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Home My WebLink About0082 HAWSER BEND - Health .82 Hawser Bend Centerville A = 192 - 090 I III I S01 110 R UPC 12534 y No.21. 53LORg�,�, YAiTIMpi.Yy \ G CP C� : i*Fa c� B.ORTOLOTTI CONSTRUCTION, INC. , 45 INDUSTRY ROAD,MARSTONS MILLS, MA 02648 508-771=9399 508-428-8926 FAX: 508-428-9399 7` 4,-! . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date Of Inspection 21 S'/ Inspector's Name: Owner's Name and 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 perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.TV system:. to Passes Conditionally es Needs Fur er valu io y the Local Approving Authority Inspector's Signature Date: /q/ The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (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.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) SYSTE PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303: Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not. determined",explain why not The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is clue 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 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping.more than four times a year due to broken or obstructed pipe(s). The System will pass.inspection if(with.approval of The Board Of Health): Broken pipe(s)are replaced Obstruction is removed.-- C)FURTHER EVALUATION.IS REQUIRED.BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board Of.Health in order to determine if the System.is failing to protect the Public Health,Safety and the Environment. 1.)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE SYSTEM IS NOT.FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy is within 50 Feet of a Surface Water Cesspool.or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh_. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC.WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNC.TION- ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system.has a Septic Tank and Soil Absorption.System and is within 100 Feet to a Surface Water Supply or Tributary to a Surface Water Supply. The System.has.a Septic Tank.and Soil Absorption System and is with a Zone 1 of a Public Water Supply Well.. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and is less than 100 Feet but 50 Feet or more from a Private Water Supply Well,unless a Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the facility and the presence of ammonia'nitrogen and nitrate nitrogen is equal to or less than 5 PPm•, D)SYSTEM FAILS: I have determined that the System violates one or more.of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to vorrect the failure. Backup.of sewage into facility or system_ component due to an overload or clogged SAS or cesspool... Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or.clog- ged SAS or cesspool. Ligyid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day.flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped - 2 - TOWN OF BARNSTABLE LOCATION �/ a sL'S�/It/J� vim' _ SEWAGE # VILLAGE p221 �� ASSESSOR'S MAP & LOT 106PELTOR - NAME&PHONE NO.Q&M &6 � , SEPTIC TANK CAPACITY /^UC� / .C,_%LZ/ �' LEACHING FACILITY: (type) I'1 (� � (size) /000 e?Z� NO.OF BEDROOMS BUILDER 0 OWNER / -� PERMITDATE:�� /5 COMPLIANCE DATE: Pla?91W 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 aCi' �- ------ -- -- - -�7 1J07 A d 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 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 copyof 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 ggd 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 1I.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 315 CMR 5.00 and 6.00. Please consult the local regional office.of the Department for further information. SUBSURFACE SEWAGE DISPOSAL .SYSTEM INSPECTION FORM PART B CHECKLIST .Check if.the 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 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. IRAs-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.. - pl-The system does not receive non-sanitary or industrial.waste flow. Jk--'The.site was inspected for signs of.breakout. All system components,excluding the Soil Absorption System,have been located on site. J,-"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:, depth 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 b non-intrusive methods.. _.. PP Y - 3 - a SUBSURFACE. SEWAGE .DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) V The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL Design Flow:a';V gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder . Laundry Connected To System: Seasonal Use: Water Meter Readings,if ailable: Last Date of Occupancy COMMERCIALANDUSTRIAL: Type of Establishment: Design Flow gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank.Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter:Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS.any source of information: System Pumped as part of inspection:, ) -ryes�e pumped: gallons Reason for Pumping: . TYPE¢F SYSTEM: :.. eptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): ARPROXIMATE AGE;of all components,date installed.(if known) and.source,of information: O z /roe `� Sewage odors detected when arriving at the site:/ -4- , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) (p�/ SEPTIC"TANK:0 Cata. 2=)it Depth below grade. Material of Construction: f/ concrete metal FRP Other (explain) . Dimensions: ,Y ' Sludge Depth:' 1�_ 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,conditioin of inlet and outlet tees or baffles,depth of liquid level in relation to outiponvert,structural integrity,evidence of leakage tc ' 4: q 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 float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: �1I� -�° Comments: (note if level and distribution is equal,evide a of solids carryover,evidencS of leakage into or out of b x,etc. ,� � PUMP CHAMBER Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) - 5 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS):. (Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive methods). If not determined to be present,explain: Type Leaching pits,number: Leaching chambers,number: Leaching galleries' number: Leacahing trenches,number,:length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note conidtion of soil,signs of hydraulic failur level of ponding,condition of egetation,etc.)_ V IF CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:. Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped,as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) ' PRIVY Mater� s of construction: Dimensions: Depth of Solids: Comments: (note condition of.soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) , - 6 - I 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. -1 ..... ..... r, l/ a r 0 O �f DEPTH TO GROUNDWATER: i Depth to groundwater: Feet e Meth d ofmnatonrA rox atioen':/ p v�/�/�'�/ .L`!" i •J� �1a /` r ; - 7 - No........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF ALTI—I /... OF. - "... ... ........ ...................... _.-- Appliratiou for Uispniia Workii mitrurtiun ramit Application is hereby made for a Permit to Construct ( or Re air ( ) Individual Sewage Disposal syst at _"�_ � Z.._.L. a.J.---_.... . .................. ........................................................... ocation-Address or Lot No. ... .._ A.._ ......... .. .............................. ..........•----........... .................................................... Ow Address Wrli?�t+ .............................................................................................•-•-- Installer Address PQ T2' ' of Buildin rr Size Lot............................Sq.� xl U Dwellingl- o. of Bedrooms...........��...................Expansion Attic ( ) Garbage Grinder (( per, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ................ ................ . W Design Flow............ .............gallons per person per day. Total daily flow-----. ,._Z.d...............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........ .__..._.. otaH ch" g area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �,1 Test Results Performed by--•••-------------•----•--••--------------•------•---.......--•------u-_-�----......-•------•-----------•-------- Percolarion Te aTest 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___________..__---_____. ---•--- O Description of Soil....- �� :[ -� ' - -.-. ------- _ -- - -- J` ... ..... U -------------------------- ------•- a-•G .`.-...... 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 TITLE, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ',,__�igned...................................................................................... ................................ Date Application Approved BY - •-----... ..... -•------------------••--........---------.. ..I� -----;1 -7 Date Application Disapproved for the following reasons:---•--....--••----------•••--•---••--------••-•-•--•---•------•----------•--•-•-•-----•-•-•-••...............••- .........................................................-............................................................................................................................................... Date Permit No......................................................... Issued.... C y Date r „"�_ 1 � 38 i 4S� 1 L-0 C A T f0N SEW G E PERMIT N0. . _ PILLAGE ��iTc✓i//e I N S T A LLER'S NAME i ADDRESS �V IUILDEIII OR OWNER GATE PERMIT ISSUED DATE COMPLIANCE ISSUED I�_ a 9- 79. N,W � r �41q��o � y , '1 ,K f vTd?e F THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ALTH ------------- LOF;_ ,�pplirFa#ion for Dispaii a Works Cn ttstrnrtwit t1rrrittt Application is hereby made for a Permit to Construct ( or Repair ( ) Individual Sewage Disposal Syst atlot ocation-Address or Lot No. A... .......... .................... ..........-•--------••••-•••••-••--•••---••-•--- ----•---------_.....-•---•--•---................ W Address a ,�. y ...._. _.;----••--•-•- =------------------•--•--•-•-••-_.. ....--••-•------••------------•--•-••------....... Installer Address T e of Building Size Lot____________________________Sq. f, Dwelling o. of Bedrooms.•---•------ ; ..................... Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ......................................................................... Design Flow............... __' ..............gallons per person per day. Total daily flow_.____ ,. .0 ...............gallons. Septic Tank—Liquid'capacity_______.____gallons Length................ Width................ Diameter................ Depth........:....... W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------------_------- Diameter.............._..... Depth below inlet....... Zotapeachu'lg area.__.._._____......sq. ft. Other Distribution box ( ) Dosing tankaPercolation Test Results Performed b ----•-----•-------•...............•-----•---...-------.._._..---•--•-•-• -----•- W y to Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x . . ... D Description of Soil '.".* :. ..`" ._ .. .. _... -•------------------�----�'� ----...../ - d`Q1 V t ---------------------------------------------------- ------------------------------------.................................. W VNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igned.................................... ................................. ................................. Date Application Approved BY - '. ..-- -•-•- / '-- -- -*--• X Date Application Disapproved for the following reasons------------------------------------------------------------------------........................................ --------------•--•----•--------•---------•---••-----••----------.._...-•-------•-•-•---------•--•---•-----•-•--•--•---------------•-•--•••--•---••-••------••-••--•------••-----••---•-----•---......_.. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD QJF7 HEALTH ......OF....... :. - '..�. .... ................................_._. TrrtifiraU of Totttph anrr IS IS TO CE I Y, a the Individual Sewage Disposal System constructed ( 11"'or Repaired Installer atr .._.. --- -•----• ------- ---•-_-- --------- -- •------ ___ has bee ,installed in accordance w t provisions of r of The State Sanitary Code as described in the application for Disposal Works Construction Permit N _____ ______ ___1- -_______ dated_-_-/a-_rr_/.g�_.�__ ---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE TH T THE,, SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector........-------•----------------------............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ....L ..'!."' �'.5.......OF....... , ............................................. ,,�•� �, N ...................... FEE._ . at Works ' n ion rrmff Permission ereby gr ted ............. to Construc or r.- an Individual a Dls osal stem treet as shown on the application for Disposal Works Construction Permit ,_.. ___ Dated_.: __. •"- Bo DATE................................................................................ ard of Health .. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS