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Home My WebLink About0017 SYLVIA LANE - Health 17 Sylvia Ln. , Centerville — A = 189 082 No. 42101/3 ORA ESSELTIE 10% (a 0 0 0 0 a °F� life '4„ 609 b' , BORTOLOTTI CONSTRUCTION,1_NC. � 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: ' Date of Inspection: Inspector's me: ; Owne 's Nam and.Address CERTIIICATION STAT M NT- 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 systems. The System: Passes Conditionally Passes Needs Further Ev ation tl Local Aproving Authority Fails Inspector's.Signature: Date: 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 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. INSPECTIONSUMMARY: A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The System will pass inspection if(with approval of The Board of Health): - 1 _ t' 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 Llealth): 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 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 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) TEM FAILS: 7fhave 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 sho be contacted to determine what will be necessary to correct the failure. ed BackuP of sewage into facility or system component due to an overloaded or clogged SAS , o ces spool. ss 1. 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 6"below invert or available volume is less than 1/2 day flow. 4 Required pumping more than 4 limes in the last year rLOT due to clogged or obstructed pipe(s). Number of times pumped -2- I .h 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 11 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 a 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 volunies of water have not been introduced into the system recently or as part of this inspection. / s-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. r/ he system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout: All system components,excluding the Soil Absorption System,have been located on site. _z/'I'he 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, nth of sludge,depth of scum. 1/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- )' I • ► SYSTEM INSPECTION FORM SUBSURFACE SEWAGE DISPOSAL S S PART B CHECKLIST(conlinucd) Th/e facility owner and occupants, if different from owner)were provided with information on V h' ( p , the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow:_ gallons Number of Bedroon►s:_ Numbcr of Current Residents: Garbage Grinder: o Laundry Connected To Systen►: � Seasonal Use: U Water Meter Readings, if aXai able: Last Date of Occupancy: COMMERCLAL./LNDUIMMAi /C v 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: a OTHER: Describe) Last Date of Occupancy: _ GENERAL INFORMATION PUMPING RECORDS and source of informal' ► . System Pumped as part of inspection:_ If y s,A me pumped: gallons Reason for pumping: —.—.—. TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Sjkared System(lf yes ttach previous inspection records, if any) / O r(ex lain): 4S VAO gv�- s s APP XI MAT AGE of all components, k►i n�source of information: ewage odors detected hen arriving at the site: ___ -4- w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C: GENERAL INFORMATION (conliiuzed) SEPTIC TANK: AV 6 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 float 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: Pump is in working o der: Comments: (note condition of pump chamber,condition of.pumps and appurtenances,etc.) -5- rt, "3 s 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 approxiniatcd 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 hydraulic failure lee 1 of ponding,condition of vegetation, eta S .LJ v�/Qe� _1.� i°_.(11�1-:=� Cc)/ CESSPOOLS: Number and configuration:ko y,S?Depth-lop of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:(&'A V SV40 Materials of construction: �/a-jndication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic ailure, condition of vegetation, etc.) 1 / 09 y k-o- PRIVYY& Materials of construction: 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 (cunthmed) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, lanmmarks or bcochmarks. Locate all wells within 100 Feet. � it +-7 I � `n O)ue) DEPTH TO GROUNDWATER: Depth to groundwater: ` S Feet Method of Determinatio,or App}'oximation: �Llq -7- TOWN OF BARNSTABLE 1 n / LOCH 1 ION /? S y<U�� !iJ SEWAGE # VILLAGE `/�j'J 7��I//r�l� ASSESSOR'S MAP & LOT I INSTALLER'S NAME&PHONE NO. �Di^��o1 / O`I�S 77Z 9,W SEPTIC TANK CAPACITY 15-00 (94 LEACHING FACILITY: (type) % L>< I�s &7 (size) 7 X�/SI NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: I-mil 0 -I Separation Distance Between the: _ Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S 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 � c' p ,B I Q O I A'41 O -0j i G3� j �9 3' ° No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ooaf Stem Construction ermit 0ppYtcatton for Dtgp p � Application is hereby made for a Permit to Construct( )or Repair(I )an On-site Sewage Disposal System at: Location Address or Lot No. S-4 ilia f z7e Owner's NN Address an¢j6Tel.No. G fY el Assessor's Map/Parcel Gehlrvi11e ` Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �o1'7P C®-77 r�y� Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(AW Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 31321� gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Re airs Alter 'ons(An wer when applicable) 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 Code and not to place the system in operation until a Certifi- cate of Compliance has been issue b ar f H a Signed Date Application Approved by Date / Application Disapproved fo-rte following reasons Permit No. cis. `�U 7/ Date Issued i V, TOWN OF BARNSTABLE LOCATION �.7 y`��Q . SEWAGE# VII SAGE g�2/.�1/� `� ASSESSOR'S MAP&LOT INSTALLER'S NAME dt PHONE NO. A'0--kl&t J�l SEPTIC TANK CAPACITY is eo CITI L i { LEACHING FACII,TTY: (type) 7�(size) 7 X n NO;.OF BEDROOMS -3 B:UMDER OR9 WNER Q . PERMiTDATE: Z Z COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet PriYate Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet `:.within 300 feet of leaching facility) Furnished by l p r . , � � . A Vol O� d �' u No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for Mig o ar Op5tem Congtruction Permit �l " Application is hereby made for a Permit to Construct( )or Repair( V an On-site Sewage Disposal System at: {^ Location Address or Lot No. 0 611,10 Ile Own Name,Address an Tel.No. Xis m�nlc -/`IP 415 Assessor's Map/Parcel Installer's ame,Address,and Tel.No. Designer's Name,Address and Tel.No. �/'r4Ct��i '77/- 39° Type of Building: Dwelling No.of Bedrooms 3 4 Garbage Grinder(-40 Other Type of Building eJ� �' G4No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs pr Altera 'ions(An ,,e when ap licable) 4- 9�, Leoc / .7 � O Date last inspected: t 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 Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by ' 'oar f Health r--- -- r Sign y ed Date 12 Application Approved b Date 2 �� Application Disapproved for the following reasons r Permit No. �� "�0 7 I Date Issued ——————————————————— —,;——— ——— THE COMMONWEALTH OF MASSACHiJSETTS BARNSTABLE, MASSACHUSETTS t Certificate. of tompliaice THIS IS TO CERTIFY,that the On-siie Sewage DispoW System nstalled( ).:or repaired/replaced on by Installer, U17 at 11 5 U/A /I 2rI 'I'4-` has been constructed`in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Date Inspector a t �'; 4 _✓ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. No. W lL�� --------------------- � "—or Fee 'v J THE COMMONWEALTH OF.MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migoar *pgtem Construction Permit Permission is hereby granted o Ael)t7ze/y/ to construct( )repair( t�n On-site Sewage System located at No.# /�dA✓,�Q.� Street and as described in the above Application for Disposal System Construction Permit. No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must >be/completed within three years of the date below. Date: /212 096 Approved by Board of Health • TOWN OF /STABLE n LOCATION / SEWAvGEE## �c VILLAG /1 rt 1 -11!-P ASS R'S//MAPff LOT/ N C NL `S=-'NAME&PHONE N6� R�lam/ C 1>'lJ D`, ft242 SEPTIC TANK CAPACITY LEACHING FACELl TY: (type s' (size) �✓-� �S?AJ �°Q NO.OF BEDROOMS 1 2 BUILDER 6R OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching faciti!yj Feet Furnished by x— 9 i 4 C� o'er �� Cl 5�y off" S 17 c 5-`14—%J to 4-llt t L LAJ * NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT ()LVITHOUT DESIGNED PLANS) I, I VIT J ,41MK2 ,hereby certify that the application for disposal works construction permit signed by me dated z /wlk , concerning the proper tylocated at /7 meets all of the following criteria: .,/There are no wetlands within 300 feet of the proposed septic system "'There are no private wells within 150 feet of the proposed septic system al✓ a observed groundwater table is 14 feet or greater below the bottom of the leaching facility ere is no increase in flow and/or change in use proposed There are no variances requested or needed. SIGNED : DATE: 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 f