••---.._..--•--._......-••-••-------._.....----_-----
THE COMMONWEALTH OF MASSACHUSETTS
BOAT OF EV�
3 6� ...............OF......P ,..� .�...._..±........._....._... .._......_......_.
No.... .............. ... FEE.......
...............
Ekop i Workii T tptrur#ion amit
Permission is by granted.--------- -•-Y `�=�' •/fit-Grti
to Construc ) o Repai f,awn`'!! ividual ,��evt*.wage DisposalDisposal ystetn
reet
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
Q �f -•--•-•----• --•----- ----------------------•--•=--
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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LEGEND
EXISTING SPOT ELEVATION 0x0 : ��' oFi���ss CERTIFIED PLOT PLAN
EXISTING CONTOUR ---- p -- o�� �e Lo T 3 zA cL��o� ��,►��.
FINISHED SPOT ELEVATION , ` �a WEsT- HY�+ �✓�''-�.' �. T
FINISHED CONTOUR 0 QRSE Z;
NO.i0sso a. IN 1
APPROVED BOARD OF HEALTH 90 c,STE ` �) a ,_� -�..tt .•
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GATE AGENT Al SCALES ;��30� OATEN �� /
LOREDGE ENGINEERING CQt iN .; $v0Wo A
_ CLIINT_._._. I CERTIFY THAT THE PROPOSED .
EGISTERE REGISTERED JQB N0. 9`w..�_ BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING -LAWS
DR. .A A-, AS9. ��PT
EN�OINE R <.l tz. OF BARNSTASL ' jj
. 712. MAIN STREET CH. BY;,.
HYANNIS., MASS. SHEET./. OF ? GATE E.O. LAND SURVEYOR
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INST L It NA i ADDRESS
BUILDER OR OWN
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED ��
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CENTERVILLE
PINE STREET
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PARCEL
247/019D �pG�P R�900
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LOCUS �� Drn
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PARCEL ID: �P _
247/020
ROAD
CRAIGV�LLE ROAD
0o N SHED OS�Q F LOCUS MAP
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SEPTIC
/ `�� ES� � PLAN REF: 118/123
LOCATION (V8 , TITLE REF: 9997/154
PER TIE CARD o0' 201 PARCEL ID: MAP 247 LOT 014/002
PARCEL ID: ZONING: "RB" SETBACKS: 20'F-10'S-10'R
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0% 247/014001 FLOOD ZONE: C"
COMMUNITY PANEL: 250001-81) DATED:07/02/92
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CERTIFIED
PLOT PLAN
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#136 ,;;
r 136 CLIFTON LANE
-�-WATER CENTERVILLE, MA.
PARCEL ID:
247/013 �p �p$' \\ NZ \ PREPARED FOR
GCI BUILDERS
O_ \ o \ HYANNIS, MA.
I PARCEL ID: \ \ C/O PAUL MAZZOLA
247/014002 \
to AREA=7,500f \ AND OWNER:
MAURA E. CAIN
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N�1° y SCALE: 1"=20'
A NOVEMBER 9, 2009
UPOLE OGE OF P s P
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EDWAR °yam SURVEY, INC.
A. 141 ROUTE 6A
GRAPHIC SCALE *�� STON D SALT POND BUILDING
IN28 0 P.O. BOX 1729
20 0 �0 20 ao eo Po '�F
c� T 10 SANDWICH, MA. 02563
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( IN FEET BUS:(508)888-3619 FAX:(508)888-2496
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ELEVATION 4 SECTION PHONE: 508-420-1230
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STRUCTURAL
PHONE: 508-420-123(3