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Home My WebLink About0006 CRYSTAL RIDGE ROAD - Health m �6`CRYSTAL,RIDGE, (Z}}��p-_,q 0 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .. .........OF......... ....... . . ...... . Appliratian for Dhiposal Works Tanitrartian Itrrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ........ __...... ........................� ._ : ...r .1. ......................................... .....- ._...... ...... ._...-.Location :,Address or Lot No. .... .._ Y/1. -....- Address .......................................... Gsl ►-a -----------•- - -. -------------------•------................._ ... dr Installer Address Type of Building ' Size Lot.......... ...(. ..Sq. feet ,-� Dwelling—No. of Bedrooms..................:.............. f... .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ...... No. of persons............................ Showers 04 YP g -•-------------•--•-•- P ( ) — Cafeteria ( ) Other fixtures . ..... Q ....---•••......--••........__�....-••----•••........-••--•-•-•-•-•.............•• ........................... W Design Flow.................�.�..Q... ��gallons per per day. Total daily flow........... __.... ._................gallons. W Septic Tank—Liquid" capacity.-. .... allons Length................ Width;............... Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length................. _. Total leaching area....................sq. ft. 3 Seepage Pit No..__. .--.-... Diameter....... -... Depth below inlet...3.t�... Total leaching area. _.. ... ..sq. ft. Z Other Distribution box - Dosing tank ( ) '~ Percolation Test Resul Performed by.......�....flld (1................................... Date.... . .....�,�..... ....... W _ r�-- ,.a Test Pit No. I..LZ.minutes per inch Dept of Test Pit... Depth to ground ater... a�A1 .... (% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ............................................•-•••...... ................•. O Description of Soil..... U ............................................................ ...•••.-•..........••.-•-•--......••-••--•--•-.-----.--•--.....--.--•--•-••--.....••-•-•..............•••.---••••- 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 MAU: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n •ssu d by the board of health. Signed... .. 4 Date .. F .. ... ......... .... .......................................... ......Date...... ... Application Approved By........--- �.... ........./ �=Date C J Application Disapproved for the following reasons:.................................................................................. ... ..............._._... ......................................................................................'--•-•---•-•--.........................-•--•-•--............................................. • .......... Date . Permit No....--- •....':..7Y1.................... Issued.................. -- ............................... — C+CY Date I_ ---__—_--___--_ — -- — G yw L. THE COMMONWEALTH OF MASSACHUSETTS 7 J , ,.BOARD OF HEALTH --= OF --------------------- ... .. Aji� iration for Disposal Oaks Toniitrurtion Permit Application is hereby,made for a Permit to Construct K) or Repair ( ) an Individual Sewage Disposal System at: _ ..... __.... Tel Location`/Address or Lot No.__________ ••--�•--• + .... /� .. .� f//��.....................•---^--•-T..... _......_..---...._.........�1� !�! ..................................................-._. f Ow er Address a �.... .................................... ....:........_.......... Installer ( Address / s Type of Building r 1 Size Lot _ y... . .Gr!..._Sq. feet . Dwelling r No. of Bedrooms................................�--_...Expansion Attic ( ) Garbage Grinder ( ) •'` Other—T e of Building .......................... No. of ersons....:_."......�.._._.._... Showers — k —Type ng p ( ) Cafeteria ( ) p" b Other fixtures ............:........ --•---•-••-•--- _.--•---•.................................. W Design Flow................ .�__(2.._____...__..gallons per re—r•,son per day. Total daily flow......... . ...............gallons. WSeptic Tank—Liquid capacity l �jallons Length................ Width:..._;.......... Diameter.._............. Depth................ x Disposal Trench—N o. .................... 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 Percolation Test Results Performed by.......�..._ ia? !�................. Date... 1 '�� w L i . w Test Pit No. 1._....:. _._.minutes per inch Deptll of Test Pit...�..`�� :_.._. Depth to ground water.-.X.aM_)(_:_.... rzq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . . -••...................................•-•-------•---____--------------- ••....... __......... ... Descriptionof Soil.................. .S _ ....... .._......-----•------------------......---••-•-------..._..............--•..._.....-•••-•-•-••••---- U ................................_....................................................................................................................................................................... UW .....--•---•----------------------------------•---------------------------------------------••---...----••-••------------......-------------------•••-----•---•-•-----•-...--•••-•--•-•--•....-•-_.... Nature of Repairs or Alterations—Answer when applicable..........................................:.................................................... r,a� ............................ :.............................................................................................:......--•-----------•--•----........................................... Agreement: The,undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been I ssu_d by the board of health. _. Signed...... ./.. •... .. ; ", :.::. ✓, Date �^ ,. . Application Approved By.............. ..._.. �_.---�,.•:::�..�-�--:��.....--•-----•-•--t---i----.•--- ......... I Date Application Disapproved for the following reasons:................................ ----------------------------------------------------. ------: t Permit No....... .. ......�_/-�//.... ------- Issued.. _Dace...... tw O� Date ------..--o ---.m.,,+..,. d- -- I- . ... «,. . ««...«..«------------------------ THE COMMONWEALTH OF MASSACHUSETTS _ �,p BOARD OF HEALTH ........... /.v.w.�.........OF....... 1!I74�......................... (Irrtif iratr of Tamplittnrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed (,?C) or Repaired ( ) by................ .�._...._. .......................................................................................................................................... :.----•--..................--•-------•--•-------••-•--------------•--••-•----- -.._..._..._...........---------..................._..... h Install-J� �— at.........._/rl� �L� ... Ca__.._...�ICcQ.....------.�...gC=_ � has been installed in accordance with the provisionY of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........ ...... dated....... ...................................... THE ISSUANCE OFI THIS�CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. f.'_•"'s_..�. /�b. .................... Inspector............ _._ I! ��a.�:.,-,. •.��••� :,••,3,cyp,o-wadmarr ar��.:.+.+ns,�m�sr.�-rr�0amram s3 aver�a m.s.t••�«••�>.t"..�..cf�!cee�t�t��r wr w��rwev.rw.aw wiwm�a>+a�,�,r.a.-,.kaap+r��e!.er••••n ,...x�.RM�ea-�- THE COMMONWEALTH OF MASSACHUSETTS Q BOARD OF HEALTH No.11.�- �' OF....../ �..�....�c `1. ,.� 7�./... FFz. � :..:... 19iapoattl Marks Tonstrilftwin Permit Permission is hereby granted---------- ---'_.:_.. a---`-! --------------- •-•--------------------------- ... ................ - to Construct (X) or Repair ( ) an .Individual Sewage Disposal System Street -7 �Zas shown on the application for Disposal Works Construction mit No.-(?.,..�P-.-. ._ Dated.......................................... /. - Board of health DATE------ ...... r '/ 7 TOWN OF BARNSTTA,BLE LOCATION �e7-8(��/5 4� / ew)�' ucu� SEWAGE # VILLAGE ®�6 00g� VILLAGE_ ASSESSOR'S��°� ASSESSOR'S MAP & LOT — INSTALLER'S NAME & PHONE NO. ITT S>2r�s`Go SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER "� DATE PERMIT ISSUED: a A Le z DATE COMPLIANCE ISSUED: L/c O 9 ' VARIANCE GRANTED: Yes No coy- u 9 s 6 TOWN OF BARNSTABLE LOCATION C3 C�RI/t�',a�dPI �j� SEWAGE ___ � VILLAGE .�c�'�j�1`T" �56-ODa- ASSESSOR'S MAP Q LOT__ INSTALLER'S NAME G PHONE NO. � SEPTIC TANK CAPACITY / bd LEACHING FACILITY:(type) ��-'— (sue) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No V coy �y f S cq Nod bs3 V _ �• BORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD,MARSTONS MILLS,MA 02 Z 508-771=9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address. Date Of Inspection Ins ector s Name: Owner's Name and Address- CERTIFICATION STATEMENT: 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 Inspectioin was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems. system: ' Passes Conditionally Passes 'Needs Further Evaluation By the Local Approving Authority Failure �`-�- / T l / ' Inspector's Signature Date: 7!2- TheSystem Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (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 Offie 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) SYSTEM PASSES: I have not found any Information which i ndicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. ' B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfd- tration,or Tank Failure is iimminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming 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 pipes)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): 74"Ve • dry. AA� . - 'f t h lr "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 pipes)-are replaced _.. _ 4. .. .. Obstruction is removed FURTH ER 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. i)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 WELL 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 S 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 pending of efiuent to the surface of the ground or surface waters.due to an overloaded.or clogged SAS or.cesspool: Static.ligWd level in the distribution box above outlet invert due town overloaded or'clog- ged.SAS or cesspool' _ti.. 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 limes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- '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 A 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 A 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.' r 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 F (IWPA)or a mapped Zone It 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 CUR 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 CH ECKLIST Check if*following have been done: V 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 volumes of water.have not been Ptroduced into the system recently or as part of this inspection. -Asbuilt plans have been obtained and examined. Note if they are not available with N/A. '�' _L,Zflte facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow.' 3'he�site was inspected for signs of breakout _ `fha All system components, the Soil Absorption System,have been located on site. w, .... 00� txptic tank.ntanitoleswere ttncovered,opened,and the interior of the septic tank was in- for eonditiogof baffles or tees„material of construction,,dimensions,depth of litpud, depth_a�f 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- .r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) 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 RESI>QRNTIAL: Design Flow:_a3Q_ZWlons Number of Bedrooms: Number of Current Residents: Garbage Grinder:___4ao_ Laundry Connected To System: Seasonal Use: Water Meter Readings,if v ' le: Last Date of Occupancy: — COMMF.RCIAL11ND 1CT IAI.. .,:A)u Type of Estabhshm ent. :A Design Flow: -. "'sallonstday 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.- Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information. 1,4 �� System Pumped as part of inspection: If yes,volume pumped: gallons Reason for pumping: 1'YPJ,.OF'SYSTEM:' _/V Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): ROXENATE AGE of all eompo&nts,date installed(if known)and source of information: . rs detected when'arriving at the site: .� •4- SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: l9 " Depth below grade: Material of Construction: ✓concrete metal FRP Miter. (explain) . Dimisions: ,5' 'X 51 Sludge Depth: / Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 26 �� ffl Distance from bottom of scum to bottom of outlet tee or bafIIe: - z " Comments,(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level Lt lation t utlet Invert,structur I integrity,evi ence of I age,etc.IL / ii GREASE TRAP:, A Pe ' Depth Below Grade: Material of Construction: concrete metal FRP_Other (explain) ,4 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.).- HT =s 11 G OR HOLDING TANK: �U Depth Below Grade: Material of Construction:—concrete—metalFRP_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 I el and distribution is equal,evidenY 411d &mZrr,, ver,evidence of 1 ge i o out otbox,etc. 7. PIIIVIP CHAMBER;j6,j—D ',� Pump tictnng order: Comments;,(note.,condition of pump chamber,condition•of pumps and appurtenances,;etc) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL.ABSORPTION SYSTEM(SAS): ✓ (Locate o' n 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 gafferies,number: Leaching trenches,number,length: Leaching fields,'number,dimensions: Overflow cesspool,number: Co (note condition of soil,si s of hydraulic failure leve f ponding, nditiop of v g ation, etc / i CESSPOOLS: v Number and ooa6guration: 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 vegetation, etc.) PRIVY: (J 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(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 46 ' DEPTH TO GROUNDWATER: Z to ?i Method��od dDeterm Feet tion or Approximation:F �✓�� D� ��1 �l i`J Ue i4/� v try h 7- R,_!�, �t t•!� Wit""'kaLti.C..iG S � \ k,ITY►.lp,�.,', 'DU�lnit�CTr�� Z Gt,•EI.� l�tE citt,��•l � l T I• (�G'fU►( _MS.t�t,ti..l Cam/D TD 1LE A� �?.,Or'I '.{�=�CO''��!f ,'-J (Ap v Z.MuKAICIPpt_ WaT�s'Z evc.I�P�t,,E . '-- � 5. 12I9E ?I-Tck• 1/4'/FT ur�t�s� oT ewts� �•lorEo. Ilad.O t,• b-LL+ CCCAST U►.175 AO-4-�C) -� '� � � ./tP� f ,'..-�' �0 �� 5. P t�Flo r r.t.Ts 5+•41�.t..t.. PEE M ooE 1.•i a'CE¢'R 1r�+1. Co• corssTEzUGTtor`1 DETdt�.6-('0 � ��E�• 2Datlrt' t�►tT1-a � 1 Maw Et IQv goWtN E� tsl, C,p) "CIT i 3 `, •-T itS 7LNa e�OCPbSCv Wo21C-ailL: drip AC%A t,D►I07 'aE a sE D �C P7-OF eT\(L- ►.LG',TA w LIO-r To r 2-"nF f1F.1►STor 17 4o, o - Akr ,U, -- y 4; ,G�-}l If i O! 3 f. r►�Ar -e ►to'cw,; = 4 �t LI>L T CDC Tom)✓t,6- - iZ�f T� (4+"�. 'Z7'cam w�.r_� I{ / "U-rLV'T'm 20 �G,";��", (a G�owtis} � UA.D LE . I h G 60 r-'L' CIAL ... ,L LO" 'TA K r'ti ry ,OTdI_ 4 \ Cr x 4- P(ZJEc..a.ST :.sue-s•G+�i P'Y' .i .r r•+ �, . -r .s c 1�.,'>�.�.r.t,::,� !--�%-'�, (r 7 M A . /'VI "I downGa e C n ini�c i� � atA << p g f / crv�L %} atli gca�E , �+,-� Do.'TE >v `1 1 ,�� 3r, �, t CIVIL E, tJggZS ;, at o� t�f.4i-T1� ` IZ7E CGd -(eeNtOUT", M&SAS . c