Loading...
HomeMy WebLinkAbout0025 GREENWOOD AVENUE - Health 25 GREENWOOD AVENUE, HYANNIS A- C Q�- ��� -00 i 0 f TOWN OF BARNSTABLE LOCATION o� SEWAGE # VII.LAGE 17 � �/ ASSESS MAP & LOT �Ss�c 7ps IN htle-, NAME&PHONE NO� (O� ,/; I), SEPTIC TANK CAPACITY /Oc�O C� /.r C AI�� Ici�� -31S�`. ,l LEACHING FACILITY: (type)�i �C /� (size) 0 ae- . NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f: / 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 o��jj``leaching facility) r � � /�' � Feet Furnishedb r"1��C) fz mac. J9 'I O os 'Q f No. )a,3 .2 0 Fee �J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYicotton for Dt5po5al �&pftem Con5trurtton Verna Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(� ❑ Complete System ❑Individual Components Location Address or Lot No. gs C,/Q EZ_?t U_)o0-0 1411 Owner's Name,Address,and Tel.No. A14AMULCI rKA1,JvE-E- 1 � G G C 14 1 A 0 AO-oSzs4 Assessor'sMap/Parcel 2S9 ©q P.O. 'ivY- 905 Wy,( OK Po-T Md Installer's Name,Address,and Tel.No. SvF 47Z V 7 Designer's Name,Address and Tel.No. 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer 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 Certificate of Compliance has been issued by this Board of Health. Signed 0 Date Application Approved by Zw Date ::;2 �f j Application Disapproved by: Date for the following reasons Permit No. 2-0JIT-261 Date Issued �Z No. O i✓ — t'J / Fee J ~ Entered in computer THE COMMONWEALTH OF-MASSACHUSETTS -•� Yes PUBLIC HEALTH�DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpptication for ;Di,5pogoY i§p5tem Con.5truction Permit ,,Application"for a Permit to Construct O Repair.( )—Upgrade-( Abandon(� � Complete System ❑Individual Components Location Addressor Lot No. a 5 !fR 6EgJ W OOO AtV15 Owner's Name,Address,and Tel.No. A rIMVtS MAk- JE-. � GE C(4(Aq ()AeosrA• Assessor's Map/Parcel ag 9 P,O. b U)C 905 4Y,(001 S Powx MA Installer's Name,Address,and Tel.No. So �77`S S 7 Designer's Name,Address and Tel.No. 4 0A)(w GV4'1-?P/11 LGC � ' .. 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(min.required) gpd Design flow provided t gpd Plan- Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. `Descrip(ion of,Soil .1 Nature of Repairs or Alterations(Answer when applicable) ,: IU�otil C CIS`Z7 yar SL-- en e. 115,1F S r`mtit Date last inspected:. Agreement: e The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in } ac ordance with the provisions of Title 5 of the'Environmental Code and not to place the system in operation until a Certificate of �. Compliance has been issued by this Board of Health. r� Signed t Date I A 5 —Ao t 3 Application Approved by ( emu.., ` Date ::;2 Application Disapproved by: Date for the following reasons Permit No. o f�—2 61 Date Issued THE COMMONWEALTH OF MASSACHUSETTS L BARNSTABLE,MASSACHUSETTS C (Certificate of Compliance THIS IS TO CERRTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned(A)by CAP C—(-'J(UC &jWTWk(S S, LLC at, ,15 6 6-TENL000D AUQ {"'Y41J)U!S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 ,>/3 6 5 dated /2 /'/ Installer djkP )1DG EVIOZPAJ.56S U-0— Designer #bedrooms �/1 fi Approved design flow lJ l} / / gpd` The issuance of this permit shall not be construed as a/gua� tee that the system 1If f pftio/fi� (as/dJ�si �ed.Date ' M / Inspectorff �,f/ o — — I / --- / C — No. _2 C) 1 Fee 2 f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1=IgfJo!9ar ,p$temY Con$truction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon (�) System located at :2!�; Ai_jc-7_- 14 y g Qi 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: Construction' must be completed within three years of the date of this erm)t. . Date f Approved by �/ �1. / f AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE ASSEZos R'S MAP&LOT 7�/S�sNAME&PHONE NO t'�o�/4/i SEPTIC TANK CAPACITY ,, ' 0 .Of3 LEACHING FACILITY: (type) (size) J��S . NO.OF BEDROOMS 3 BUILDER OR OWNER :�O/1)PS c--/SSO/7 PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f / 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 faf dity) /Y Feet Furnished byar-JWQ4! . C/ZZa--e, CAR GG P�bl<S� o , 5'ID G�3� 0 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=289093004&seq=1 7/25/2013 NO'. ... ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD HE" 7. A OF.......: ...... .......OF...... qr,11_i.1x�-r----_---_----------------- Appliration for Bwpoiia1 Work,5 Tonstru.rtiun Prrutit Application is hereby made for a Permit to Construct � or Repair ( . ) an Individual Sewage Disposal Syst .3......... L..... - r No.�'�r!� er dress 21 ............•.. ..fxtly,�_dj..... ... .._,1�. ............................... .....0... ... •........... ........................................................ p Installer Address Type of Building . Size Lot_!__ / -----Sq. feet— Dwelling—No. of Bedrooms.......................... ...___._..Expansion Attic Garbage Grinder (�•'� `L4 Other—Type T e of Building No. of ersons...... Showers a YP g ---------------------------- P •-------•--------- ( ) — Cafeteria ( ) Q' Other fixtur ----------- - ---------•----------------•--------------------------------------------------------•--•--------•------------------------•------ Design Flow.................... ... .?__.._.__.. -_gallons per person per day. Total daily flow------------- e' W 5. ' dons. WSeptic Tank—Liquid capacit gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---_---------_---- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �` - a Percolation Test Results Performed by............................................ -------yr..._._._.---_-. Date... ..... _......_._.... � Test Pit No. L��__mmutes per inch Depth of Test Pi ..... Depth to ground fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Jf�� x _ O Description of Soil.................... ------• ! l/ r x '� - - ? ---------------------------------------------------------------------------------- U W U Nature 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 TITI,L 5 of the State Sanitary Code—The un 'gned further agrees not to place the system in . operation until a Certificate of Compliance has been i d by th d of health. Daj Application Approved B ..............•... .. v ----------•----•................. Date Application Disap ove or he following reasons-------------------------------------------------------------................................................... --------••-•-••--•-•.................••-•....----------••-••••--------•--...•---•----•.......-----••...-- Date PermitNo......................................................... Issued........................................................ li► No. ... s� ... _ FRic ....%.............. THE COMMONWEALTH OF MASSACHUSETTS y--� BOA R D, H E M T . ....----..II OF.........., �1isJ/.,... .. , pphration for D opoiiaf Works Tomitrnrtion ami# Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst ...............-at } ..... . ------------------ �' ; .................................... ....... Locations Addr ,►wt Lot No. }ywner9f, .� �16 _1............ . ......... . A T- dress .. _ .. ._ �f A - 1..__. Z�s' .•• ----....U►_ .. ............... ---------------------....-----...... Installer Address d Type of Building Size Lot...31-mr-0.....Sq. f�eft U Dwelling—No. of Bedrooms......."...............................Expansion Attic ,(dl.69 Garbage Grinder ('wl Other—Type e of Building .._...... No. of persons...... ................. Showers ( ) — Cafeteria a YP g ••----......-- P ( ) p' Other fixtur c''" d , •-•---•--•--•-••-•----•--- ----------•--•----------------•-...----••--------------------..... --•---- W Design Flow.................... .....................gallons per person per day. Total daily flow__._._.......-"'� 4..................gallons. WSeptic Tank—Liquid capacity, .gallons Length................ Width-____---_._--__- Diameter.-..--__---_---_ Depth................ x Disposal Trench—No...................:. Width.................... Total Length.................... Total leaching area---------------------sq. ft. 3: Seepage Pit No..................... Diameter..........-......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) yy Percolation Test Results Performed b ........................... ........ ..__.____.__..___ Date.... __..._..______...__ _........__. ,4 Test Pit No. l.'�—'_.Z-__minutes per inch Depth of Test Pit__ .. ......... Depth to ground 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.............-.......... Description of S G oil------------------- ...... r-----.... h^' ...,. .......-�------------------. .................................................... x ztD -- ------------------------------------------------------------------------------------ c� W ----•-••--------------------•--•••-•--••-••-•-•--•-----•-------------•--•---------------•-•-- .._..__...-- Nature 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 TIT?n 5 of the State Sanitary Code—The un gned further agrees not to place the system in operation until a Certificate of Compliance has been is d by tl d of health.Signed--•---. --- ---•--- 1----------•-•----••---•-. •---2---_7` •-•- D to Application Approved�B„y==-�._--•-.......................... ' t` Application Disappr ov d�f orathe following reasons-------------------------------------•----------------------------------------------.......................... ------------••_••••-••-----•.........-•----•-•.................•-••-••••••-•••----••••-......------•---------•-•----•-•••---•---••--•••-••--•---...---•---•---•-----•----•----------••--•--•••---•--•-•- Date Permit.No......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA T _ OF......:.:. V.f''"✓+ ....+ '............................................. 1rdif iratr of Tomplianrr THIS IS TO CERTIFY, Th t' Individ ewage Disposal System constructed (Q` ) or Repaired ( ) Ins{alley q has been installed in accordance with the provisions of TITIZ 5 of The State .Sanitary Code � des�bed in the application for Disposal Works Construction Permit No. ".. _ ________________ dated..-./._..:~. ?'.`.; ��""............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................••...........---•---••-•-.......---....-----•--•------•••------• Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD s F HE T1 ............r -.................OF..... .f, ��............................... .w-- Nof.........�`1�...._ FEE.. .: .............. Disposal Vorhii Cron Ilan . mit .. Permission is herebygranted....... .•.• _ry °`"�"' _-....-._------Jl. . 7........................................................ at No.•--•-•..L.* .. ................................ w �_.�sal System to Construc ) a�. �.2 Individual e gel/*�a'spo ....... ........ `'` �;:� .. _..----�/............... Street, as shown on th/appX11itio for Disposal Works Constructio eririit .I\To..__._____ .._ Dated.�. _ ='_ ....%a...�:......... �• Board of Health DATE.._../.... ---------•----•-•----•-----•----. r" FORM 1255 HOBBS & WARREN, INC., PUBLISHERS . i LD r ce a4 700 3 3 LOT'9 of �. (oxlQ CCAcrti p.IGPrT� JI .; Ole �. 00�00 R mf � Y LOT nl LOT 4 "� 1.3� 000 SF. �QO'~ ° : �� 1s,.90osr-- N 44.0 -- ;,,0 0 10 PL GA Fro.EL 44,0 Z .. 30 ==�► I`: 9 G t 10 F 0. 10 EDC,E OF �9VEME NT"' T 91 �IN\OF 4 C/ZLEN wa0� LANE . or IOHN �f MOSERlJ: �'iELLIS - .p No.29874 Q - o, :::�c>.:> _.. �= �OISTE�yO� �ND.SUR�� LEGEND tt�p CERTIFIED PLOT PLAN } EXISTING SPOT ELEVATION 0%0 . OF EXISTING CONTOUR --- 0 — FINISHED SPOT ELEVATION (� �" A� ,, , LOT 3 C�REEN WOOL)bNe' MYANN�S FINISHED CONTOUR ® asEI 1N ® No.10951 APPROVED , BOARD OF HEALTH A DATE. AGENT.. SCALE, 1 _ ,30 ' . DATE Nov 29 82 { LDREDCE ENGINEER Co! INC N CLIENT Avs�DE I CERTIFY THAT THE PROPOSED LEGISTER REOISTMED JOB NO.,82181 BUILDING SHON ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS0INEER ,SURVEYOR DR.BY JDD OF BARNSTAB, er , MASS. 712 MAIN STREET CH..BY.. .AAM_..I). M LL= H Y A N N I S MASS. SHEET OF _I 3 ATE ( t G. LAND SURVEYOR � .w v�awr+Fa :ice, „nw- ..w .h.,. .,♦ pw ^+�.Aw:+a.. �+.,',.,.� ...,-yw .w.:.. � .- ,. , lYaTE /G .E/TNER .T�7� S=r�Ti rq .V 20 FT.' M!N fl n < O� G1-/fiVG P/T .4RE /'IORC TH9.V /,2 " BELOiv . ; /p iT M%N. �RAOE� � 24 'O/AMETEK GGNCR;T'c- CGVER BROUGHT TO <7,TA OE. r 4 PVC.PIPC y CAS � CO/VCRCTQ /�EAYT /RON C b i/E.? 5:== -?L L PlTCN. QR/VEWA y EL la�L a". G'OYE IB PF.P FT. 1 CQNc�L�T A al G,G�c7E / CJ i/E.4F =d -- /RON .' O L: 'e , a SriEO Sr-,YE ,': ql� /4`Pc.•c IT SFPT/C TANfC D!ST. o • A • • « • r • • a i r, f 4 r • • DEPTH • ' • ` � o o _N4S.•fEJ STD,YE :. i Ito • . • • r.. • • o;a • r p y PPECAST SEEPAGE' i o .y. r r • • • • • • r a o ?/7 OR EQL//V� l Nlie f T CL E✓A77ON s A S S ► lYYERT'AT QU/LDING 99:0. FT '. CAAG►T`� Sq C�/�' . SEPT/C; TANK g 9 FT, :1NLE T . , h t- OtJ7CET_SEPT/'C TA V.#<, 1� F'T O/A/ti ,.C SEE TR,9VL.4 TION /HEFT D/STR/8l/T/ON'BOX 8•'4 FT GROUND W,,4TER TABLE 98 SEGT/ON OF GtJTLETD/3TR/Bt/T/ON BOX FT - - .S'El-t/AGE O%SPQrSA l SYSTEM /ryT LEACHING PIT 9fT ' -T/IBCJLAT/D/V f `r il?/T. . G v , L E.4 CH/ ,., D:ES%GN :CRl TERM '; r • sc.�L,E; s v a i f; t ,40 AfXN5 S � ,vUMQER:Of B � ® HENS/0/Y C 4- _F T G,4RaAGE"D/SP0 .. y SO i L TEST itl "SOIL.TES7- TQ TA L k3-m%ofsTEG:FLO H/' GAL':�DA...,, SO/L TEST r NUM84FR_4F•4f4CMiHCF P/TS_ C ' t EtEY. Ca YT7 EL1FY ' OATE OF SO/L TEST s` 'RESULTS H//YNESSED 8Y J I,: < L64 y -7g j9oTTOM L�+1CN/NG PER P/T' SQ. FT d 2. ec PL`RCOLNT/ON.R�4TE / L TOTAL .LEA CH.I/►rG"AREA 2� SQ FT - ToPso►L AE.eC0L.4TION R.47-X j,RR5ERV/ ZZ4CNING AREA �0 54.-.FT • k' F 4= SC lL71=�T. of H of �1.4 MAD k.. tit �a, ��- ,� 2' 12 Ls:>T 3 ao.D ACBtg ' �\ •. (��(�tom]N I �. rr C y r U ttSE„ N ` caIELUS. } 1U951 c O���� o 2t moo L� _ EL DREDGE ENG//Y.EER/NG Co.,a 7/z MA//v s 7- El-7IONIA ,.�1 �0:SURD s'` '�'`►ti a`� [�NO GROUi1CA y:Vi4T�R, ENCOCJNTER...O .' CL/EwT:, f��fSfD� DATE : = F_ GRO UNO. LvA.TE.Q AT.ELEL/:. 7! --ST +-loll' LpT ,I _ s+-1 3 b F` SHEET 2 OF JOB /va• _�2 ! a ! = Comp1`ete°d by' H I GN.GRQ�tdD=WATER. LEVEL `CO'MPUTAT I ON 777 �-I y A t� f i t e 'L'oca t ion. GDD � K1-�vIbC�� f��l E�-t �G Lot No.,. �` Owner:: (tilrC" f= .` rwoo© Address: Contractor,; RSiDC (� i�©i�.r� Y Address. C +�T �wi�1c: Notes: G EC). cti �� F?®nn l TF`c�F G- -Pe STEP l Measure depth to water table ' r: date STEP 2. UsingrWater Level Range" Zone , ;' ` and Index We l' Map Aocate:` site. and deteYmine: } T SW A) App.ropr.iate• index:.:well` . B) Water-level :range zone< z STEP 3 -Using monthly report.'Curr.,n Water Resources' Condi,tions" r determ.inecurrent depth to J2 ,4i ` water .level for, index wet] . .. q /8ti mo yr f , STEP 4 Using Table of Waters-level i Ad j us tments for .,i nd.ex.we 11 t STEP 2A ,; current depth to water level - for 'index well. (STEP 3) . .and water-level . ; zone.:(STEP. 2B.) determine level adjustment , . . . . . • water- STEP 5 ; Estinat.e depth to .hi.gh 'water . .: by subtracting the water level adjustment (STEP 4) . from measured depth to water T3�SI level at site (STEP 1) + . ... . . . . . . . . . . . . . . . �1= Lc�T' I /. LAJA-�-a e. / TAT D1�ZE .�1=PT F _ -7 . Pr-N ''r'a WATI=_ ;'. { 4. .o — �LsE:.P>✓f rhL-_N-. ��Tt��2_ cc->.u.P s 'OCn . 9 WftIR EL P�Q th6.H L Q 9 - 7TLSM a F R T. ' Completed "by 'HIGH GROl:1dD-WATER..JEVEL COMPUTA.T 1 014 I�IAt�r��tiS t site Location• DD�� �` � � � /�yE�uG Lot No. ' Owners Htc�� e�I= iA:r�.rcz�D Address H`lArr�.iiS`. A.i Contrac;tori ( 4�(�iD (wig©�rr� co' Address; l. c ., Notes: Te�2'_ FP-ca nn `EtN—_-_�T - — - 1 — Y 1 s STEP I. Measure depth Ao waterL table to nearest .1/lp ft. � date . STEP 2 Using -Water-Level Range Zone' ,s_ and. Index Well'-:Map locate x ' site and determine: A) .Appropr.i_ate'.index .we1.1 B) Water'-16veI .range zone C $ • STEP 3 Using monthly report''Cur rent. ` Water Resources.:. ConditionS" determine current depth' to 1Q :4i ' water .level for index we'1'1. mo yryr= STEP .' Using 'Table .of Water-level Adjustments for index we STEP. 2A , current d�pth` to ;water Teve] . for. index we•11 (STEP 3) , and water- -level_;: zone (STEP 2B) determine . o water-level adjustment . . • • . . . . . • • . . . . . i is STEP 5 Est,inate depth to high water'; I: by subtracting the water t. level adjustment (STEP 4.)' from measured depth to water � •S level -at site (STEP 1.) . • . . • • . • • • . O . i� k�aT I WEE_TES e . '7 S� / TEST DftTE SI=:PT. 2 i I 49 c, Q -IO+J - -_7 S. - DePT-H rc� w ►�,� Co 9 - w�t't�R EL Pc� :t 1i�H 6_,A i�� `, c.on+F + . 4Pcp Tr rtE V 3 P, C' - -7- L O CAT ION SEWAGE PERMIT NO. I �. LAGE Ali' INST LL "S i NAM ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED L � _ 1 � Y'• BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 9 �® Address Prop (J d©C1 1 Date of Inspec} Map Parcel Owner �^ CHECK IF THE FOLLOWING HAVE BEEN DONE: PART A — CHECKLIST VPUMPING 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. AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. 7HE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. v 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 MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL No of Bedrooms �,Q(Gs7-1- No of Current Residents _z4-0 Garbage Grinder RPsr�e�7� `P Laundry Connected to System ,� Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: GALLONS Pumping Records and Source of Information: 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) Appr ximate age of all components. Date installed,if known. Source of information. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: t/ Depth below grade: Dimensions: Material of construction:. oncrete Metal FRP Other} Sludge Depth/ Distance from top of sl dgg jo bottom of outlet tee or baffle Scum Thickness ,/n e Distance from Top of SctT{m to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle d Comments: L DISTRIBUTION BOX: j/7 DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT ments: .b � . / Z7 PUMP CHAMBER: Pumps in working order? Comments: SOIL ABSORPTION SYSTEM (SAS): IF NOT PRESENT,EXPLAIN: TYPE: /— /000 s lea C12 '14 Comments: o to - ,L acl Q on w CESSPOOLS: ro Number and configuration _ 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: ii 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' o a' o DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: A-POKOA4Y�V ,�' yf p, dl1 ; 5• �'��, ��O�h�,2fiv'o '� �i ; 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.) IV 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? Al Required pumping 4 times or more in the last year? Number of times pumped IV Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? I✓ Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? 1Y Within 50 feet of a surface water? I/ Within 100 feet of a surface water supply or tributary to a surface water supply? IV Within a Zone I of a public well? A/ Within 50 feet of a private water supply well? IV 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—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: /HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY Q ELY 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