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Home My WebLink About0290 WAQUOIT ROAD - Health 290.WAQiJOIT ROAD,!c-b UIT�Y + A= 006 070 � ` �.IA BORTOLOTTI CONSTRUCTION,INC.I r0'�NoF / 19 .765 WAKEBY ROAD,MARSTONS"MILLS,MA'02648. tiFq�rH FPTT�� 98 508-771-9399 5084284926 FAX: 509-428-9399 0A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSF'ECT)j4N FORM fIr B. PART A , CERTIFICATION- Property Address:_o2 O UJQ Date of Inspection:_ G I I') I 11, In tor's Name:_ Owner's Name and Address: . 13 coo,., d TT #43 . ' . - CERTMCATION STATEMENT* s r ti I certify,tha$�Ihave°.personally inspected the sewage disposal system at this'addres!$,and thatthe'tnforma- tion reported below`is true,accurate and complete as of the time of inspection. formed based on my training and experience in the proper function and maintenaraco of,on-slte-sewage disposal tems The System: -4. Passes r Conditionally Passe 4 Needs FurtherEv tion By Local"Aproving Authority r fi' •�_�=Fails' pectoes Signature: _ Date: The System Inspector shall sub a copy of this;inspection report to.the'Approvtn4j�authofity' within thin ty 30)days of,compledng this inspection. If the system is a shared system,or hastO'designkflow of:10,000_ gpd or greater,"the inspector and the system owner shall submit the report to the;appropriate regional,` office of theDepartment of Environmental Protection:tThe original,should be send=toAhea "system owner and copies sent to the buyer, if applicable and the approving authority. NSIT XMARY- .' A7 � 'i"'ASS�iS:, T,! h .2 have not found any information which indicates that the system violates;ai"yof the failure — criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated,areffiindicaia" id I �t ' below, Na�21�a�±�k. till �:.'S�a rry :' .! ,- ''. •a - .. By SYSTEM CONDITIONALLY PASSES; q; �A Y ,One or.more system components need to,be replaced or repaimd.f The systttm;upon comple tion of the replacement or repair, passes inspection. Indicate t>4- yes,1 nor�,or not determined Y N R D �nc `��*� ( , ,O N ) Describe oasts of�etermanatiren.in instances.A If "ant a lainrwh not. - ' `3"`" ,' y n .. rw .6 h a,<k A nta yr.r a The septic tank is metal,crac:ad,structurally unsound,shows substantial w8ltra_ tton ors; t k ` r.<.ltexIIltration,,or:tank failure is imminent:kThe stemwill trim s3' pass';' 'pe U if�the'ex ng {.tic tank is replaced with a conforming septic tank as approved by.The� of.Health.` 3ewage'backkup or breakout or highstatic water.leveGobserved:"In,itbe;dist"on boxe s d»e to broken or obstructed i r Y pipe(s)or due to a broken;settled or uneven.d�srnbutIon box.` The. system will pass inspection if(with approval of The Board of Health): ' - 1- 4 ryh �. ,Z1-.l' mm� -"Rt..Y i ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A" ' s CERTIFICATION(continued) Brgken pipe(s)replaced s -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): Frokeri:pipe(s)are replaced- . <! removed, - '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 envionment'.` � w•) -) 4 Q,SYSjrZMjW. LL PASS UNLESS BOARD OF HEALTH DETERMINES.TH�T THE`' rSYSTZMf4S NOT•FUNCTIONING IN A MANNERWHICHaWILL PItO'I'ECT'THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT• ' , r, Y,x, FE�4 '� ` � s Cesspool or privy is within,50 Feet of a surface water 4 or privy is within 50 Feet of a bordering vegetated wet)and or a galt.marsh „,. n �p00� p vY , 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUI;IWCWATER.:; SUPPLIER,IP APPROPRIATE-)DETERMINES'THAT,THE SYSTEKI&FUNCTiON M ING IN A MANNER THAT PROTECT.THE PUBLIC HEALTH AND SAFETVAND M ENVIRONMENT: E , The system has a septic tank and soil absorption system and as within 1.09,Feet'to a surface 8 '4 water supply or tributary to a surface water supply." i The system has aseptic tank and soil absorption system and i =with a Zone I of a public'),V water supply well. p i The system has a septic tank and soil absorption system and is wttiun 50 Feet'of a rivets water supply well. � xi ;fi 5"� ,, . .. .� .t ba The system has a septic tank and soil absorption system and is.less than OO Feet but$0 Fact W,0 at Feet or more from a private water supply well,unless a well water•aualysis;for ooliform � bartPria. :d-volatile organic.compounds indicates that the v 0l is free from ponution from ; y _'.' r A � T the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to orrless •�ww s ppm t F.,j e r9 3 7d3 ' 3tir� 1 D)S�YSTEM1AILS:. I have determined that the system violates one or more of the following failure criteria as de5t�od t in 310 CM R 15.303: The b&4is for this determination Is Identified blow. The Board of Health should be contacted to determine what will be necessary to correct tlae failure d ibs Backup of sewage into facility or system camponentAtie to sWoverloaded or"clogged SAS or cessp001. yr:l ^r v".'1 �x✓r ; Discharge of ponding of efluent to the surface of the ground or surface waters due to an a overloaded orclogged SAS or'cesspool" Static liquid level in the distribution box above outlet invert due ti,`sui`gverloaded or cloy g�SAS'o'r cesspool: i1 f� k Liquid depth in cesspool is less than 6"below invert or available volume`is less,than 1/2 f 777 day flow. ':r i#.§. - .1A �..� F,.4"�$t {•.kt. Required`pumping more than 4 times in the'last year NO!due t�►ivlogged or'o6structod j pipe(s).'Number of times`pumped° t � I: f Ij SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION N FORM } PART A CERTIFICATION(continued) i Any portion of the Soil Absorption System,cesspool or privy is below a high groundwater elevation Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface watei supply. Any portion'of a cesspool or privy is within a Zone l of a public ivll Any portion of a cesspool or privy is within 50 Feet of a private water suppiy well. 1 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 1 las been,analyzed:: to;be acceptable,attach copy of welt water analysis for coliforn bacteria,volatile organic oompourids;ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: M The following'crileria apply to a large system in addition to the criteria aboye: +_. 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 ok mora ithe following The system is withn`400`Feet of a surface drinking water;supply t r� t spy ,, The system"is within 200 Feet of a tributary to a surface drinking water„supply..i.s > � �` The system is located in a nitrogen sensitive area Interim WeRhead Protection=Areal c (IWPA)`or'a`niapped Zone Il of a,public,water supply.well,r , 6t,,Wj C ovvnef or,opprator of.any such system shall bring the system and facility into fulldoompltanoo &_0Wwater treatment3program requirements of 314 CMR 5.00 and 6.00,.,•Please oonsui Y local ' regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST,, .. ..�,`C",if the following have been done: .,r. ,, ...•.•r. s *i *i} yt,,w " y t u►g information was requested of the owner,occupant,and Board„of Ialth.,� ' one of the system.components have been pumped for adeast two weeks,a4td`theA been receiving normal flow ratesAuring tha(period i Large volumes of vvat�r�haveynot b xr introducedutto the system recently or as part of thii.inspection.. r r� ✓ As-built plans have been obtained and examined.,Note if they are riot, ,available i The facility or dwelling was inspected for signs of sewage back-uppi.,. The in does,not receive non-sawtary or.industrial;waste flow; *.. 4 , ✓ ' ,site i was inspected fot:signs;of breakout.. . -V/ Allsystem go i nents,excluding the Soil Absorption System,have been 1 ..trod on site.N sep_Wtattk�manholes.were uncovered;o n and the intanar o$r4t aseptic(aril ingg � r :..1.• " V •eV: R+ Si!£4 b, { 5(%IN 3 sported foi,condition of ba lea or,tees,material of construcl1tion,dime ttston6,{¢epW�o 4 ut i 1 ..� . . depth of Sludge,depth of scum. 5 rlpzr �9 f �i QS ii •, 4jnFs QQW`�tyR i+.j &vP'S d tk r e size and location of the Soil Absorption System on the site has been determinetl based on_ fr. '' existing information or approximated by non-intrusive methods, . -3- 2. ''"." FON'.isi.*"e yR.li },„ '.'1!"c `.i. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) j ra,�The facility owner(and occupants,if different from owner)were pr®vided wio information on the.proper'maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM:1NO PF TION�FORM ' PART C I SYSTEM INFORMATION FLOW CONDITIONS : 4 RF4IDF.N'1_'IAi w �y 1 0 Design Flow: 30 ;_gallons Number of Bedrooms:y2 Number of Gufrent Res1dents:' Garbage Grinder: jr)o Laundry Connected To System: Seasonal Use rl O lvlWatevfM er Readings* if available: Last'Date of Occupancy • COIi{LMERC ALIINDUSTRIAL! Type of Establishment: DesigriyFlpw ,4,, _ aallons/day Grease Trap Present:(yes or no ,s ,,a, '0 s'` , " IndustrialWaste Holding Tank Present:- iori•Sanitary Wastc Discharged To The Title V System: " Wate Ue6r'Readings,If Available: Last Date of Occupancy 'z''J x.: .r: 3x�34, OTHER:I Describe) .Last Date;of Occupancy: GENERAL INFORMATION 1UMPING RECORDS and source o! iformation: 3 ? r � System Purnped'as part of inspection: /)D if yet volume pumped .Reason foipumping: TYPEVOF SYSTEM: t Septic Tank/Distribution Box/Soil Absorption System Single 1 Cesspoo s'Overflow Cesspool Shared.System(if yes, ttach previous inspection records,if any) , Y' � pRia F dyer a '4 3 L a ✓ Other(explain} q '{ 'o4 ::e AP P OXV"TE AGE of all mponents,'date installed(if known)'and'setirce of"ipformation j 4.. f.* a :SF. . qs �r•_ �' ,ink 6 3�3et� 3 ¢ ge odors"detected when arriving at the site- /V0 -4- : - =,,,,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM b :. §... PART C t ;, GENERAL INFORMATION (continued) SEPTIC TANK:_ below a /a �� /D�CyP�th + grad Material of Construction: metal Other . : 1..a,4'i Dimislons:! Sr.S"xG 'cs' Slud a Depth: t Scum Thickness `' ylonA Distance.,&o ...top of alud a to bottom of outlet tee baffle:or bae. Distance fiom bottom-of scum to bottom of outlet tee or baffle: D ; Comments:;(recotntnendationfor pumping,condition of inlet and outlet tees or batlles, epth of liquid level wrelstion`to'outleflnve,structural integrity,evidence of lealta a etc. '� �� 12 df. r d Depth Below Grade Material of Construction.`' concrete metal"" FRP Others"3 770 Dimensions: _. Scum Thickne _ ss: '. Distance from top of scum to top of o_ytlet lee or baffle: , 'dommeats:,(recommendation for pumping,condition of inlet and outlet tees or baBles;depth of li it!,�� ~level an relation:to outlier invert,structural;integnty,evidence:of leakage: }:.WT4 , .{ , TIGHT�04 HOLDING TANK:�/D Depth Below,Grade` Material of Construction: concrete- metal �FRI Other(explain) .�tmensto '., r Capacity _ — N gallons Design Flow: t:allons/day'. Level• � � . , CoiQtments:I(condition of inlet tee, condition of alarm and flout switci�es,etc.} f" S: ,<.:..`{ ,... •: .:rna •^r...vr y+r "n'"i'N'xf '*, ," a:t.g iso-. �.., DLST*lBUjT1ON.BOX:1✓c) Depth o(aquid level above outlet invert: r x �w Comments`(note if level and distribution is equal,evidence of solids carryover;evidence ofleakage'into'`'": or out of box,etc.) -PUMP CHAMBER:-A .Pump is in wo*ingVder: Comments:(note condition of pump chainbei,condition of pumps and appurtenances,etc.) } �..... i'.'c{ ..µ_..e,f.. ,yam,". i .. -. .. -.••W,. _ -c ^,-.._ _ •.-` _ < _ I t s .. b yt�tr'�rty i lryrr'' J :�M�r;�1't$5i `� d 7r „N ga SUBSURFACE SEWAGE DISPOSAL SYSTEM IN'SP'ECTION FORM I PART C �. SYSTEM INFORMATION(continued) Splu.AB�SORP!TIOli SYSTEM(SAS): (Locate on:site plan;if possible;excavation not required,but may be approximated by pon-intrusivwu4,4r:* f• - methods) �'lf not determined to be present,explain: �7!^' .d i .. Uighing Pits,number:Leaching chambers,number: Leaching gaile�ies,number Leaching trenches,number,length: Leaching fields;number,dimensions: tweifiowcesspool,number: - Comments:(note condition of soil,signs of hydraulic failure level of ponding,condition ofvegetation, etc.) '4600 f A ,'VaYVM�O?LS:� p• . - q Number aid oonfiguratidIC' Depth-top of liquid to inlet,inve 1 Depth of solids`layer, + Depth of scum layer: Dirnensiofw of Cesspool G r. ' r �' > p) `� .�.:ri .. t A w-,.Mi•,�.vm.:e.v�..�,ua.�•,+, 'rr I,+.. c f°P'c�' Materials of construction: Indication of growislvwter Inflow(cesspool must be pumped as part of inspection) Ya} t$ Comments:(note condition of soilk,signs of hydraulic failure, level of pondiatg,a�ndition of vegetsNon,°� Qj I� P�:�V Materials of construction: Dimensions:• Deptth of Solids: Co" (note condition of soil,signs of hydraulic failure,level of pond'ang,condition of vegetation, {` "Y 4ti'ry ;t ,tir ,P fi .< g w 1tWE I , !f. s t r'•'i n Amy{e +a y.Nt bA�r t p S q ,fop JJ{ Oi'N� ' .4 c,,ry�t p sE:i .•e.✓'!'n �.., I i ,1 f}yr1 -6- i;' tray,. t '5f I �a t r -'SUBSURFACE SEWAGE DISPOSAL SYSTEM 1141TEgC'!bION FORM C PART C SYSTEM INFORMATION(con41nued) i SKETCHIOF SEWAGE DISPOSAL SYSTEM: Incl#de ties to atleast:two permanent references,landmarks or bencl u nirks. Locate all wells within 100 Feet. � .. n a —10 .eA- c _Y 6 4 < DB,PTS TO GROUNDWATER: Depth torottndwater: Feet Method of Detbrmination of Oproximation: iI- i t -7- - f i CY r ry ego TOWN OF BARNSTABLE LOCATION 099 -tsCC .a al"44 goad SEWAGE # VILLAGE �OTU/T ASSESSOR'S MAP & LOT ODto Q—'JD �n NAME&PHONE NO. Ao6ecl- �. Goi +JaAki Sint 9I/-%3j� SEPTIC TANK CAPACITY id00 9Q,&O r') LEACHING FACILITY: (type) 6, P_ 4—w s4,r,e (size) /000 q�� NO.OF BEDROOMS v '3C I // // WaHE)R OR WNER S4e✓e hto-r=P )a n PERMUDATE: 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 Ike or within 200 feet of leaching facility) Feet Edge of Wei`and and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) "' Feet Furnished by