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HomeMy WebLinkAbout0156 WHITMAR ROAD - Health 156 WHITMAR ROAD, COTUIT ----- - - - -- -_ A= 056 074 ----- -- -- - / >S ! BORTOLOTTI CONSTRUCTION, INC. V �D o�y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Of Property /S i p�iY)Ci L d Owner's Namep -- Date Of Inspection9�- PART A CEIECKLIST Check if the following have been done: r/ Pumping information was requested of the owner, occupant, and Board of Health. - v 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 columes of water have not been introduced into the system recently or as part of this inspection. �j As-Built plans have been obtained and examined. Note if they are not avail- able with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The site was inspected for signs of breakout. All system components, excluding the SAS, 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 SAS on the site has been determined based on exist- ing .information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If/residential 7 number of bedrooms number of .current residents garbage grinder, yes or no e S laundry connected to system, yes or no wry seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Ce!✓r�e��' Last date of occupancy GENERAL INFORMATION Pumping records and source of information: ' /yQ System pumped as part of inspection, yes or no ' if yes, volume pumped Reason for pumping: Type 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: /� (� Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION CONTINUED SEPTIC TANK: 6% (locate on site plan) depth below grade: k material of construction: concrete metal FRP other(explain dimensions: /©.5r6 X 5`1v.rGA/ sludge depth p distance from top of sludge to bottom of outlet tee or baffle scum thickness. Z� 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. ) ns � o ,• Sd% �� DISTRIBUTION Box: Y -- (locate on site. plan) �ehepth 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 fro r pairs, etc. ) 1 /� i�2/a f�PiJOf U�W'/�P d ir7P_Cb�/�54� Q/�C/ (� �h��•- PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Cc ments: (note condition of- pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. B SYSTEM INF3RMATION CONTINUED SOIL ABSORPTION SYSTEM (SAS) :_lam (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 c2-/OD leaching chambers and number 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. ) IOU - 'PQ C/ , i l 42 1/- CESSPOOLS (Locate on site plan) : ��J 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) Continents: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) PRIVY• A! (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, recommendations for maintenance or repairs, etc. ) 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' K� O DEPTH TO GROUNDWATER j 3 depth to.groundwater method of determination or approximation: L y- �lei�rl`i®tis 4"ItO/ SUBSURFACE .SEWAGE:DISPOSAL.SYSTEM INSPDCTION 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. Backup of sewage into facility? I Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? 4 4 Liquid depth in cesspool, 6" below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? .substantial exfiltration? tank failure imminent? Is an portion of the SAS / Y Po , cesspool or privy, below the high groundwater elevation? Within 50 feet of a .surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? _/V Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, net the SAS)? 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, amonia nitrogen and nitrate nitrogen. Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CER`IZFICATION Name of Inspector: Company Name 'j� lei ✓Jspj/`�o 0��1�6�, �C Company Address 1Cos ?/C7hPlOrbal/ Z2ZAS, IZ110-;vP.�le lbw, - 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 recomTiendations. regarding.upgrade, maintenance and repair are consistent with.my training and experience in the proper function and maintenance of on-sitezewage disposal systems. Check one: V 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 determinimation 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 C)'7X No...7,d.73y.,d- FzB ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -----------7-m-O.-27.........OF."" .. ......t.... ... ................................... Appliration for Bhipaaal Works Tomitrurtion runtit Application is hereby made for a Permit to Construct (X) or Repair an Individual Sewage Disposal X Sy em t t: r. 8, W ........................................... ...................... ........ ...................... -- ---- ---------- Location.-Address ?0 ------------- --------- ........... ------ �j Wner Address ............. .. ...... ..........& ...................................................... ------------------------------ Installer Address Type of Building Size LotA13,_:5b.0....Sq. feet U Dwelling—No. of Bedrooms... V--­-------------------------Expansion Attic Garbage Grinder (&2? a Other—Type of Building No. of persons............................ Showers Cafeteria Otherfixtures ......................................Mz..................................................................... Design Flow.................AQ..................gallons per person per day. Total daily ..........#V------I. .............gallons. 9 Septic Tank—Liquid capacity/s gallons Length....ZO..... Width__.........`(_. Diameter---- Disposal Trench—No..................... Width.............__._... Total Length..__........ Total leaching area.....I sq ft. Seepage Pit No.........)----------- Diameter........jo...... Depth below inlet......6............ Total leaching area._S3.y..sq. ft. Z Other Distribution box Dosing nk ,( Percolation Test Results Performed by..... . ... .. .. q.. ....j4........ ;...................... Date___...___.._..._.....__-- Test Pit No. I...!�,-)__rninutes per inch Depth of Test Pit._....1............ Depth to ground water_.__N.............. rX4 Test Pit No. 2................minutes per inch Depth of Test Pit............__.._... Depth to ground water_.__._..._....__........ 0 Description of Soil....10............... ------ ----_------ -- ---n............-------Cei.,,. . ........ x ------------------------------------------------ ------------------------------*-----------------------------------*--------------------------------------------------------------------­*-------- -------------------------------------------......................................................... .................................................................................................. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Indiv. ual wage Dispos System in accordance with the provisions of ITHE 5 of the State Sanitary CJ�e\—The id s* furthergr of to place the system in 4— operation until a Certificate of Compliance has been i y th he It Signed............ .... ....... ....... .. ........ .......................... --- /` ... Q.... Da e .......... App,.lication Approved By................... --------------------------------- Date Fimis . .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ..........OF.Z�) al. .................................... AVVfirafivu for Bitipatial Worko Tomitrurtion Van it Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal SO=At o .......................................................................... ........4'� .........................7.........................7-------- Location-Address �F,k ?,�—: N?" Z"� ... .................... ................................................... ...... V............ ...... Owner . Address . ............................................. ...... Installer Address Type of Building Size Lot... 4L5.62-----Sq. feet U ,_4 Dwelling—No. of Bedrooms.... ...............................Expansion Attic Garbage Grinder -------------- No. of persons............................ Showers Cafeteria Other—Type of Building4mo Otherfixtuyes ------------------------------------- ..... ................................ Po Z.517 Desi . Flow................. I - 9 wo gn ............................_._.gallons per 15;6 n per day. Total daily flow__._.............. gallons. 0: Septic Tank—Liquid capacity/.­lZu._gallons Length....112...... Width---­t5__'.'.' "... Diameter. .. Depth... Disposal Trench—No..................... Width..................... Total Length___........ Total leaching area____-— sq ft. Seepage Pit No______02----------- Diameter........ ..... Depth below inlet.._.. ............ Total leaching area—_ q. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by...25 .... ................................. Date....................... Test Pit No. I---4L :___minutes per inch Depth of Test Pit-----L..:......... Depth to ground water------I---- ----------- (r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._-_-___________--_.___. -------------------------------------------------------------------"---------- n �J--- ----------------- �.............. . . 0 Description of Soil.... ......Z.:f . .... ; = ILI�L'Ld.............. x ......................................................................................................................................................................................................... ---------------------------............................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual TwageDi sal�ystem in accordance with o 5 of the State Sanitary The d rs �j 5; — I s�090 1 A s the provisions of'T'IE de of to place the system in fu rtive CRe- e, Z operation until a Certificate of Compliance has been 1 y th li It Signed......... .. ... .. ............•....... .................................... ... Date g Application Approved By..................lJ ... .... --------------------------------- .......... ..... Date Application Disapproved for the following reasons:............................................................................................................... ........................................................................................................................................................................................................ Date PermitNo.------yo=... .................. Issued-------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ........OF.... ................................. Tntifirate of Toutpliatirr T IS TO CERTIFY That the Individual Sewage Disposal System constructed or Repaired by....J!,`�t�4__"2�........... --------------- ------ Installer ............... ................ -------- ---------------------"--------------------------------------- ------"------------ at.......... AA(...................!�� ...................................................................... has been instilled in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the (::;P' application for Disposal Works Construction Permit No....... ...... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSJJRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. :e eDATE........ . �72 ........................ Inspector : d----- ---- 41--V.. . .......... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.. 4��.a/vvva.. ..................... . ......................... No.../..v. FEE../Jc>......... tsv. Vv�Oii Tonstrwtivit "pamit Permission is hereby granted. . ................................................................................................................................ to Constr7 ct or Repair an Individual ewe Di sposal System a, 4i ........... ............................................................................................... Street ZZ as shown on the application for Disposal Works Construction Permit Dated.......................................... ................................... _')D.................................................... rl -A Board of Health DATE...................................la................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �)5 o TOWN OIL BARNSTABL$ LOCATION cof 4 ice �.�nc� -SEWAGE # I)0 - y''q( VILLAGE�Co41 tt � -_ ASSESSOR'S MAP c1i LO'T RINS1.ALLER'S NAME & PHONE NO. 1 SEPTIC TANK CAPACITY 9"t lljk 5 4LEACHING FACILITY:(type _-_ ' (size)_ NO. OF BEDROOMS PRIVATE WELL O < PUBLIC WATER BUILDER OR OWNER ce j f DATE PERMIT ISSUED: u 5 I DATE COMPLIANCE ISSUED: _ VARIANCE GRANTED: Yes No s � � I i1 N 41 S I^IGLE FAN1tl.Y — � P.,EI�SZoot� `� DA 1 L-Y FLnv j = 1 I O x 4 44 0 .G_P D. ` ceAt ou-r C4LW eATt.01A S E PTI C_ _TA Y__ 440 ),- I SO 17 = (o(G O G-.P; D. 5.= USE I oo AL. TAN1L O 0ISPoS,yL PIT - USE (`) I000 &AL 7 51 DE WALL A 2EA = �Z) K. 188 = 3'7� 5-F. RkL �))u ��� � �4N v 6,, '37L 5. F. � 2,S , = f F3 OTro r-1 x 78 F. /. D = >/S6 G. P. �. ToTfIL DCS1&-J = 109�, G•P. TbT.4L ►DqlLY FL.ow 440• ,6-tPD.. P0_C_0LA7TiaK) R-ATE _ I",N z Mim. o2: LESS . TEST HOLE # P- So¢S` flEc' .i9 ►�>3s' W,T�sS�� BA,otQ.e, tQYE roc.. / w. rTOP EL. SS. q F.G, = 5 ,.__ F.G /,,,SCHED. 40 P.V.C, INV t .S3 1000 GAL. ( 4 DIST. 1500. ° ," r' 4 INV.S INV. GAL. INV. ee LEACH PIT BOX �z. SEP TIC u ° 0o WITH 2 o ( TANK CoTv i-T 3/4' TO ° INV. INV - ' SHr1l� % 11/2" g SZ•? 52.r ' WASHED ..�� ��j� �� aye" STONE Q_46, v or Wt� tit, ', E.` „� . PROFILE � ,� NO SCALE SUtLIVAN rti L L 30 Y +e QISTE���rk• � CERTIFIED PLOT PLAN I,CERTIFY THAT eTHE PROPOSED FOUNDATION LOCATION Cc .),T- SHOWN HEREON. COMPLYS WITH SCALE. THE SIDELINE -AND SETBACK , a 1 ! 4ko DATE w; 'REQUIREMENTS ,OF HE TOWN OF _ PLAN REFERENCE . . BARNSTABLE.AND `IS`NOT LOCATED WITHIN THE FLOODPLAIN.A y DATE : Tot y '7 07c G u BAXTER 8 NYE, INC, THIS PLAN IS NOT BASED ON AN REGISTERED LAND SURVEYORS INSTRUMENT SURVEY AND THE OFFSETS 8 SHOWN SHOULD NOT BE USED TO CIVIL ENGINEERS OSTERVILLE, MASS, DETERMINE LOT LINES. APPLICANT 12> 4. 20 \oMIn1• � I i IG ZD 3 ZP T 11� So. \ ,o. Iva1 s� Ua R— 73 Q0 IUE Lo : 43,sb v v s 40 cAla /7L7J QF v , �c ao js SULLIVAN aAttrE� ij No. a733 y 'lSTFP�<�; Fir..` ° `i jz1 Iq 0