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HomeMy WebLinkAbout0068 MARINER CIRCLE - Health 68 Mariner Circle, Cotuit i A 023 - 059 i 2�6 cr V,, P' n 0c) ,3 Alt BORTOLOTTI CONSTRUCTION,INC. 16 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 V T04*0F', 199� 508-771-9399 508-428-8926 FAX: 508-428 9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RT A jNaine:V4" LFICA'1'ION Property Address: Date of Inspection: Inspector' Owner's Name and Address. CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at Ihis address and that the informa- tion reported below is true,accurate and complete as of Lhe 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 dstems. The System: Passes Conditionally Passes Needs Further Eval lion By th 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 now 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. R A)SYST M PASSES: I have not found any information which indicates Lhat the system violates any of the failure criteria as defined in 310 CM.R 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 slalic water level observed ill 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 Heal(h): - .1 - I r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r 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 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)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 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 G"below invert or available volume is less than 1/2 day flow. I - , , _ Required pumping more than 4 times in the last year NOT,due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE UISi)OSAL SVS't'F;M INSPECT7ON FORM PART A CERTIFICATION (cowhinc(l) Any portion of the Soil Absorption Systen►, 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. ll'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 CMII 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 CIIECKLIST Check if the following have been done: _Pumping information was requested of the owner,occupant, and Board of Health. _V—None of the system components have been pumped Ior atleasl 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 N/A. &I ' he facility or dwelling was inspected for signs of sewage back-up. -- The system does not receive non-sanilary 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. �he septic tank manholes were uncovered,opened, and the interior of the septic tank was in- s mkd 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 or approximated by non-intrusive nactl►ods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 11 CIIECKLIST(continued) U The 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 v RESIDENTIAL• / Design Flow: g zJJ gallons Number of Bedrooms: Nui ber of Oirrent Residents: Garbage Grinder: Laundry Connected'l'o System:. Seasonal Use: Water Meter Readings, if 'table: Last Date of Occupancy: Jy,_V1_ COMMERCIAL/INDUSTRIAL:/" 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: OTHER: Describe) Last Date of Occupancy: GENER NFORMATION PUMPING RECORDS and source of inform ion: �P�, � Cyr System Pumped as part of inspection: If yes, volunr iuqped: 2� V gallons Reason for pumping: TYPE OF SYSTEM: _-1,-'Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): APPROXIMATE AGE of all co m onents, date installed(if known)and source of information: Sew ge odors detec ed when arriving at the site: _ / _-4- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: 11 Material of Construction: L- concrete metal FRP Other (explain) - Dimisions: Sludge Depth: Scum Thi�kness: Distance from top of sludge to bottom of outlet tee or baffle: ;3 y Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for.pumping,condition of inlet and outlet tees or es,depth of liquid I el in ation too let invert,structural integrity, evi nce of leakage, etc.) e r 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, e(c.) DISTRIBUTION BOX: f/ Depth of liquid level above outlet invert: z� Comments: (note if lej and distri utio is equal, eviclenc of solids carryover,eviden e of leakag into or out of ox,etc.) PUMP CHAMBER: Pump is in working order: Comments:-(note condition of pump'cliamber, condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): y (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: J Leaching pits, number: / Leaching chambers, number: Leaching galleries,number. Leaching trenches, number, length: Leaching fields, number,dimensions: Overflow cesspool, number: Comm ts: (note condition of soi signs of hydraulic ilure level ndi ng,conditio of vegetation, etc.) / rr r CESSPOOLS: 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(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: 10U 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 (conlinued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to adeast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 01, , (P�� o DEPTH TO GROUNDWATER: Depth to groundwater: % y Feet ) Method of Determin don or pproximatiow !°G ),?)"/ -7- cP1 0 I I 0 a � act IA — 2 e A � Cam! 9QN 7 'M ad 9OQ-, man ��n TO>VN OF BARNSTABLE 1 _ATION SEWAGE # VILLAGE ll Tr - ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 000 LEACHING FACILITY: (type) (size) NO. OF BEDROOMS V. BUILDER OR OWNER C-tekSly PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 ~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION(cumfin-d) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include lies to adeast two permanent references,laudnmrks or lamclmrarks. Locate all wells within 100 Feel. �I S'3 DEPTH TO GROUNDWATER: i r Depth to groundwater: %..y Feet ) MethodofDete' 'on ar pproximatian: /"GX.0 p09' G�i.S. s sL 9'7�2'C` s1J(Z'.I�j w rw TO OF BARNSTABLE . LOCATION�� SEWAGE # I �» _ �i 1/7 VILLAGE ASSES R'S MAP & LOTD 59, Tit,�Sl�CG7Z^�NAME&PHONE NO. 54),f- � SEPTIC TANK CAPACITY /DDn P t; z f ►2jy LEACHING FACILITY: (type) .C� (size) 1600 Qf2:Ya2 . NO.OF BEDROOMS BUILDER OR WNER 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 facility) Feet 4 Furnished by d � -- ' "` :.. ��1�� c 3r i� �, '� o � 3i '� v v • - c z o !7 75 r ^^ O � s � O n N $ N C v v v `^ z I o r p / a �✓� ! � 'r r �) T � �: �iS'`�� �® 7��K ,. ��� 0 � � C- r ���IJ�� �,/� r ���� � d C.. .............................. THE COMMONWEALTH' OF-lMASSACHUSETTS BOARD OF HEALTH ....... ..............OF.... ........... ---------..._....------..................... Appliration for BiiivniiFal Works Tong rurtiun Pumit Application is hereby made for a Permit to Construct ( or Repair ( . ) an Individual Sewage Disposal System at: ca on-Address 7>`,.�3 /////!/-��f, r Lot No. .. ....._. L..f.(1t....SrS.� o............... ` ................... O er a � .... ...................... ......................... ................................................................................................. Installer Address Type of Building Size Lot._c .,._g___f----Sq.(feet d � Dwelling—No. of Bedrooms _.__._.__ _________________.......Expansiontttic ( ) Garbage Grinder per, Other—Type of Building No. of persons..... P! Showers ( ) — Cafeteria ( ) 1 Q' Other fixtures......................... . W Design Flow.................5-�..................gallons per person per day. Total daily flow......3,,-��'--.�-J-......................gallons. WSeptic Tank—Liquid capacity../�?gallons Length...X ... Width....4.." . Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........../------- Diameter.......4/..... Depth below inlet......;7..3_... Total leaching Z Other Distribution box V Dosing to ( ) Percolation Test Results Performed by..__..__ _. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----- .. e Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------.-------------- -•----............---.........------......._....._ -•-----•----.......----.....---•----............... O Description of Soil - ----�=-----------------------•-----------•-----•------------•------------------------ ... ---------------- V ------------------- .. t, x =�� ---•------------------------------•------------...----------------------------•-----•-----•.._...-- 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 ii "T I-. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ued by t o d of health. > �j Sid. . .....................•................. ........s...... . .._ / Dafe Application Approved By----... . .... ....................... .-- Date Application Disapproved for the following reasons______________________________________ ........................................ ---•-•---•------------------•-----.......------------......•------------•-------------•--•---------....------------------------....._......----.........----------------------------------------•-..... •------------------------ Issued.:L _. Permit No............. .`......Date...... Date No.................; . Fxs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CG! ......................OF.... Appliration for Disposal Works Tonstrurtinn Prrmit Application is hereby made for a Permit to Construct (,?�) or Repair ( ) an Individual Sewage Disposal System at: 15,7 ----- -. --•••__------------------••-;••---•-- .............e. - ......... ..-- ----_...._.._._. ...•-•------....--- --....... ...- c ion-Address /� T _• or Lot No .... :�,/-� dre,�.C_�`X� ........... � ........---• --•—� � 2 .................. .. 42 C9 ner A �L"ciea€ers '�.c.•'F� a � , 7./u __ i u .......................... ---•----•----••----•-----•--._......----•--...•..-•---•--•-------....•-._...........-----•-•-•-- Installer Address Type of Building. Size Lot--- J -. .....Sq. feet �., Dwelling—No. of Bedrooms.................„_...................._...Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building /��� ��' No. of persons a YP g -- ---'- . .�'.------ P �•---------------- Showers ( ) — Cafeteria ( ) Q Other fixtures W Design Flow.................:' . •__•_•_.•••.....___gallons per person per day. Total daily flow.......�a � __._...-.•_....•.__•._gallons. i ,' W Septic Tank—Liquid capacity_- gallons Length---Z.-,a••-- Width.__1(`. ~_ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_______--__-_--_-___sq. ft. Seepage Pit No..... /..._._.__ Diameter..........._•._.- Depth below inlet...... ` •.•. Total leaching area_:-?�_ �s'�j'f Z Other Distribution box V Dosing tank l a Percolation Test Results Performed b ._ ��� ??� :?G.•.." - _ _.--- •,/-)1�/,� Y ----- - - ... Date_ .,�--..._•... ................. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water__ �� - �T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......___.............. a 0 Description of Soil....... !.••_ •_...-, �lr �t x ... ^-------------••--•------------------------•-•-------•---------...... ---------- •------,-------------- ..................--------••••--••••• •..._.. �-2 ...... -= a x � j = - 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 TLI L,'_-5-of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by bo d of health. Si d- :_ . :. Qz .....�� �... /`/ � Da e Application Approved By....... --���2�- --�-•••--- -- --� - -Y-•.............•------- -._/..._.:�_­_ j Date Application Disapproved for the following reasons: -••---------_ ...-------•--------------••--•--•-----•-------•••--•••--••-•••--••••--••-•-••-•-•••••-••••-•••••--•---•,--•- Date PermitNo................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH `.............OF. Trrtifirtt#r of Tuamplittnrr THIS I TO CER -I Y That the Individual Sewage Disposal System constructed (. ) or Repaired ( ) by >. ..............................................................st .....-..---•------------------------•------ ----..............-------•-- at has been installed in accordance with the provisions of 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit tNo __. __•___•.�...________-•___-_- _- dated........ ............ f THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F NCTI SATISFACTORY. DATE..... ............................................................ .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAk-TIJ -/........ OF.......... >- �C�?.��............... .__... ................. .. Disposal Workii T - ssirnr#' n rrr it -Lr v ?S Permission .f _= -- .............................................•- s hereby granted to Construct or Repair ( } an Individual Sewage Disposal System atNo... _ ••• - --•••- j ��: ..._...0_......_ ................................................... as shown on the application for Disposal Works Construction Per it No.r__ _..-___•_' ated••_.,� ...'`�.-__". � Board of Health /' • ,,.:,r DATE----- ""__.'�...... ,,,� -------••••••-••••-•-•-•••-•---••--- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ~ wn » F.FL. E.LEV.=_ 2.. FINISH GRADE s xo FINtSN GRADE F1N18N GRADE-- OP OF, FOUND. ;.�. OVER TANK Z,x OVER PIT i. ♦k �• . • L\ CHIMNEY ®1_OCK 't .. 4" V.C. _ - V C✓�� wl+Eae NEEDEO BACKFiLL - ` 3 PEAS TONE er — --_1, r •� _—, 0 CELLAR )OVU GALLON } ' `A• ° o p o o � N „ E1.EK, xa , REINFORCED GONG. d a O (D C) o 3/4 TO I-!/2 } ID r t CRUSHED STONE ( o ° O O O o ' ofD�0 DIST• a I v. t • o ° e 9v e ' Vi♦ / v I p a e I a O r) �J O O ',! 0 c SEPTIC TANK ( TO BE LEVEL v 7 I o o 0 O o � BOTTOM OF PIT 11 M •, rr11.1 AND STABLE ) /1 c © o 70\j, 777N O o a ELEV 5LL2 SYSTEM PROFILE ( NOT TO SCALE) LEACHING PIT DESIGN CRITERIA L a T' 118 Nl R QF<'FOR©Qw3 ; _ 1 GALLOWS PER DAY GARBA$E faRWDE.R Vif IA rOTAL DAILY FLOW S Istm 2Z2-o" $ LEACHINS AREA PROVIDED- �c�� r•_t�� ! � `�'` ice•°r c .A, Ws. (4) , v 1.o N N 3 `•r k1 EPT1C '4o P ! r - � t L T Ilia ! (' PROPOSED SEWAGE KiJl+lr U I �:..�..k.��.F 1 t ' �►!�1 DISPOSAL SYSTEM £` PROPOSED DWELLING tt l?5PEGT£q w e r M6.i kfRA o.3 z, oAT E _ a t MASS. F'tERat31,.ATf ON RATE 04t1}1 MlCt1 i, SCALE AS NOTED VATE 1e/0(917e' ©Trio.: °''."'f'��,"( -=----- ----_--- _.._ __ -•_ __. _.� ;______ ,. �•�;, DW EjI{ D 9Y, `' �^►t)r~�1R!'•. ,^� (�E�J e.) 1`.;> „7Tda,: (..1)I t .:,T I`:'JG.:'�et r,ti . d� 2 - LoT '�1.•1G�r4fht Cis�v�.,.� -Tut3�. !�'7 �HE�-r' 1�.10 � 2 � , 3Wyy a�A��pp �a _` 24 C�e�-,�.T PO 0 C:)P-tV� c NORAAAN GROSSMAN PE, R.LS • ` ► ; E" 226 HOLLY POINT ROAD "f " I tS-r C`.oAj'Tot.3 CENTERVILLE, MASS.