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Home My WebLink About0028 MANNI CIRCLE - Health (2) 33 MANNI CIRCLE, CENTERVILLE A= 169125 UPC 12534 ' No.2-1�53LOR HASTINGS.SIN BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop CctiTLrvi'l Deft of Inspec} M �� s %6 Z owner CHECK IF THE FOLLOWING HAVE BEEN DONE: PART A — CHECKLIST // PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. SAS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP. -THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON—INTRUSIVE METHODS. THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANC OF SSDS. PART B — SYSTEM INFORMATION RESIDENTIAL FLOW CONDITIONS No of Bedrooms No of Current Residents Garbage Grinder _Laundry Connected to System Seasonal Use NON RESIDENTIAL Calculaeed flow. WATER METER READINGS,IF AVAILABLE: Pumping Records and Source of Information: GALLONS uM ec� 619y G SYSTEM PUMPED AS PART OF INSPECTION? a IF YES,VOLUME PUMPED= GAL Reason for Pumping: TYPE OF S Septic tank/distribution boX/soil absorption system Single Cesspool Overflow Cesspool Privy system (if yes,attach previous inspection records, if any) Other(explain) APP�dmate age M � Z�d Daf irlled,it know. Source of information. 8EWAGE ODORS DETECTED WHEN ARWNG AT THE SITE? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM q PART B — SYSTEM INFORMATION (Continued) BEPIM Depth below gee: 6 Dimensions: a,Sx6.rs" Materiel of constructlon: Concrete Metal FW Othw} Sludge Depth O Distance from tap of sludge to bottom of outlet tse or baffle Scum Thickness 0 Distance from Top of Scum tD top of outlet tee or baffle Distance tram bottom of Scum to bottom of outlet tee or baffle DIWIBUTION B DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: D-6dX ��/Bl 4 %X fsiDr' ra o rr' PUMP010 BE Pumps in worldng order? Comments: IL ABSORPTION SYSTEM AS IF NOT PRESENT,EXPLAIN: TYPE: rl' //-Jtt Z /006 v ��Q�a/•��w r T i�ls/// 7' Z! 9,5' Comments: CESSPOOLS: & JA Number and configuration Depth—top of liquid to Wit 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 Dim°nsiorts Depth of solids Comments: A 04 is= c.: / . �.. TOWN OF BARNSTABLE LOCATION �L �0��9 �� SEWAGE # VILLAGE C COW Ile- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /DD® gre* 1. LEACHING FACILITY: (type) . /,00-0 � � (size) `�® NO. OF BEDROOMS ' B&ILDER OR OWNER PERMITDATE: Zl ZYA� COMPLIANCE DATE: 7C'" ? " 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 facility) Feet Furnished by ,4 A r 3a , AA- /IPA kq - 33 C 3 TOWN OF BARNSTABLE LOCATIO; �ni �%`G�2- SEWAGE # VILLAGE62(Wliel-Qille- ASSESS57S MAP & LOT /�- SrvsnGcr�,es Jb1S==BW&NAME&PHONE N r QQ�C��`` F1 _U`IcP �r�� SEPTIC TANK CAPACITY /00 92/ v✓C�4�lC /�/��.�%s� `UGC LEACHING FACILITY: (type) (size) /060,Q2,d�, 642. NO.OF BEDROOMS � BUILDER Oii;OWNER l C.�7r'/�SC�Ci�sJ+ 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-000f�feet o��f�/l",eaching fac' ' ) // /_ Feet Furnished ry-&`h`�/� % VkS kuw—0 fin, /(r` �� /� �t� �Q�T �� s� �; i � ��,� . o �� '�� oa� �<�- TOWN OF BARNSTABLE LOCATION SEWAGE VILLAGE ASSESSORS MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUTT-nER OR 0,WN17 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED• A4 - o : - TOWN OF BARNSTABLE LOCATIO (L,0 PR SEWAGE # / "s �DILLAGE Ce �I ASSESSOR'S MAP 6t LOT �6 INSTALLER'S NAME & PHONE NO: r+`, QEPTIC TANK CAPACITY 1600 �491 LEACHING FACILITY:(type) S7— (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER P� E C BUILDER OR OWNER ► A"Aj DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ILI D ITS 5 l t� 616 ? 57 ' SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM • ,t - CART B 8YSTE1� INFORMATION (Contlnuadl SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEASTrwo PERMANENT REFERENCES.LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WnHN 100' 3 2 ' poi 3 2 IDdD�� 10iT DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETEFjwlNATION OR APPROXIMATION: Leo/o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA pndbeft Y—yes N—no ND—not desm.. d.Dembe basis of delsrmMafion.M'not dela nMwd',e*ain 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? A4 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 Al Septic tank is metal?cracked?structurally unsound?substantial infiRration?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? Within a Zone I of a public well? 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 1 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—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE v I HAVE NOT FOUND ANY IN HEALTH OR THE ENVIRONMENT AS DEFINED IN PUBLIC 3 0 U CMF 15.303. ANY FAILURE RE 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 1&3W. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA'SECTION OF THIS FORM. INSPE CTORS SIG NATURE. / DATE ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable).APPROVING AUTHORITY