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HomeMy WebLinkAbout0042 FULLER ROAD - Health 42 FULLER ROAD, CENTERVILLE A= 188 030 I ,I I �+///__/__ All // � J/7l/IGllli. UPC 12534 No.2_ 15_3LOR •�� HASTINGS,MN Commonwealth of Massachusetts egg So Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4-2 f:�;I_L-tz- a, Property Address pl&6t E M A-t t0 c LJ 5 W-l Div tiS o f SSA 9AJ5r$�-G Owner Owner's Name _ information is G r ✓t�� A/A- required for every ) -> page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important When fillingng out A. General Information out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not r=—t7t4—)by—y A ` S Ty AJ = use the return Name of Inspector key. CAS vJ NZ 4-D Company Name Company Address citYrrovin.L4e 6�g _ 3G l9 state Z e q Z Zip Code Teleph2 e N be License Number P�lb�� B. Certification CMm _:zr- I cerify that I have personally inspected the sewage disposal system at this address and that the info ation reported below is true,accurate and complete as of the time of the inspection.The inspection f-- walperformed based on my training and experience in the proper function and maintenance of on site Q- se age disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of cr_ Tit e 5(310 CHAR 15.000).The system: 0.'` ., d Passes ❑ Conditionally Passes ❑ Fails tr; rY, Needs Further Evaluation by the Local Approving Authority O N a lnspedor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing 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 DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11f10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 1 of 17 d QW13 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4-2 f-w-L61- 'ZV Property Address A 1At�.L {JI�p�J�►�1 Owner Owners Flame information is � -� [UL L a26 required for every ( — 3 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ] I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: I 'J V-j t-VtaC0o1-1 i0 �ZUcTUf�-tic. �� (�SYDR�k►t,tc.dt,c.�! t,oco.-�rj Ind �'t'��J-r y�.¢9 AIUTE'I LA 00111 0,1Q0 ��n/r� FIFE R-6Pw Pt 8 69 -0 gnu PTyA4 D `y`{5 e(YM $et L Pt CAE A,roa 26p.,i2y44.0 VV.,(Vj6Z.LT0 t3jE5- A,.ea Ww11 q NfA B) System Conditionally Passes: ne or more system components as described in the"Conditional Pass'section need to be re ced or repaired.The system,upon completion of the replacement or repair,as approved by the rd of Health,will pass. Check the box r"yes","no'or"not determined"(Y,N, ND)for the following statements. If"not determined,'pleas explain. The septic tank is metal a over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial i bon or extiiltration or tank failure is imminent.System will pass inspection if the existing tank is re with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is cturally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y s old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4-2 (-v L-L-C3 t-Tio Property Address ti(4 t,t rJ o ul S ILA Owner Owners Name information is C,%9YO7=—,(VtL�L t57 Zp (. required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cont.): u�a ❑ Observation of sewage backup or break out or high static water level in the distribution box due broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pa inspection if(with approval of Board of Health): ❑ b en pipe(s)are replaced [IY ElN ElND(Explain below): ❑ obstructio removed [IY ❑ N El ND(Explain below): El distribution box is veled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year a to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board o ealth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ Explain below): C) rthee Evaluation fs Required by the Board of Health: ❑ Conditio ist which require further evaluation by the Board of Health in order to determine if the system is fal In test public health,safety or the environment. 1. System will pass unless Board o determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning i anner which will protect public health, 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 t5ins•11110 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-_Not for Voluntary Assessments Property Address Owner Owners Name information is eg_�f,_17VW%L11Af required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) System will fail unless the Board of Health(and Public Water Supplier,if any) ermines that the system is functioning in a manner that protects the public health, saf and environment: ❑ e system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of urface water supply or tributary to a surface water supply. ❑ The sy m has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system h a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup well". Method used to determine distan **This system passes if the well water analysis, ormed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure crite' are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ pq Backup of sewage into facility or system component due to overloaded 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 clogged SAS or cesspool ❑ ��p ® Liquid depth in cesspool is less than 6°below invert or available volume is less than%day flow t5ins•11110 Title 5 Official Inspection Form'.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4Z F,Lt6� `Ky Property Address Owner Owner's Name information is required for every page. City(Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or E] N/� tributary to a surface water supply. ❑ N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Nip ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ N/a 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. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. a/A E) 4rge Systems: To be considered a large system the system must serve a facility,with a d n flow of 10,000 gpd to 15,000 gpd. For large syste tthesystem thin or"no"to each of the following, in addition to the questions in Sectio Yes No ❑ ❑ t of�abi a surface drinking water supply ❑ ❑ the system is within 200 feet ary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitiv rea(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public ter supply well If you have answered"yes"to any question in Section E the system is con . red a significant threat, or answered"yes"in Section D above the large system has failed.The owner o erator of any large system considered a significant threat under Section E or failed under Section D sha grade the system in accordance with 310 CMR 15.304.The system owner should contact the appr e regional office of the Department. t5ins•11110 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 2 Fv t_I.trf—' F-0 Property Address Owner Owner's Name information is G�n�r�-(L✓lLl�lc' M �21i3 Z i1"\\ t3 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by th owner ccupant, or Board of Health ❑ S Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ Dg Have large volumes of water been introduced to the system recently or as part of this inspection? R1 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) �] ❑ Was the facility or dwelling inspected for signs of sewage back up? (� ❑ Was the site inspected for signs of break out? 1K] ❑ Were all system components,excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS on the site has been determined based on: A--5VWkLr' t PxPLLI.&-tj v� ,� :tj Wua.rr o'J on.) F-t t_� x�1- g0 t-k o Ff=lLt3 V 96-336 ❑ Existing information.For example,a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 -Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address MP.L tt.�514� Owner Owners Name information is Gn-%/kt-'..C _ I,?— required for every State Zip Code Date of Inspectionpage. City/Town D. System Information Description: �j � /alt is tb4 of 1 oQ / S ��g e4y> tirfir�l`rrr� crreN/j /•s�1-�ids a�-i� Pn Sic) Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No .Y-ls laundry on a separate sewage system?[if yes separate inspection required] [9 Yes ❑ No }'Laundry system inspected? z tl6aV%&tAV"- s u ® Yes ❑ No Seasonal use? `YA-� Stxc-IFt e "Ode �W��E>7 El Yes ® No RA _,rpt2,� ,[1 yttjV2t-10 SEaC'!�' Water meter readings,if available(last 2 years usage(gpd)): — — De II: ZdtZ /2aaalap Ze✓ODD pA usd�.e Sump pump? ❑ Yes JW No Last date of occupancy: Date KJA %Typeof aUlndustrial Flow Conditions: blishment: Design flow(based o 0 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? Yes ❑ No Water meter readings, if available: t5ins•11f10 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is /�q k�� TEA_ (jJ�(p�Z required for every u page. State Zip Code Date of Inspection D. System Information (cont.) f ocMelow): y/use: Date Other(describ General Information Pumping Records: / Source of information: (e;4, /ev) �GNrs atio 1 �f� r/✓ev a�zc Was system pumped as part of the inspection? ] Y1es ❑ No If yes,volume pumped: gallons 1�O� How was quantity pumped determined? Reason for pumping: if U�cLV AR,11 ��rrc� a. AOL��i k Type of System: Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Tide 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address 1,4L/n/ak/5k r Owner Owners Name information is required for every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes Cg No Building Sewer(locate on site plan): Depth below grade: feet Z/ Material of construction: ❑cast iron K40 PVC ❑other(explain): Distance from private water supply well or suction line: feet .er �r✓`e .v cZ�� si ctc ebv►�" Comments(on cdition jomts,yenting,evide ce of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: feet /3-Q✓f �'Lam✓¢✓S kI� f� e n L•� Material of construction: a�y ra "n40 r�fj/Pf d«ess (�concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years � Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No AIJA Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments Property Address Owner Owner's Name information is /le _ a6?2 required for every page. CitYlfown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 264 Scum thickness Distance from top of scum to top of outlet tee or baffle 411 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? ,,,,,� Comments(on pult� 4ecer�%mendations,inlet and o}a�{Ilft�or baffle condition, struora'Tfntegrity, uid levels as relate� outle invert,evid�rt�e f eakage,etc.):2nGy� y.��-ra/) C l o � S hip I ID``�.�Q U" �-2 IJA Grease Trap(locate on site plan): Depth belo rade: feet Material of construction. ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11l10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L�Z�yLcx rL �J Property Address Owner Owner's Nam information is / required for every LLC " '�" D�32 11-11— 3 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Il114 Comments n pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as r to o outlet invert,evidence of leakage, etc.): W1k Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):to Depth blow grade: Material o%con ction: ❑concrete metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: Yes ❑ No Alarm level: Alarm in orking order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41- ";u t-c-c-�2- -zy Property Address M/.trt,tu&JaW S V-t Owner Owners Name �p information is Tj;71LILLL '"l�- ��3 Z t( L l required for every — l 3 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet i v rt OW � f��/�v�1 7 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): lo �s P p Chamber(locate on site plan): Pumps in ing order: El Yes ❑ No Alarms in working or ❑ Yes ❑ No Comments(note condition of pump tuber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS) Iocate on site plan,excavatigin not required): �!X'o bz�L o,+(to Q 04 �jf��j 1 If SAS not located, explain why: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address M a Ll rJOLJ S l-t Owner Owner's Name information is �� -��t�Ltc �- LOZ4 5Z required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits(� " nn 11 number:leaching chambers 64Vzi++ck �`�Y �`'m) number h k � - ry Y ❑ leaching galleries number. Q ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note co ition of soil,signs of ydraulic failure,lev I of po ding,da s I,condition of vegetation,et�.a M� vMj tea: � � a , �•v� \ \• . a . ( \ ,� -. � !/IOG//�—"'._- ,2 : T77 /�� I�/r✓ ,Y�lLS ools(cesspool must be pumped as part of inspection)(locate on site plan): Number and c uration Depth—top of liquid to inle Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14Z(yu-e-rL� Property Address Owner Owner's Name information is t,l�t� W�}- d ZG 3 Z l - l l- l 3 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) /Y/, Co ents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): m p/A R (locate on site plan): Materials of cons rac ion: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic e,level of ponding,condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 14 of 17 r T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 4 2 FiS L-cx Property Address MA,L(n1 OCZ 5V-t Owner Owner's Name information is � &J'Tc�V(c_t� � UZG 7Z 0z&;z,2 required for every n1 �- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: hand-sketch in the area below drawing attached separately I �hl3A�100►,QC`�2 RiflklEi.L� 4 11 3 /9= 2'' ja-3 2, --:2' I J t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address �}�/No�✓sk j Owner Owner's Name information is required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ff/Check Slope EV'Surface water A1/4- heck cellar d`/ Shallow wells / e'' i Estimated depth to high ground water: feet 2C) Please indicate all methods used to determine the high ground water elevation: D6 Obtained from system design plans on record ,, /► / If checked,date of design plan reviewed: Date P ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: /40 ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you establis eded'the high round water eleva 04 Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Rim Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address /1'/&1i1AIS/<I Owner Owner's Name information is /y,�R/ [[e required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E3/1'rispection Summary:A,B, C, D,or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION 44 41—e I2 R U - SEWAGE # U 334 VILLAGE \ �s��\ram_ ASSESSOR'S MAP & LOT U 9- 0AQ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S:oc2 LEACHING FACILITY: (type) o�f.f/ F&/_C. 7"OC • (size) 'NO.OF BEDROOMS b3 ,. BUILDER OR OWNER f--rwts� PERMITDATE: COMPLIANCE DATE: /n �% ✓ : 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 14 _ 13 o A tag, 13-1,4L 3 13 33A is No. Fee THE-COMMONWEALTH OF MA S HUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BA TABLES MASSACHUSETTS Application for ;Diopoml *pgtem Conotructiou Permit Application for a Permit to Construct( )Repair(L4 pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. LA a>�'v� �, � ��) Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1 S V -O3 O Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. MrI ©-Gofa- S>° p-AcL Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 0 gallons per day. Calculated daily flow 3 L�Cf gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank LS'6U W� � Type of S.A.S. 00 S& Cr�CQT4 2Pc&_fkTrcvaRS Description of Soil Nature of Repairs or Alterations(Answer when applicable) W is. n_ Cie o L a-c-q---T-1nC1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described,on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental CAe and not to place the system in operation until a Certifi- cate of Compliance has been ea i. - Signed Date 7 '"o e� Application Approved b Date Application Disapproved for the following reasons Permit No. � Date Issued No. �� t THE COMMONWEALTH OF MA S HUSETTS Entered in computer: L Yes PUBLIC HEALTH DIVISION - TOWN OF BA TABLE, MASSACHUSETTS 01pplication for Wgpo!gal *p.5tem Conotruction Permit Application for a Permit to Construct( )Repair(_ )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. "t-i—VV� LV C "C Owner's Name,Address and Tel.No. Assessor's Map/Parcel $ 03 0 ci0 ll� 1_e_ InstaaAll��er's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. SLR okc Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3� gallons per day. Calculated daily flow 3 u r� 9 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank \SOU Type of S.A.S. k4.!�`n Cr cc,RM Description of Soil sylV Nature of�(Repairs or Alterations(Answer when applicable) , -ot-S-t i/a�\ 1 W S'r 0,( c--F 0` C o f2�__T i L`'Cv a,.,(,,It 1 (,4_ tW 6L--, Sk i)-r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance.with the provisions of Title 5 of the Environmental CAe and not to place the system in operation until a Certifi- cate of Compliance has beelssu�d�by fh eaTtFi- } c Signed - Date. Application Approved b Date ti.f% Application Disapproved for the following reasons Permit No. *' }Date Issued t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded k-IC') Abandoned( )by '� 0-C 14-P E. S E(A kC at ,�- �` d Iw A O G F l,t'rC--f v t has been constructed in accordant with the provisions of Title 5 and the for Disposal System Construction Permit No 055rdated Installer Designer The issuance of this pert shall not be construed as a guarantee that the system will function as designed. Date_ ! Inspector No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigogal *p5tem Construction Permit Permission is hereby granted to Construct( )Repair(`,I Upgra e )Abandon( ) System located at V1�- !F:I- f and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Const uction must be completed within three years of the date of this it. Date: "� r c- Approved r i TOWN OF BARNSTABLE :LOCATION hLec✓t R 4 - SEWAGE # c_ -136 ASSESSOR'S MAP & LOT_ QAQ ;INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f SOC, LEACHING FACILITY: (type) �1,y Fy l_6 .7OL (size) 9 y X ,NO,OF BEDROOMS_ BUILDER OR OWNER t�'rx►�� P.ERMrfDATE: 1'W -75 COMPLIANCE DATE: S:tpaiation Distance Between the: 1 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet `P i-vite Water Supply Well and Leaching Facility (If any wells exist on.site or within 200 feet of leaching facility) Feet Edge-4 Wetland and Leaching Facility(If any wetlands exist ::::within 300 feet of leaching facility) Feet Fuini'shed by i I d 4 � 1 i ,i O i I 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) i i hereby certify that the application for disposal works construction permit signed by me dated "���? , concerning the property located at meets all of the fol wing criteria: • here are no wetlands located within 100 feet of the proposed leaching facility 61./ T There are no private wells within 150 feet of the proposed septic system /There is no increase in flow and/or change in use proposed There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will rapt be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: �q A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) J{O. B)Observed Groundwater Table Elevation(according to Health Division well map) 017 SIGNED: DATE: 2 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert G Cl) • v / Xl< MENU BORTOLOTTI CONSTRUCTION,INC. C9 APR 2 9 1996 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 4WOMMM= 508-771-9399 508-428-8926 FAX: 508428-9399 ffAUHI Pi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 9 ' CERT1 �ION Property Address: /-' ' � 'Jb` 'viAe Date of Inspection: .2 — Inspector's Name: Owner's Name Address: "L- CERTIFICATION'STATEMENT• ' I certify that I have.personally inspected the sewage disposal system at this address'and that.the informa- tion on reported below is true,`accurate and.complete as of the time of inspection. The iction.was per- formed based on my training and,experience in the proper function and maintenance of on-site sewage disposal ems. The System: r" ° Passes Conditionally Passes Needs Further uation B the oral Aproving Authority Fails Inspector's Signature: Date: l The System inspector submit a py of this inspection report to the Approving authority within thin- ty(30)days of completing,this inspection If the system is a shared system or has a desigriflow of 10,000 gpd or greater;them'spector'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 t6 the buyer, if'applicable and the approving authority. INSPECTION SUMMARY-. A)SYST PASSES: ✓✓"I have not found any'information which indicates that the system violates`anyof 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 wiry 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`ieplaced'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 Thee Board of Health): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 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). 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 faili to protect the public health,safety and the environment.. ng , 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 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 hasYa septic tank and soil absorption system and is within 100 Feet to a surface. water supply or tributary to a surface water supply. The''system has a septic tank and soil absorption system and is with a Zone I of apubhc water supply well.. .. , The system has a septic.tank and soil absorption system and is within 50,Feet of,a private;, Jn 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 free,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; t should be contacted to determine what will be necessary,to correct the failure., . due to an overloaded or.clo ed SAS facility or stet�component �f � wa a into fac t Backup o se g y y . or cesspool. Discharge,or ponding of efluent to the surface of the ground or surface waters idue to an a,r, overloaded or clogged SAS or cesspool. 3 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 - or obstructed i more than 4 times in the last year NOT due to clogged Required pumping Y pipe(s). Number of times pumped -2- 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: 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 (IWPA)or.a mapped Zone Il of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 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 following 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. /"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. _.eL'Ihe system does not receive non-sanitary or industrial waste flow. ___j!:�fhe 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 wasIn spected for condition of baffles or tees,material of construction,dimensions,depth"of liquid, epth 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- ry � r 4 3s wy v�}aM p�r1 1'�, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(conlinued) The facility owner( occupants,ants,if different from owner)were provided with information on P the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RF.SIDENTLAI_ Design Flow: gallons Number of Bedrooms: a Number f Current Residents: Garbage Grinder:Q_ Laundry Connected To Systcm: Seasonal Use: Water Meter:Readings, if available: Last Date of Occupancy: COMMERCLAi./iNDIiSTRLAL: 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 ;im i ,c�� ax_16o /g�PUMPING RECORDS and source of informatio is �j S stem Pumped as art of inspection: y P P if yes,vo ne pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy ared System(If yes,n ch previous inspe ion records, if any) Other(explain):_ � S'aX�O,� / CARE qiJ OCier' APPROXIMATE AGE of all components,date installe (if nown)and source of information: Sewage odors detected when arriving at the sire: -4- SUBSURFACE SEWAGE DISPOSAL SVSTF,M INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: /l b Depth below grade: Material of Construction: concrete metal FRP Other (explain) Dimisions: Sludge Depth: Scum Thickness: 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.) GREASE,TRAP: Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other (explain) 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,-condition of alarm and Moat switches;etc.) DISTRIBUTION BOX: -All Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -S- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): b� (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: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields, number,dimensions: Overflow cesspool,number: Comments: (note condition of soil signs of draulic fail re level ponding,condition of vegetation etc. S (o'� � -S ii yL g O v CESSPOOLS: 1/ , Number and.configuration:Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions,of Cesspool: Materials of construction:, "Ulndication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs 1 draulic fail u , le of pondin ,conditio i of v getalion,etc S PRIVY: Materials Ofconstruction: _ Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - 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. t 0 f4c, DEPTH TO GROUNDWATER: Depth to groundwater: % 41 Feet Method of Dete 'nation or Approximation:!'©�'�f�lll' � l,/'�/!1 lit ✓, �a r raq .s - 7-