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HomeMy WebLinkAbout0189 STRAWBERRY HILL ROAD - Health 189 STRAWBERRY HILL RD, UVILLE A= 247 207 i llll���Ct UPC 12543 No R HASTINGS, MN e �x .l FEE No. --� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 3 TOVIV OF &4-R-1 c-M PG E APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Appl cation fora Permit to Construct ( )-Repair ( Upgrade (V�Abandon ( ) - ❑Complete System XIndividual Components Z1 _ `LL j.9i✓�f//E .�?AE/CE�/TURY 7CENTEtpV%CGE) LMA�'24�'LD T 20l 2 Z J Si�T�W /ner'sjame PGyrIDaN Map/Parcel# Address - 0925 te[/�,,Lot# Telephone# All, F-tC7-Q6 COGYST� c - Installer's Name P,D f30X /742 emu/ c��9,/y,4,G6 D ZY76 � q ' p��¢�e� A +�/� �so��✓Q 9dres6 1O/ �44Cii IY7a /y7'` Telephone# Type of Building: 5_F I Y, Lot Size , 384 Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required)_s•330 gpd Calculated design flow_330 gpd Design flow provided�L gpd Plan: Date JZ—/3- 008 Number of sheets Revision Date Title Slro F_ SEPT/C J&4,f- 9 Description of Soil(s) L OOSE C&MR946 46149 Soil Evaluator Form No. 101008 Name of Soil Evaluator S. /'EESE Date of Evaluation .12-12-0 8 DESCRIPTION OF REPAIRS OR ALTERATIONS /QEPC•4CE FAIL,FD P/T ram// JVEw S.,4,S — EPI- f GE E4----L ES /N EXisr /DOD 6Al r4mt/!t� w/ pyC 15,4y1rA-ky TEES oA The undersigned agrees to install the ab Fj 'vidual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a s not to plac e s 'I a Certificate of Compliance has been issued by a Board of Health. Signed D � u FE Hjr 9 r.; 8 TERM "i A R4A ti FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 NO. THE((COMMONWEALTH OF MASSACHUSE47s�T,W c 3,- FEE BOARD OF HEALTH APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair 46 Upgrade'(/ Abandon"( ) - ❑Complete System RIndividual Components &/2 F SM s GU E" Y !L l tp D fX/V .SAE" 11W1V 7Z X Y 71 Location Owner's Name lr Wj e F) ,AW ?W71 Or RO!7 2 2 9% .ST.4riE 81 11 mil,1WI7/ Map/Parcel# Address Lot# Telephone,# w Installer's Namea;cneli��Ii�t t w 8 013Dx �176 w. w.4&CoY4,19, 2s-7,,6 vVvV�Ri�iZYI!! 11 f f� fares �s XQ Q0 Telephone# Telephone# ' Type of Building: vrOE& Lot Size //. 384 .,-Srcj •feet r Dwelling—No.of Bedrooms Garbage Grinder ( )'* Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) '�36 gpd Calculated design flow gpd Design flow provided, �gpd Plan: Date 7`- Ig• 'e28 Number of sheets _ Revision Date Title S6l y- Sy t+ Description of Soil(s) L 005Z-" COARSE .54AO Soil Evaluator_Form No. 121208 Name of Soil Evaluator Date of Evaluation y 7bESCRIPTION OF-REPAIRS OR ALTERATIONS Pl4 C _ FA Lf'D G The undersigned agrees to install the a 11510ries idual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a s not to placg- e o trip I a Certificate of Compliance has been issued by the Board of Health. r� n Signed ! (o D e _ inspections ' E FORMA - APPLICATION-FOR DSCP DEP APPROVED FORM 5/96 No. ( 1 TIAE COM O WEALTH OF MASSACHUSETTS FEE 1 �t #�- a BOARD OF HEALTH ,� r CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Components) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: _ C Tr_ C - L,X• d e_70. at ( S' T+e 2 J a !.c, , has been installed in accordance with the provisions of 310 CM 15.00 (Title 5) and the approved desigj=t p ns/as-built plans relating t applic"tion No. dated A Approved Design Flow (gpd) 1 Installer Al d, Designer: Inspector i! _ i Yl t D. / The issuance of this certificate shall not be construed as a guarantee that the system-will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP `APPROVED FORM 5/96 _ -,---___ _- __ ___ � + __ __._.- - _,__- ___--- ..,,_-_-_,_.._- r No.o—��11 THE COMMONWEALTH OF MASSACHUSETTS FEE �� BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ) Repair ( ) Upgrade Abandon ( ) an individual sewage disposal system at � ZZ a 4 tl as described in the application for Disposal System Construction Pe it No. OOeF dated /� . Provided: Construction shall be completed within three years of the date of this permit.All.'local co ditions must Re met. Date 8100 Board of Health;;1;/1- I ✓-7/; ,%I FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARRENrM PUBLISHERS- BOSTON'', DEC. 18.2008 10:43AM BARNSTABLE BOARD OF HEALTH NO.825 P. 1i1 c 4 Town of Barnstable , optHe to,,, Regulatory Services ,STY yq, Thomas F. Geiler,Director BARN81'ABM Public Health Division XAM sa�9' Thomas McKean,Director �EOMAaa 200 Main Street, Hyannis,MA 02601 office: 508-962.4644 Fax: 508-790-6304 Date: /4?-/9- '08 Sewage Permit#2bd Assessor's Map/Parcel Installer & Designer Certif catign.Form Designer: R, 0/�'��� i�.S, Installer: Address: � NNOGy EESG �/ Address: !( L 23 G& IeSA1161 64, n`2"6ST6- 71fJ -, Wv Gr(!/�� �il.�Gf•� OZ 22 025�,6 On ' I8' Q� D.14, F4:6ZYrwas issued a permit to install a (date) (installer) septic system at based on a design drawn by (address) RIC P, 0 dated (designer) ✓ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & ,oL 9W. an revision or certified as-built by designer to follow, Stripout (if ir p. : . and the soils ere fo d satisfacto ,`ill OF / RICHARD R. sa S O'KEEF.E I (Instal s Signature) NO. 469 AM� (Desi ?IT e) r (Affix Designer's Stamp Here) PL ASE TUO STABLE PUBLIC PIEA.LTH DI ISION. CERTIFICATE ", OF CO L CE W NOT $ I SUED UNTIL BOTH THIS FORKD AS, BUILT CARD ARE EIVED BY THE BAI2NSTABLE PUBLIC DEALT DIVISION. THANK YOU. q:\offiee forms\designerceitification form.doe r HIGH GROUND-WATER LEVEL COMPUTATION Date: Site Location: /89 11_rR4W9eAKVf/1LL 190 Permit: C�NTE�li/GL E Owner: /AfAlN/E eeAlrORY 2' Phone: rSQT)763- 38,54 Contractor: fj,y, FLET�&" WAIST, Phone: 6S08)3-09- 45 Notes: 0 NO? EeVCdlllV TERED 14 STEP 1 Measure depth to water table to nearest 1 10 ft. (depth is in feet below land surface) Date: /2/2Q� t0 mm/dd/yy feet below Is STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well B) Water-level range zone (. STEP 3 Using monthly "Current Water Resources Conditions" determine current depth to water , level for index well. mm/yy STEP 4 Using Table of Potential Water Level Rise for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level �� ' adjustment. 0 STEP S Estimate depth to high water by subtracting the �' 9 water-level adjustment (STEP 4) from p measured depth to water level at site (STEP 1). NOTE* Tables 1-9 "Potential Water-Level Rise" are attached as worksheets to this file. monthly index well data: www.capecodcommission.org/wells.html t Potential water-level rise, in feet, for use with Table 5 index well Mashpee MIW-29 WATER LEVEL ZONE A ZONE B ZONE C ZONE D 5.7 0 0 0 0 5.8 0.1 0.1 0.1 0.2 5.9 0.1 0.2 0.3 0.3 6 0.2 0.3 0.4 0.5 6.1 0.3 0.4 0.5 0.7 6.2 0.3 0.5 0.7 0.8 6.3 0.4 0.6 0.8 1 6.4 0.5 0.7 0.9 1.2 6.5 0.5 0.8 1.1 1.3 6.6 0.6 0.9 1.2 1.5 6.7 0.7 1 1.3 1.7 6.8 0.7 1.1 1.5 1.8 6.9 0.8 1.2 1.6 2 7 0.9 1.3 1.7 2.2 7.1 0.9 1.4 1.9 2.3 7.2 1 1.5 2 2.4 7.3 1.1 1.6 2.1 2.7 7.4 1.1 1.7 2.3 2.8 7.5 1.2 1.8 2.4 3 7.6 1.3 1.9 2.5 3.2 7.7 1.3 2 2.7 3.3 7.8 1.4 2.1 2.8 3.5 7.9 1.5 2.2 2.9 3.7 8 1.5 2.3 3.1 3.8 8.1 1.6 2.4 3.2 4 8.2 1.7 2.5 3.3 4.2 8.3 1.7 2.6 3.5 4.3 8.4 1.8 2.7 3.6 4.5 8.5 1.9 2.8 3.7 4.7 8.6 1.9 2.9 3.9 4.8 8.7 2 3 4 5 8.8 2.1 3.1 4.1 5.2 8.9 2.1 3.2 4.3 5.3 9 2.2 3.3 4.4 5.5 9.1 2.3 3.4 4.5 5.7 9.2 2.3 3.5 4.7 5.8 .9.3 2.4 3.6 4.8 6 9.4 2.5 3.7 4.9 6.2 9.5 2.5 3.8 5.1 6.3 9.6 2.6 3.9 5.2 6.5 9.7 2.7 4 5.3 6.7 9.8 2.7 4.1 5.5 6.8 9.9 2.8 4.2 5.6 7 10 2.9 4.3 5.7 7.2 10.1 2.9 4.4 5.9 7.3 r 10.2 3 4.5 6 7.5 10.3 3.1 4.6 6.1 7.7 10.4 3.1 4.7 6.3 7.8 10.5 3.2 4.8 6.4 8 10.6 3.3 4.9 6.5 8.2 10.7 3.3 5 6.7 8.3 10.8 3.4 5-. 6.8 8.5 10.9 3.5 5.2 6.9.. 8.7 11 3.5 5.3 7.1 8.8 11.1 3.6 5.4 7.2 9 11.2 3.7 5.5 7.3 9.2 11.3 3.7 5.6 7.5 9.3 11.4 3.8 5.7 7.6 9.5 11.5 3.9 5.8 7.7 9.7 11.6 3.9 5.9 7.9 9.8 11.7 4 6 8 10 11.8 4.1 6.1 8.1 10.2 11.9 4.1 6.2 8.3 10.3 12 4.2 6.3 8.4 10.5 12,1 4.3 6.4 8.5 10.7 12.2 4.3 6.5 8.7 10.8 12.3 4.4 6.6 8.8 11 12.4 4.5 6.7 8.9 11.2 12.5 4.5 6.8 9.1 11.3 12.6 4,6 6.9 9.2 11.5 12.7 4.7 7 9.3 11.7 12.8 4.7 7.1 9.5 11.8 12.9 4.8 7.2 9.6 12 13 4.9 7.3 9.7 12.2 13.1 4.9 7.4 9.9 12.3 13.2 5 7.5 10 12.5 13.3 5.1 7.6 10.1 12.7 13.4 5.1 7.7 10.3 12.8 13.5 5.2 7.8 10.4 13 13.6 5.3 7.9 10.5 13.2 13.7 5.3 8 10.7 13.3 13.8 5.4 8.1 10.8 13.5 13.9 5.5 8.2 10.9 13.7 441 5.5 8.3 i 11 1;., 13.8 14.1 5.6 8.4 11.2 14 14.2 5.7 8.5 11.3 14.2 14.3 5.7 8.6 11.5 14.3 14.4 5.8 8.7 11.6 14.5 14.5 5.9 8.8 11.7 14.7 14.6 5.9 8.9 11.9 14.8 14.7 6 9 12 15 14.8 6.61 9.1 12.1 15.2 14.9 6.1 9.2 12.3 15.3 15 6.2 9.3 12.4 15.5 1 15.1 6.3 9.4 12.5 15.7 Cape Cod Commission: USGS Well Data-November 2008 Page 1 of 2 w United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties,the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey(USGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001: Estimation of High Groundwater Levels for Construction and Land use Planning to predict high groundwater levels. For your convenience,we've also provided links to USGS national and state data. See the last column in the table and the footnotes below. To see what's happening in real time at a separate well in Brewster,visit the USGS site: USGS 414630070014901 MA-BMW 22 BREWSTER, MA. For further information about any of the data or links on this page,please contact Hydrologist Gabrielle Belfit at the Commission offices (508-362-3828). November 2008 3--62-3026 Departure from USGS Site Number**** Location Well No. Water Record Record (Average" links to USGS national Level* High* Low* Monthly g Overall water-level database) Barnstable 230 24.6 20.5 26.6 -0.1 -0.9 413956070164301 Barnstable 24w 25.0 20.5 28.6 0.1 -0.6 414154070165001 Brewster BMW 21 10.4 6.9 13.6 0.2 -0.3 414518070020301 Chatham CGW138 25.4 20.9 26.6 -0.8 -1.5 414100070011101 Maslipee MIW 29 9.0 5.6 10.0 0.2 -0.5 413525070291904 Sandwich ZDw 47.4 45.8 48.2 0.1 IEHI 414418070241601 Sandwich SDW 50.3 45.8 55,1 0.4 -0.2 414124070265901 �00 Truro TSW 89 12.2 10.2 13.0 0.1 -0.2 420206070045901 Wellfleet WNW 17 11.9 7.3 12.8 -0.8 -1.5 415353069585401 CONDITIONS- Cap qIQ,.neVW@iweos.h 12/11/2008 ovember 2008 Page 2 of 2 Techical Bulletin 92-001 Page 1 of 2 1 y^e � -Cape C nunnr CunlnnM , Ki ]VON. 1.=' 4 i Home .. ESTIMATING HIGH GROUNDWATER LEVELS Contact Us Online Resources for Estimating High About the Team Groundwater Levels on Cape Cod Mission Team Members The following files are available to download to be used in Groundwater Education conjunction with Cape Cod Commission Technical Bulletin 92-001. Water Festivals Publications "Estimation of High Ground-water Levels for Construction and Helpful Links Land Use Planning-A Cape Cod, MAssachusetts, Example- Update Water Conservation 1991, Revised 2006." Project TOUR The estimating technique described in this bulletin is specified as Water Recycle an acceptable method of determining the maximum rise of Stormwater groundwater levels in a given location on Cape Cod according to Project Storm the State of Massachusetts Sanitary Code(Title 5). Raindrop Journey Pollution Solutions Downloads are available using Adobe Acrobat Stormwater Links Don't have Adobe? click here to download Drinking Water Supplies Ponds & Estuaries Technical Bulletin 92-001 (Complete) Pond &Lake Stewardship Technical Bulletin 92-001 (Text Only) Program PALS)_ Massachusetts Tables for Potential Water Level Rise(9 tables) Estuaries Program MEP Worksheet for High Groundwater Levels Computations Wastewater Planning Current Activities State of Massachusetts Sanitary Code Wastewater Committees Individual Town Maps (NEW!) With Annual ranges of Groundwater Levels and Index -well Areas Barnstablel Bournel BrewsterI Chathaml Easthaml Dennisl Falmouth I Harwich I Mashoee I Orleans I Provincetown I Sandwich l Truro I Wellfleet I Yarmouth Please note that the key to the maps differs slightly from older maps as follows: ZonelAnnual range 0.0-1.99 feet ©2.0-2.99 feet ' ©3.0-3.99 feet D[� .0-4.99 feet ®5.0-6.0 Feet http://www.capecodgroundwater.org/flighGroundwater.htrnl 12/11/2008 j r � ® f,. � `- _ r J.t10 3] F• ( v�� �Y J.(10-J.'J9�a spa i •�,�► '.� T� ,� e. ,a �.aa,i.99 •I �� � �' f4'�' � i�A•R'. �'�' "I• '. +1� _�.6�1 w s • •� J. 0-J.9'J F, I � �_ - �'�.. ...., •�'41 �l•�Y� �� � w���O6`i�`� � • 0"2.9+ � � � ,,. . _r' . �� . .,r��"'�;1/�y' � tsr� _ f; �,. � ., s .�, ��� ® �`��s+yg.�y+.�w.✓,,�•a•����®�1 Ilf� �. '` [.h11=9 F-e o3 -.79 .! ��7,•'/� .l`l% '�(if�R'4'�l 'Y11 MIND r I ' �- _ •. cel , ` I I M-FINAS TOWN OF BARNSTABLE ^ LOCATION AWes! 1(L WAGE# V VILLAGE '� 1 G LZ7 ASSESSOR'S MAP&PARCEL 1� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �� [�(� 50974W 1 � LEACHING FACILITY:(type) (size) �� 2 NO.OF BEDROOMS 3 OWNER rc 6 PERMIT DATE: 20 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 7 I O ` Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) hl D U.9 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within x'x 300 feet of le Jfacili V O V eet FURNISHED BY F rep 0 kJOIL P, •rfr� � .. V ,� �Zr � fS, , Q ✓ � 2�-` 8-321, 3 3� TOWN OF BARNSTABLE LOCATION l ff 5 f ylll��j�'I"�^ y �i r�l� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT ' INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /®®O ja'/ LEACHING FACILITY:(type) (size) NO. OF BEDROOMS 2 PRIVATE WELL OR P �WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VAR ANCE GRANTED: Yes No 4 r .y TOWN OF BARNSTABLE L('-^..ATION�� S w SEWAGE # (... ; VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ulU NO:OF BEDROOMS PRIVATE WELL 7RPULIC R BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 ''� C� �E c�eG ��\ \ N � � �i �S'� i Town of Barnstable P# G gyp'' Department of Regulatory Services ' a Public Health Division Dt ' + tuxxer,►et,�, � e MASS •t639.. 200 Main Street,Hyannis MA 02601 - SEC All Date Scheduled ��/ Time Fee Pd. MT) Soil Suitability. Assessment for Sewage D s osal o Performed By:5,4AIoy AnE F- eEg!�Se Witnessed By: 1 00eNkg kM f LOCATION& GENERAL INFORMATION Location Address c18 ul Owner's Name 64j(/^//E.-A E 9 cSTiP•q (jERR�Y H/LL � 9 CENT.2/ Address 2277 S7,47_6rRD SviTEK R<Y,V6V ZfI AM 02 J6 0 As Map/Parcel: __gf47 Engineer's Name 23 GOOh-,yam/CC CA •eaeAo4e,-',YTFAV NEW CONSTRUCTION REPAIR Telephone# 0.6770 Land Use 1QE5 6062171AL Slopes(R'o)_ 0-3 Surface Stones //ONE Distances from: Open Water Body 500 t ft Possible Wet Area S�ft Drinking Water Well ft Drainage Way ft Property Line g y P rtY 2J`- ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) N Lo to pa ii:3 t E> A CED Ahl IF ti h 02 100.33 Parent material(geologic) OUcS// Depth to Bedrock Depth to Groundwater. Standing Water in Hole:/tiOTENcLl 14 Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: i Depth Observed standing in obs.hole: 1'�INOT� EIV in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well 01Reading Date:/1-19,8 Index Well level Adi,factor ee. Adj.Groundwater Level-&,9� PERCOLATION TEST We Thne._m�._ Observation Hole# �/ - _ Time at Depth of Perc �' _6�p y Time at 6" Start Pre-soak Time Time(9"-6") Im n End Pre-soak / •Z 3 Rate Min./Inch oe rn,ly. Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\.SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.), (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% ravel a 0 3 Z �I ' S. 2,s DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon ' Soil Texture Soil Color Soil Other Surface'(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling „ (Structure,Stones,Boulders. Consistency. o Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistency. Flood Insurance Rate Mau: Above 500 year flood boundary No_ Yes . Within 500 year_boundary No Yes,:,.� Within 100 year flood boundary No— Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ES If not,what is the depth of naturally occurring pervious material?------- Certification 01 I certify that on _.40•Q�r (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required.t ' ing,ex ertise and experience described in 310 CMR 15.017. Signature o Date Q:WEVn(-VERCPORM.DOC � Q • s ' `� • eq Oi'A � ` �r BORTOLOTTI CONSTRUCTION, INC. Rep Y 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 508-771-9399, 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date of Inspection: I 1 Inspector e: / 9 9wlter's Name d Address: �EgTIFICATION STATEMFNTo 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 stems. The System: Passes Conditionally Passes Needs Further Ev on oval Aproving Authorit`� Fails Inspector's Signature: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design now of 10,00o 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: �V1 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 exfilration,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 - .� r _ , 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 ii 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 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 LS 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 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 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 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 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 or cesspool Discharge or ponding of efluent 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. Liquid depth in cesspool is less than G"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- h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continue(l) 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 coli.form 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 II 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 tie following have been done: _L/Pumping information was requested of the owner,occupant,and Board of Health. __done 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. V Zbuilt 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. _L�LAII system components;exclu' ding'the Soil Absorption`System, have been located on site. he septic tank manholes were uncovered,opened;and the interior of the septic tank was in- 'spected foi condition of baffles or tees,material of constriction,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 by non-intrusive methods. -3- ` P ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) 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 RVISIDENTI -z Design Flow:1'js Ions Number of Bedrooms: & Nun ber of Current Residents:z)ae_f Garbage Grinder Laundry Connected To System: Seasonal Use: Water Meter Rea , ' ailable: Last Date,of Occupancy / �1�°Ia;Dl p Type of Establishment: Design Flow: aalIons/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: i GENERA FORMATION PUMPING RECORDS and source of information: Cyst �o System Pumped as part of inspection: �C) If yes,volume pumped: sallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System . Single Cesspool Overflow Cesspool Privy hared System(If yes,attach previous inspection records, if any) Other(explain): �� _�,�(/ AP OXIMATEAGE of all components,date installed(if known)and source..of information:. Sewage odors detect when amving at th site: 4�0 -4- �s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grader Material of Construction: concrete metal FRP Other (explain) X / Slud a De the z Dimisions: g p Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 3 Distance from bottom of scum to bottom of outlet tee or baffle: lelae e " Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, aural integrity, evidence of a etc.) /060 i1 ✓ oe 641- GREASE TRAP: Depth Below Grade: Material of Constnuction: concrete metal MP Other (explain) -- Dimensions: Scum Thickness: �. Distance from top of scum to top of outlet tee or baffle: r Comments: (recommendation for pumping,condition of inlet and outlet tees oubaffles,depth of liquid r° level in relation to outlet invert,.structural integrity,evidence of leakage; etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:,concrete_meial_FRP_Otiter(explain) Dimensions: Capacitv: gallons Design Flo«: l;allons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and Iloat switches, etc.) DISTRIBUTION BOX: 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: . z Pump is in working order: Comments: (note condition of pump chamber,condition of punips.and appurtenances, etc.)" i *g,-s A "r.- 'AA I', SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): Ll (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,numbw Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Co ts:(note condition of soil, igns of hydraulic failure level o )nding,condition of vegetation, etc.) 17 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 soilk,signs of hydraulic failure, level of ponding,condition of vege(ation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) ... _ ........�..._...... __ .... .... .... ...�..,..-...,.......r.........»..,... .... . .. .Ate. ..a -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. �3 DEPTH TO GROUNDWATER: Depth to groundwater:_ Z/ Feet Method of Determination or Approxii "WYk,a' '" 10or Z!, N BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop ley 6-4— 10 Date of Inspec}� Map arce Own CV r� PART A — CHECKLIST c- CHECK IF THE FOLLOWING HAVE BEEN DONE: ' 'l9 LIMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. d7 /NONE//• OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM CO RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTR TV jTHE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. t1 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. BALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. ,. -`HE 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. //fHE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. v/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 p� No of Bedrooms � No of Current Residents YW Garbage Grinder Laundry Connected to System Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: GALLONS Pumpi g Records and Source of Information: s f O SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS Reason for Pumping: TYPE OF SYSTEM: Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes,/attach previous inspection records, if any) Other(explain)`�Y"'G 'ZYI.2 G�rl� Sl`�S Appr Amate age of all components. Date installed,if known. Source of information. StIg k - SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below grade:/^�// Dimensions: p , lV3 0 Material of construction: Concrete Metal FRP Other} Sludge Depth Distance from top of sludge to bottom of outlet tee or baffle �y , Scum Thickness / Distance from Top of cum to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle Commen �_ 5 � D ng I` ,Sod G ay4 .. / cV w —: /�£cccr►�atic .d0 j7U✓✓)n v.r� pG 7�+'6- -s L+-Vl DISTRIBUTION BOX: Q DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: PUMP CHAMBER: Pum s in working order? Comments: SOIL ABSORPTION SYSTEM—(SAS): IF NOT PRESENT,EXPLAIN: TYPE: - OOD 101) 01,e -(,O,S14 ' Comments: S OOO 4L CESSPOOLS: Number and configuration U s Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Materials of construction Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' OF � � 2� � S'I o a� DEPTH TO GROUNDWATER: y DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION:lit. W S. � � ©/-l" _7-yl , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.) Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? \ Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Al Within a Zone I of a public well? /1/ Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508)771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SrrE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: V I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY /C 5YSTEW1 PROFILE - R STD RTE' 2 NOT M 50.4,4E FIN/6 GIYADE OYER Z EA CH C/-14W' �/%5 9� � F/N/Sf/ GiP,/OE OVER SEPTIC T.INA-= 39.39 ' FIN/SH GRApE OVER WEST � � � '�9iiV ST • ... .. RISERS TO W l TN/N r : W `O ' BOX = -�O, 0 5T Q.•A,' 6 GRADE . p �� � � PINE �9' •. ..• �• F/N/SH 9,V,4Pc- A - 38. OV �� � f3U/,GD RISER TO G1P•90� rV3 9 75' 7 Pz/,/D FOR //S�'-o zEyes FOR PE.�STONE � /9 S' Ot35ER V�4 T/O/Y pOR T � OR F//-T,� . ,� n n n o n n n IGAA . ; 3Zg9 V r, . 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