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HomeMy WebLinkAbout0186 WHITMAR ROAD - Health r 186 Whitmar Road, Cotuit A= ��� - - - -- -- - --- -- -- -- � I RE'f . . BORTOLOTTl CONSTRUCTION,INC > 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 J4 508-771-9399 508-428-8926 FAX: 568-428-9399. N 199T, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION vat, f PART A l 'CERTIFICATIO Properly Address: co LC/hi 1�/'nQd' Date of Inspection: a- -2 Inspector's Name: dL Q7, r' Name and A dr Cl _ ll CERTIFICATION 4TATrM ENT 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 inspection was per- formed based.on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System ,Passes Conditionally Passes Needs Further Evaluation By th ocal Aproving Authority Fails Irs or's Signature:P !' � 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 flow.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 ap :roving'authority.., INSPECTION�i1MMARY•. A)SYS PASSES: ,.have not found any information which indicates that the system violates any of the-failure criteria as defined in 310 CMR 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. t, 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 static water level.observed in the distribution box is due to broken or obstructed pipe(s)or due to a broke�i;settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1.t ' 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 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 WH ICH H WILL PROTECT TH E 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: and soil absorption stem and is within 100 Feet to a surface system has a septic tank a rp system st _ The sy p 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 6"below invert or available volume is less than 1)2 day flow. 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 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 -Y 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 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 alarge system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large Systemj 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 II 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 CMR 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 CHECKLIST; Check if the following have been done: C 'Pump ing 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 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. /The facility or dwelling was inspected for signs of,sewage back-up. The system does not receive non-sanitary or industrial waste flow. e.site was inspected for signs of breakout. AU system components,excluding the Soil Absorption System,have been located on site.' e septic tank manholes were uncovered,opened,and the interior of the septic tank was in- /dpected for condition of baffles or tees,material of construction,dimensions,depth;of.liquid epth 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 methods. -3- W � SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART E; 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 RESIDENTLALo Design Flow: allons Number of Bedrooms: 3 Number of Current Residents: Garbage Grinder: Lle Laundry Connected To System: 64 Seasonal Use: i Water Meter Readings,if Table: Last Date of Occupancy: ( /1,/-/ ALJIND 1STRIAL_ /KU 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; I GENERAL INFORMATION m n.n source of infor at . ..PUMPING.RECORDS and sou c /V1�'(�c" L?eE'4 - System Pumped as part of inspection:f If yes,volume pumped: gallons . Reason for pumping: TYPE F SYSTEM: Septic Tank/Distribution Box&il Absorption System Single Cesspool Overflow Cesspool Privy . Shared System(If yes,attach previous inspection:records,if any) Other(explain): API OXIMATE AGE of all m vents date installed(if known).an source of information: Sewage odors detected when arriving at the site: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete. metal FRP Other , (explain) — Dimisions: Sludge Depth: Scum Thickness: 6/7 Distance from �i top of sludge to bottom of outlet tee or bathe:g 3d Distance from bottom of scum to bottom of outlet tee or baffle: ilew ' Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in lation t outlet invert,structural integrity,evidence of leaka e;etc: i�cS Q OW07 GREASE TRAP: . Depth.Below Grade: Material of Construction: concrete metal FRP Other.. (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top ofoutlet 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 FRV Other(explain) Dimensions: Capacity gallons Design Flow:' allons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,.ctc.) DISTRIBUTION BOX: Depth of liquid level above,outlet invert: Comments: (note utio evel and distri n is equal,evidence of solids carryover,evidence"of leakage into or ut of box,etcjCt'�Y'/c/�lwO/J �/lY,r�(? PUMP CHAMBER. Pump is in working order: A4 Comments: (note condition,of pump chamber,condition of pumps and appurtenances,etc) -5- t , i SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): !/ (Locate on site plan, if possible;excavation not required,but maybe approximated by non-intrusive methods) If not determined to be present,explain: Type Leaching pits,number: Leaching chambers, number: Leaching gallenes,number: Leaching trenches, numtqr,length: Leaching fields,number,dimensions: - Overflow cesspool, number: . Comments: (note condition of soil, signs of hydraulii f4ilure level of ponding,condition gf vegetation,etc. 4:S P -l/"� 60 Pr 0 (Y� CESSPOOLS:�O . 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: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,.condition of vegetation, etc.) -G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART CE3 SYSTEM INFORMATION (continued) �1_ �� V' SKETCH OF SEWAGE DISPOSAL SYSTEM:-. Include ties to atleast two permanent references, landmarks or benchmarks...,, Locate all wells thin 100 Feet. ;Ft kl t DEPTH TO GROUNDWATER: Depth to groundwaterc 7.y Feet O / /rI Me of Determination o Appr ximatio � l'D' C s� t 4 7- THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I A , m / LI DATA TOWN OF BARNSTABLE N f SEWAGE # 'P ASSESS R'S MAP & LOT x NAME&PHONE NO. U C 5 ;i'TIC TANK CAPACITY �O 1 LEACHING FACILITY: (type)2,, :6 (size) 060 NO.OF BEDRO ITS_ BUILDER OWNER r i PERMITDATE: COMPLIANCE DATE: J 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) l� Feet Furnished by 2(,off TOWN OF BARNSTABLE LOC"ITIONLO ,36 �Jff�7�,�,� SEWAGE # 90-,!!�Z/ VILLAGE C'0i7J1T ASSESSOR'S MAP & LOT d6-4-407-)- INSTALLER'S NAME & PHONE NO. rid1Z-7-z)66W eDAIS%; .5-�-F--Y,9-.)6 SEPTIC TANK CAPACITY .LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL O BLIC WATER BUILDER OR WNER /1Ir�/d9 Grjin��J�f /�S�-/tl4UG�"" DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ` ? VARIANCE GRANTED:_Yes No .. � '* �P` �I �E�-2 �:-���� � �� .�� 2�� .� r . . )� d ✓� �'�✓! No 0 fj 6" Fims. .. .. /... _. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .TOWN OF BARNSTABLE A liratiou for Ui nsa1 orks Towitrurtiott Urrmit Application is hereby made for a Permit to Construct (k ) or Repair ( ) an Individual Sewage Disposal System mat, II qLo 3C l- ---- S .. f'� .......----•------.. .5 .1...................................•--.......--•--•-------•-•--•---•--- ..........._-_ .-• C oration-Address or t No. � Owner Address W a Installer Address Type of Building Size Lot_44.1.�........Sq. feet V Dwelling—No. of'Bedrooms___...__.3................... Expansion Attic ( Garbage Grinder Ad aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ................................. W Design Flow.............s•55.....................gallons per person per day. Total ily�flow..........330....................gallons. WSeptic Tank—Liquid capacity__� gallons Length.` ____ Width___-__�.__._... Diameter________________ Depth.....'___. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------I........... Diameter........1©....... Devth below inlet.....6----------- Total leaching area.zk?..7....sq. ft. Z Other Distribution box N45 Dosing„tank ( G ' 2 o v a Percolation Test Results Performed by.--.__._Ar1��'C+�4_q`.(-____...Y ......................... Date... -----__-- a Test Pit No. 1----4-Z----minutes per inch Depth of Test Pit....It.____...... Depth to ground water-.N -ZN`w& -iL&D f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------------ ----------------------•-••••----- .--- . . O Description of Soil-----Q-Z---Le Al.. _..S? l Sr... ® l L-------- ....1 `A ----••-•....................... W ' W U --------- --------- ----- •---------------------------------------------------------------------------------------------- •--------------------------------------------------------------------------------- V 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 TITLE 5 of the State Environment Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian s en iss d board of health. Signed . ----- ---- - ------ / OaO ApplicationApproved By .. -..-g------ ----- -------------------- ----- ------------------------------------------ - Dace Application Disapproved for the following asons: ................................................................. .................. ............................... -------------------------------------------------- - ----------------- .............................. ---------------................................................................. ........................................ Permit No. q� �! `---.. ... Issued .. --- -..-..... Date Date :L f. 1 No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratilan for Disposal Works Toustrnrtinrt ramit Application is hereby made for a Permit to Construct ( K) or Repair ( ) an Individual Sewage Disposal System at: IN ................t 3CJ...�!. LA-V...............•• ---••-----•- -•----.... ...................------.. } Location-Address 1A t or pLot No. �1(11�-IyGI_�l.t;l_.�: �Ltltt�1A'�eZr=-.�..TS.�.�'�'+-.3i4-�?--"s_f�-��-�.-•---.,_�_�r_t:;.l�(�1�1__K_.l'�7A��......��s ��Ca.�..�.._ Owner Address W Installer Address Type of Building Size Lot..A41.��.--...Sq. feet U �. Dwelling—No. of Bedrooms..........3..............................Expansion Attic (LC) Garbage Grinder (9(1 P644 Other—T e of Building No. of persons___________________•-__-__-- Showers — Cafeteria a' Other fixtures .......................................................... Design Flow............... S ....................gallons per person per day. Total daily flow........... ...................gallons. WSeptic Tank—Liquid capacity..000gallons Length.S:nG... Width.. ."rp._ Diameter................ Depth_.` .... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No..........�......_. Diameter---------'Q...... Depth below inlet...._(a......... Total leaching area..2_(n,_7. ....sq. ft. Z Other Distribution box (YE)5 Dosing tank (96 . }} 4 Percolation Test Results Performed by.... Aix I _ � U__1!.i1 C................. Date---- p��°`..� ate...__... a Test Pit No I.....�. -_-.minutes per inch Depth of Test Pit-----1.�_.._.._.._.. Depth to ground water__1�10�.F1,1_l Qut t�—r2% (Z4 Test Pit No. 2-------------_-minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ t: ----------------------------------------------------------------------------------- --•----•-•------------------------------ --------------------•-------- O Description of Soil-------�'s' L-A&±?k-- f- --- "•• -l�� + lU ............................ W V ------ •-------------------------------------------------------------------- --------•-----------------------------------------------•-----------------------------•-------•------------------------------- 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance'has b en issued by-the board of health. /� - Slgned��..v1. �. = `� --... ..-. � / o . �_• - 41vApplication Approved By ---- --r----- ---Q--- ( � . -- --- .---- �°........................................... ........................................ Application Disapproved for the following r• asons- -------------------------------------------------------------------------------------------------------------------- ------- -- -------------------------------------------------------------------------- -- -----------------------------------------------.................................................... Date Permit No. ..--..-.. ."_ ...................... Issued ........----------- -------------- -------- -- -- -- 9 Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CZerttftra e of Tontylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( � ) or Repaired ( ) by.........----- ... ............4 7y-------- ............ ------------------------ c Icucaller at _ ?" �1-------------------------_- l'�.-t-l -/k?.------....!! "�.�'?-�-T' has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -- .-c...�"1'" _4....... dated ._� ...7/__......�. ...V THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL.FUNCTION�SATISFACTORY� --� DATE---------1../��.............................................--------- ii------------------------- Inspecto --. ----------------.. ----------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �� TOWN OF BARNSTABLE No.e..........:7....... � FEE............- ------ Disposal Vorks Tons#r ion rrnti# Permission is hereby granted---------------. �� 1 c r( i�_ . .................••--•--•-•------- to Construct ( ,\)�or Repair ( ) an Indi#dual Sewage Disposal System at No. 2i..,.........,.L -r�•;f . -- Date -----------•-- Street /,1 .,`f n� as shown on the application for Disposal Works Construction Pert No._-__.___:....___ _ d_ L_ _,.__(.. .................. 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