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HomeMy WebLinkAbout0124 BLUFF POINT DRIVE - Health 124 BLUFF POINT DRIVE, COTUIT A = 034 070 Si Yr - -�U Fee------------------- BOARD OF HEALTH TOWN OF BARNSTABLE ZipplicationArVell Co0tructionpermit Application is hereby made for a permit to Construct ( 4-1f, Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel ' ---- ----- _--__------------- Owner — — Address -------------_.------------------------ Installer — Driller Address Type of Building Dwelling-- --- Other - Type of Building.-=-.__-__________ No. of Persons-------------------_- Type of Well v Ca acit Purpose of Well- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed _- � _-- ` 2 o date Application Approved By ______—____--_- date Application Disapproved for the following reasons: date Permit No. �6©�` 00 3 - -b� --- Issued---------------- date f BOARD OF HEALTH } TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS TO CERTIFY, That he Individuual Well Constructed (Altered ( ), or Repaired ( ) by- d1Zti. �1 -_ i1-� L-d�r � rr n staller at 1�_------ ---------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------____-____Dated--------------____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN;rjHAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. �C_ DATE----_ _- - - Inspector--_--- - = ----____—-- (1G� ' r ---- ------- No.- --- -- Fee- }' BOARD OF HEALTH TOWN OF BARNSTABLE 0(pplication fibrVell Congtruct ion Permit Application is hereby made for a permit to Construct ( 4,, Alter ( ), or Repair ( )an individual Well at: XodbjA' 070 ,��y Location — Address — — Assessors Map and Parcel -- f�ri l_= —--- — ---- —-- — ---- Owner Address Installer — Driller Address Type of Building Dwelling ----------- - - Other - Type of Building-----___—_____________ No. of Persons----------------- —__—_____ Type of Well— � ��-- Purpose of Well--- Agreement: The un dersigned ned agrees to install the aforedescribed individual well in accordance .�.,,... 8 c dance with the rovli gr p sons of..The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. �I Signed date Application Approved By date Application Disapproved for the following reasons: __—_____-----_----------______________—__—___—_______ - ---------------------------------------------------------------- date Permit No. f___—___ Issued date -----------'---------------------- -----------'---'-------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (VY, Altered ( ), or Repaired ( ) bys---------- ------- - - -- - ------- ------- z staller at r� ----------------------------------------------------------------------- ---------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ---------------------Dated-------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTE&THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE— � --!_ --_ Inspector-- — 67 -- '-----------------a-------------- ---------------------------------�r-------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Con$truct ion Permit N ��o• Fee- Permission is hereby granted— — -__--�-- --------------------_-_------------------____-- " `'- to Construct ( ;'Alter ( ),or Repair ( ) an Individual Well at: f Street as shown on the application for a Well Construction Permit No.-_ - -�_�—_� --------- — -- Dated------------------ - --- ----------------------------- ===� -- - a 2 �� `� Board of Health DATE 3 Mar 20 07 12: 43p dam chambers cc 508 833 3848 p. 2 19/07/2806 14:12 508428311.5 SULLIVAN ENG INC, PAGE 02 10 it IOC 1 �.Uf F Pp/NTi9�bi�- ;a? PLA O --�--- Stile • 4 -_ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE-WINTER STREET, BOSTON MA 02108 (617) 292.5500QD '6 �q /PO T DY•CSl Sec i w 'yFe,�� VDA4 ST r� S ARGEO PAUL CELLUCCI "yp� mmissao,er Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ts, . CERTIFICATION u ,I Property Address:)� 1 BLUFF Pc A D R U, Name of Owner JUU,111) 5o6 i N Address of Owner: Date of Inspection: �V I9 l I Q����/��.p Name of Inspector:(Please Print) EOWARD B �� 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) ®� Company Name: t8l tP C 'F) Mailing Address: WiX) Telephone Number: co CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X, Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signatureir / Date: 2 20 r The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspe6iion7lf 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. NOTES AND COMMENTS i r f revised 9/2/98 Page Iof11 %J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:QLI 8CVrIc f eiNT ivv Owner: 5081 A) Date of Inspection:- Q-+� INSPECTION SUMMARY:. Check(3 B, C, or ®: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Indicate yes, no, or not determined(Y,N, or NO). Describe basis of determination in all instances. If "not determined",explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup 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). broken pipe(s) are 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 is removed a i i revised 9/2/.98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A tL CERTIFICATION (continued) Property Address: ft0FF POINT( (, Owner:506i/V Date of Inspection: �_ q l 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than<I�ppm_._Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: OLUF F FWA)T DP-U, Owner:SOB/0 Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No Backup of sewage into facility or system component due to an overloaded 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 clogged SAS or cesspool. Liquid 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_. 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 1 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: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: Yes No 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. I revised 9/2/98 Page 4of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:112q gLUFF PQliVO ON, Owner: S�JSI N Date of Inspection: 1D.,Cflq Check if the following have been done:You must indicate either"Yes" or "No" as to each of the following:. Yes No • Pumping information was provided by the owner,occupant, or 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 volumes 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 NIA. 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. All system components, 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 Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 15.302(3)(b)) _ _ --- The-f-e-s+lity-owner.(and occupants, if diffesent..from owner) were provided with information on the proper maintenance of Subsurface Disposal Systems. i revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: pq &,uFp polnt/ owner: :013iN Date of Inspection: FLOW CONDITIONS RESIDENTIAL:_ Design flow:_3-50 g.p.d./bedroom. Number of bedrooms(design):3 Number of bedrooms(actual): J Total DESIGN flow 33 _ Number of current residents: Garbage grinder(yes or(9:1110 Laundry(separate system) (yes or Q:N; If yes, separate inspection required Laundry system inspected ( es or no) Seasonal use io or no). Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or f�iq'�:N Last date of occupancy:sVn7A16��FJ}Sak.'/F� COMMERCIAL/INDUSTRIAL: / Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or o -60 If yes;volunW Efted. - gallons Reason for pumping: 1fYPE.OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known) and source of information: Yt^S �S �UlLT Sewage odors detected when arriving at the site:(yes or NO V a r revised , 9/2/98 Page 6of11 j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:�02� SLUFFPotAJT Dkli, Owner: SCaiI) Date of Inspection: ; () . l rr BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan)oo Depth below grade:O i Material of construction: X concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: INC1-1 Distance from top of sludge to bottom of outlet tee or baffle:dZCNS Scum thickness: i NUNS Distance from top of scum to top of outlet tee or baffle: C��SLVOGE Distance from bottom of scum to bottom of outlet tee or baffle: OSLUDGC How dimensions were determined:'' '4 PC rn6-A4VAC, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structyrral integrity, evidence of leakage,etc.) PLA577C PC'C iIVL6-F 'TEC ,Ct2'CRr &'M/'CZb 0Lrre E% CGevo -SWE, GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle-.- Date of last pumping: 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.) i t i revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ACU-Ff P7( w-F Ov, Owner: ,`j�Pj111J Date of Inspection: Q•�qy� TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) i DISTRIBUTION BOX:1 (locate on site plan) ' Depth of liquid level above outlet invert: A7 9"PI Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box, etc.) CW PIPS OU oNE P(PE out, - PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or Not Alarms in working order(Yes or No) Comments: (note condition of.pump chamber,condition of pumps and appurtenances,etc.) l r i revised 9/2/98 Page 8of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �yl:r F PCENT Q�U Owner: ja,$iAf Date of Inspection: SOIL ABSORPTION SYSTEM(SAS);- (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: -} leaching pits, number:_.L1vE (oFF0oT &CKF1 p!! leaching chambers, number:_ leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of poil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) 0 4S 6iVL1;' N4Q A660 ftr i ODT OF L)Quln IN IT � UCP C4�AiU CESSPOOLS: (locate on site plan) 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 (cesspoci� must be pumped as part of inspection)_ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimied) Property Address: J)q St OF P61N7 00i Owner: sc;a1N Date of Inspection: CI SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) w t�R 90E 3R �0 revised 9/2/98 Page 10of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION(continued) Property J�d1dress: Q �l U Fi� P�1NZ Qg�t Owner: J v B I m Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record AObserved Site(Abutting property, observation hole, basement sump etc.) XDetermined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11orn C c a r r > r n r > p l IN v� P i 1�1 > c7 r4-s C O 07 � N � a N � > O !'f � CIS. 1� klZ > _ 1 Z0400a Q r - 1 DrG& Municipal Water 4