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HomeMy WebLinkAbout0066 ROOSEVELT ROAD - Health 66 ROOSEVELT ROAD, COTUIT A= 039 134 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property Z,-n-�tF_vr,::--r r-t> T, M4- MAf `03-1 Owner's name V. J t- LAMS Date of Inspection 4-Z o-0it> PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the r-4X-iQ4, 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 the are not available with N/A. y The 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. y/ 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. v/ The size and location of the SAS on the site has been determined based on existing information Ll The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. i' - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms number of current residents garbage grinder, yes or no laundry connected to system, yes or no ES seasonal use, yes or no If nonresidential, calcu;lated. f ow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: N0jm IVACO 4,ce-o2r�,► & v System pumped as part of ins e if yes, volume pumped NOction, yes or no Reason for pumping: Ty of system Septic tank/distribution box/soil absorptiori. syst`m Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: 83 F,oH 1ZQ:,ozbS Sewage odors ,detected when arrivingat the site, .yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate. on site plan) depth below grade• material of construction: y concrete metal er ex lain FRP oth ( p ) dimensions: X �- l0 ( 14StDC X 4 sludge depth -- distance. from top of sludge to bottom of outlet tee or baffle 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 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, recommendations for repairs, etc. ) . 0 5 u L- NO i ' >:c MMWO g o f co,j tre-S 1p W tj Cp wc is Li C4U I D c9N I,H 2'- 3'` DyPT14- . q '>=i�`fiW�4a T77B v�- 1.14r��4 �rJ Ro7'fOM D F ovTt1�7 Tt"'>L DISTRIBUTION BOX: ES (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or. out of box, recommendation for repairs, etc. ) `�-�o x i s y,���� ►�►0 1�►�T��NGC o� �o(,��S C,422yo�J� � rJ o Ctl t 4 ir►•tCt= ti� O 2. v yr' D� 1. �6?��+� �Isr 7•!� !o'� � I '/L" i3 C1.oW o U't'1.� iNvER-t- Iro''x Ito" Vu iS'w Twml` stvni PUMP CHAMBER; N (locate on site plan) pumps in working order, ' yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) v 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (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 leaching pits and number . ES leaching chambers and number �����_•� X leaching galleries and number leaching trenches, number, length — leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) 14" U t4 tr> EE 21��5( 1 co►.S►�( (9►� '`16 5 w� rE?3oV� �lOtJ�SD W —lo�l CESSP LS (locate on site plan) : number an configuration depth-top o iquid to inlet invert depth of solid layer depth of scum la r dimensions of cessp 1 materials of construc 'on indication of groundwate inflow (cesspool must be mped as part of inspection) Comments: (note condition of soil, signs of h raulic failure, level of ponding, condition of vegetation, re mmendatio s for maintenance or repairs,etc. ) PRIVY: (locate on site p n) materials of. nstruction dimensions depth of s ids Commen (not condition of soil, signs of hydraulic failure, level ponding, co ition of vegetation, recommendations for maintenance or r airs, etc. ) 11 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 ' 1, ,1 � � S�PrtG 1A�11L, 44 1 � DEPTH TO GROUNDWATER > 1z depth to groundwater method of determination or approximation: oQ��r tissrt, P 1AM1 4,)r-, 50l1. "gd.n-rOS U �v 2vV�lD ryAfit.�(L.- t.►.)Gc�vt� an.l.'� t t0 1 Z 1zo2t.�Cs S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) IV Backup of sewage into facility? Discharge or g ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distri button box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 da', flow? 1V Required pumping 4 times o more in the last number of times pumped year. Septic tank is metal? cracked? structurally infiltration? substantial exfiltration? tankufailure imminent?al Ar Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? �V within 50 feet of a surface water? within 100 feet of a surfa ce water supply or tributary to a surface water supply? within a Zon e I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh y, not the SAS) . —A within 50 feet of a private P water supply well? 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 co _ for coliform bacteria, volatile organic compounds, ammonia nitrogenand nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL T DSYSTEM INSPECTION FORM PAR CERTIFICATION Name of Inspector DA1J 1 r::7L W . SAAJ7aS Company Name ha-swl � Wit wL Company Address F, D . 30x- -7 P_A-9wsTAi6t.E, M4 02.16 3 C) 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 recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Che k one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 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 to: Buyer (if applicable) Approving authority �•I�,\ �@ r to �X GfiR-b&.t� e�. I Gajc�S `. `...._.�_ �d 6,:G 7 - t /L PoN hearth D rOn � I Barnstable Town of Ba .��-r PO Box 534 / Dl� ,• siU :..•, . 4 ;�. -� Hyannis,Massachusetts 02601 µCw 33 f c -- - • �- Fax(5 44 06)775 .. _ 0-6265 n 50 8 79 — _ - P ho • NOQ1?_.DCGK t fLal_ ' :�' I ' '•. O'Sll.l Ooo 2— .I� � I 1f �� r I tsa rM sA- - fl� � .77 I{ �-U 1n111M PO ,y I 1 I I F�'— M I E• •r,l '.j�.. / �p _ �/ f � c ,1F ,1' �..1(((� 1 � � I� �o a 1N.. � i ' OO ®.gEOR � �1Nn 1 •li'�'Se?�^ 1 I I I i'''_4fRt5 � •1i1 - g <I � � _I� -1 _ '6 1 Y� 1 I i" �" 11'•o• 1 '}---r— It_ . �•- .., - x_ PITCH 41• To pool C\ I _au:avi►1.�-ro HoUs�,. - I��i )�� •�I1..IY�-'yI .Q I 'I, i � in' I�•• -i• > i Y G _ C ...Y . 1. •� •L• _ I ING R O O tj � 11'•l0' ' tinC• �••T. i :+j•rl' OM Doom 9'/l'C1 H. rjoOC 902c. - i PEE O fLn ,L TILL v i , d1iGP. 41c0 • � � I ee vy�k +yet•4l,q,t • _o TO I►d OF BARNSTABLE LOCATION WAGE # VILLAGE ASSESSOR'S MAP & LOT S•ir INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY //?e,, d LEACHING FACILITY:(type) (size) er)"i A CJ NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Lea C. %6L S e'P{;c tfci h K /Jo .re o 'QccK �i 3 �1 �J L O CATION E W A G E PERMIT NO. VILLAGE I N S T A LL 'S NAME A ADDRESS 494 ® U I L D E R + OR OWNER ' DA T E P ERMIT I S S U E D Al DATE COMPLIANCE ISSUED "5 14 i I Q N�fJ 3`„U3 Fss...�...�. ........ THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH 8tc�iJ...............oF.....:0a .fZ T --e......_.................------ Appliration for Disposal Works Toniitrnrtion Pjamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: nn �r� .....66J.-•-.......s.,x?.7-.Ua .... ................................ ?'z........................................................ L.c n-Ad t No. a Owner Address ` . ............ ••-•--..........V. .......KA........ D Installer Address d Type of Building Size Lot....-�7 fl� ._Sq. feet U Dwelling—No. of Bedrooms_.._.._... Expansion Attic Garbage Grinder 01� Other—Type of Building _./i�®.�1 .....__.... No. of persons...... ................. Showers (�) — Cafeteria (Afc} Other fixtures -------••---•-•------•••......•. Design J ............................gallons per person per day. Total daily flow.......... ...................gallons. W n Flow........ ... : WSeptic Tank—Liquid capacity...LP. allons Length....b�...... Width......4...... Diameter---- _.._'--- Depth....'......... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..e2.4_6.....sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area............:.....sq. ft. z Other Distribution box ( Dosing ta ( a Percolation Test Results Performed by........ �.� e!Il..� ..... Date___....Test Pit No. 1... minutes per inch Depth ? ....r'It Test PW---- ground water....., Y 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------•--• . r......-•••--....----- ...�_-------- -----•------t ••-•••............•......................................................... O Description of Soil......C>-..:-_._�- ......._. o.?-SOA+.- e,5_ -_ n...... T6. t �T6.e,5_�0_z'..4...................... x W ..........:•-..............................................................................................................................................=............................................ VNature 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 TITLE 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 the board of health. A Signed.. r 6� .. _. a�. .......... ----=.. .. ..... Application Approved By..............................' LB -- ... -- -•-•-- -• --•---... Date Application Disapproved for the f ollowin' re ns:--••...-•-•---•-•-•----------------••---•-•------•••-•-•-•------•--•--•-••-•-•-•---•---.._....•--..........••••- ..............................................................X -- ......•.....•••.......•.. '----............-•---------•.............................. --..........Date............-- PermitNo......................................................... Issued-....................................................... Date i � .... .........0........ - 1­1-,,— THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I M A I / �C(�� L DATA N�,1 ,3` 3 Fxa..:� , ....... �y THE COMMONWEALTH OF MASSACHUSETTS r _ BOARD OF HEALTH _ ...............OF ..t�,. J.`.. ' - , lirtttion for Uwvwial Workii Tomarnrtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..................................:.:...................•----.... ...----••------------... 11// Location Address / or Lot No. ...............l ..C. ..........:a-.!-- -- I • t l b 1 ✓1 t-_ .......•.......... ........................ - ,Owner` Jy (' - •-• c\ --.....1....t_ _.e--------------•-•- ..........................................I_Address..............-•-------•-•-•----------••--• Installer Address d Type of Building Size Lot...... (> Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic (/Vt) Garbage Grinder (��) aOther—Type of Building j....._,., c Not ersons.......�1`................. Showers (�) — Cafeteria (4))% d Other fixtures ..................... ---= "" ••-•--•--•--•--••---••----••-••......--- •---•----•--•--•--...----•-•.............................•••• W Design Flow.........?.. ............................ allons;per e n` `er day. Total daily flow...........:5..............................gallons. Septic Tank—Liquid capacity...- gal 'ns U_...... Width.._.__>:._.._.. Diameter-_-_6.._...... Depth.... ......... xDisposal Trench—No. ............ ...... WIct _:, .__._._... . Total Length.................... Total leaching area....__._____._......sq. ft. Seepage Pit No_____________________ ameia . ............... inlet................--- area..................sq. Z Other Distribution box Dosing tank ( ) .r Percolation Test Results Performed b ...............................t`1��� b4...h....���° ........:%........... Date......-._�f.�!� Y , Test Pit No. 1....�_......minutes per inchAD,,pth o e ,iiit.../.�... Depth to ground water...... !��._.. CL, Test Pit No. 2________________nunute inch �o Test Pit.................... Depth to ground water........................ o' _..._. ---------------------------- ------ --- ------------------------•-•._............. O Descr>prionofSoil . �� �� /G -.( . . f-----'--�-- ` ------------------------------------------•---• x ............................... / ` W -----------------------_....----_:------•-•----•---........_-----......_...._.............._.__...---......._...-•-•------....----....----............................................................ UNature 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 TIT1Z- 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 the board of health. Signed........... .r . <:t.�...i., ... .. IJ ApplicationApproved BY............................... . . •_.•..................................................... .....�-';.......... Date Application Disapproved for the f ollowin rear' s:-------•------....-•................•--•-•----------------------•--•--------.........••••....................._ -------•-------------•--•-----.. Date PermitNo......................................................... Issued.................. ................................ Dattee THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.......! ......................... ........................................ Trrtifiratr of Tontpliatta THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( Zl or Repaired ( ) by......... ,1 a , ; - ;--c-(, '...................•----........_..................... Installer/ // r ,f / / T`cJ / ! at �:.......... ..1...'`_f__u has been installed in accordance with the provisions of TI"' F 5 o State Sanitary Code ®es d in the application for Disposal Works Construction Permit No.......................................... dated..........,./.___11..... ......___....._........... THE ISSUANCE .OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL FU,CJTION SATISFACTORY. DATE-••.�•%••-��-•-•-------....•......................•---•--•-•---- Inspector. ... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF r I i r H�'.EALTH �(///�(4. ...................OF............................... N FEE.... .............. MsVaoal WorkiiOunnotrudian rrntit Permission is hereby granted........ ^..%.........._ .. :!+.-%.f -------•---------••--•-----------------------------------••-••-•------....... to Construct ( V)or Repair ( )fart Individual Sewage Disposal System at No � . ✓ _t � r` � -f,,/i ?` ...........s r-••- --•--•. .•....-•--••......•...................... ..••------------••-----•--•------•---•---••••-•-•-•-•-•---•---- ---•-- •- Street as shown on th/ap cation f r Disposal Works Construction Permit No....___..._. Dated./ __ _..9�7..._.....__. .............................. �...•-----••-------••-•-•--••-----•-•••--•-••-......•-•-•-.......•-•-•- l Board of Health DATE. f ......................................... FORM 1255 A. M. SULKIN, INC.. 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