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Home My WebLink About0174 TANGLEWOOD DRIVE - Health 174 TANGLEWOOD DRIVE, OSTERVILLE 4 ,, /'. T JUL 1 2 1999to 40rft ' BORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD,MARSTONS-MILLS, MA 02648 a A 508-771-9399 508-428-8926 , FAX: 508-428-9399 '' %V E Z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r , ,.,.. :. CERTIFICATION , Property Address: Date Of Inspection Inspector's Name: VaW26 It Owner's Name and Address: AlkOaL9 SCR CERTIFICATION STATEMt:, ; I Certify that,)G,kayq personally Insp�cted,the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of lnspec4on.' The Inspectioin was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal System s.:'�he t/V Passes, Conditionally repes _. � ,.,Needs Furt r vain 'o the Local Approving Authority Failure Inspector's,Signature Date: A(,/o ' �,-- TheSystem�Inspector shall submit a opy of this Inspection Report to the Approving Authority with Thirty . (30)Days of completing this Inspection. If the System is a Shared Syster'i 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 Offie of the Department of Environmental Protection. The Original should be so nt to the System Owner and copies sent to the Buyer,.if applicable and the Approving Authority. r, A) SYST .PASSES k: I have not found any Information which i ndicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any,Failure Criteria not,evaluated are-indi- 4F_� cated below. r t . B) SYSTEM CONDITIONALLY:PASSES: One or more System Components need to be Replaced or Repaired: The System,upon ' 'completion of the Replacement or Repair,Passes Inspection. Indicate"yea,nor,or not determined(Y,N,OR ND). Describe bases of determination in-all instances. If"not determined",explain why not. "The Septic Tank isMetal,Cracked,Structurally Unsound,shows Substantial'Infiltration or exfil F tration,or Tank Failure is iimminent. The System will Pass Inspection if Existing Septic Tank lug i is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to "y""Ibroken`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 Health): MM r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 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 "Ov 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. se >I)SYSTEM WILL-PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE -,€ira 3SYSTZWIS.NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT„THE xt... 'i P.UBLIC.HEALTH AND SAFETYAND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water ; Cesspool orjpnvy,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 MANNERTHAT 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. t.,r, 9,; 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 V 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 orless than'5 ppm• ; `D)'SYSTEM FAILS: Ili - 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 r^' = Rshould 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 orponding of efluent to the.surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static quid level in the distribution boz above outlet invert due•to an overloaded or clog- " ga1.SAS or.cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow: '' t tt'' Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- u Y 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 urface 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. if the well has been analyzed for coliform bacteria,volatile organic well water analysis to be acceptable,attach copy of w . compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAIIS: f The following criteria apply to a large system in addition to the criteria above: . is a significant'._ m .and the. stem . � , • to . The design flow of.a system is 10,000 gpd or greater(Large System),. system , threat to,public health and safety and the environment because one or more of the..following Zdaditions exist system is witlun`400'Feet of a surface'drinkin water:supply "# Ppyt- The systein.is.within 200 Feet:of a'tributary.td a surface drinking su 1 The system is located in a.nitrogen sensitive area Interim Wellhead Protection :.,(MA)of a-mapped Zone Il of a public water supply well. '..j s,r;?• The owner or operator of any such system shall bring the system and facility into full compliance:with the groundwater.treatment programirequicements 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 4 , f 1 PART B 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 atieast two weeks and the system,has.,, .x been receiving normal flow rates during that period. Large volumes,of water have nPSI ot been `r introduced into the system recently or as part of this inspection. t �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 or industrial maste flow , t A 3� The system does not receive-non-sanitary ., kr� ✓• The site owas inspected for signs of breakout 1. ' All moo vents excluding the Soil Absorption System;have been located on site JV_The septic manholes were.uncov'er`ed,`opened,and the interior of the�septic tank was in. spectod for condition of ba>Iles or tees,material of construction,dimensions,depth of liquid,,"' • x r/ ,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 methods. x -3- ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) 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-FOAM PART C SYSTEM INFORMATION FLOW CONDITIONS 3 Design Flow: gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Iteadin 'if fable: Last Date`orOccapancy . .. -CO1V1L11RF.R AiJIND 1CT iAL.•'�� ,.. i e ^.c, r .. ! ::' ' Type of Establishment:` Design Flow: xallons/day Grease Trap Present:.(yes or.no) Indy0al 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 ofFOccupancy: GENERAL INFORMATION . //D�. . PUMPING RECORDS and source of information:- System Pumped as part of inspecdo if yes,volume pumped. gallons Reason for pumping , TYP FRSYSTEMi s Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool' Privy Shared System f s>_attach previous,inspection records,.if any). ,.,.- .... _._. Other(explain): APPROXIMATE'AGE of all components,date installed(if known)and source dUinformation` a .3 n f '.5 -S ,At pt'r ..4. Iq• a..F Sewage&dors detected when arriving at the site:_ 4 Y 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued), SEPTIC TANK: ✓ 3 �✓"�'` �, - Depth Wow grade: Material of Construction: concrete metal �FRPI'' Other (explain) s �Dimisions: Q,S�,K Co X5'1 Sludge Depth: 8 Scum Tldckness: Distance from top of sludge to bottom of outlet tee or baffle:° �36) Distance from bottom of scum to bottom of outlet tee or-baMe-: - Z " ' / Comments:(recommendation for pumping,condition of inlet and ffl outlet tees or baes,depth of liquid level in relation to udet-invert,structural integrity,evi enW of I age,etc.) ' 61, \ 4Yq d. 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 inletifid'oullef tees or baffles,depth of liquid' level in relation to outlet invert,structural integrity evidence of leakage e(c.) -•F tit';i4 Z iI:.•Yt fin.. kzaF{ .� "' - p x . v r, p TIGHT}OR HOLDING TANK: Depth.Below. Grade: Material of Construction:_concrete_metal . FRP Oilier(explain) Dimensions: Capacity: gallons Design,Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION.BOX: Depth of liquid level above outlet invert: Comments:,(note'if 1 el.and distribution is equal, eviden a of solids carryover;evidence of 1 ge into or out of x,etc.) �. - , Puiiip is�n worluii Comments:,(note condition of pump chamber,condition of pump and appurtenances,etc:) - „r yyy tziWk SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTIO11 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,number: Leaching.chambers,number: Leaching galleries,number: ' Leaclung�trenches,,number,.length: beaching ieldsnumber,dimensions: Ovetflow'cesspoo1,number: Co (note condition of soil, sig s of hydraulic fa' ire le el f pond' g, ndidon f vege don, t` etc. /� .. CESS1POOISs Number'and'oonfl don: De th-to �•of li uid to inlet invert:.. :�-• P P 9 th Ofsolids } Dep 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 soiN signs of hydraulic failure, level of ponding,condition of vegetation, etc.) k•tyEd;;t� ... s i s PItmr:,42U Materials of construction: _ ' Dimensions: .. _ A Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) S 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. i Ot t ..�. _ � _^� ..av �'�i:�° 1 q s � ,' S�`•'"Az..«.r x. _1,s � ,�: i .+ '�.: y'�. tE 7a. ... _ •A -r{ 4 - /U.1 DEPTH TO GROUNDWATER.- Depth to groundwater: Feet Method of I&rmination or App oxi on: 6we/a i 7- fp !'BUY` a,-&,.L� ,•}. t LOCATION L.OT v SEWAGE PERMIT NO. VILLAGE i INSTALLERS NAME &- ADDRESS 3 OR OWNER ,,�G / G DATE PERMIT ISSUED DATE COMPLIANCE ISSUED t C9 ^' ��11 L X -l\I-- ----,��- - - - - -- _ C - � _ 4� u ___---_ T _ ___ ._ ____ - ----__- �-�--_-____ _ __ n _ _ ._ _ --6=--___ _-.�_ _ _ ---= -----G=-------- �__-_ _-_- ---- - --. S MAP N0: - ASSESSOR No... ... .:.. PARCEL NO.. c THEBO/"9IZDALT F F�-�I HEALTH--" TS I-Q w EV....................OF...... ..... 5 .C. . ............................. Appliration for Uiopoottl Workii Tonotrurtion rrutit Application is hereby made for a Permit to Construct (y) o A � an Individual Sewage Disposal System at: lr �® /°y ... Ir�CLsG000U �2 UL�. �/LS/2Ul G GGr .. .. _ .............. ........................... 0 Locatio Address - or Lot No. ��— GQ 1.4 Installer Address d Type of Building Size Lot................ Sq. feet Dwelling—No. of Bedrooms' ....._l 2........:....................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ..._�7�``'`_ _ No. of persons_....__G________________ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- w Design Flow............ "-....gallons per person per day. Total daily flow......3,3......................"..gallons. 1:4 Septic Tank—Liquid capacity/M-8..gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No.................... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No........ -�__.. Diameter.._._.____.:_. Depth below inlet...... Total leaching area... °®_.._.sq. ft. Z Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date........................................ 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •-•---•----•-------------•-•-•-••...........---...........•---....._._...........-----------......._........................................................ 0 Description of Soil.......................................................................................................................................................................... x U .............".---•--•---•---------DlSlli1vlKl�aI '"� F�iSE -"-"••-----"-------------"--------"--"-""-"---""""----"-""-"------------•---------...--•"•-"""-""""-----""-"""-----IiVS'TALLA--TION"AAA-" Yl�f""IN""VYIWING... U Nature of Repairs or Alterations—Answer when applicable---_•--___� �_ ��.� ""-"-""-"""-""-"""""------"-----"------..:---"•""--""-........•.................•..... 0 R APB-TOPLAN:.-..-"-"------------.------------.----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beef} issue by the bo d of health. �� ................. .... Application Approved By............ ............................. ............... _zr) Date Application,Disapproved for the following reasons:-----""•-----""""-"--"-"""-"--""•"-"-"""-"--""""---"--"--"""""--"-----"-----"""-"....................•-••_.... --..................................•••••---....._.....•-•-•-•-•--•-•--........._..._.._....._........................---............••-•............-•---•-.............................................. Date Permit-No."- -- ------ - --' Issued..................... -- - - ....................................................... Date -------------------------------------------------------------------------------------------------------- ------------ ------- THE COMMONWEALTH OF MASSACHUSETTS T' �. BOARD F HEALTH !1w ....................OF...... .... �N51C� Appliratilin for Dispersal Works Tonstrurtion FPxlAd Application is hereby made for a Permit to Construct or. A,.....:_ ��an Individual Sewage Disposal System at: .,elll. Aiyo.............. ../� f�/l�lG'u!�v/�....17,!L UL ...��s�Z:!2 Ul G GGr. ......................................... Locati2a.-Address or Lot NoSid -• /,9 u� //..`,' .�:_.C........................................... �>d''S..............'�';_,�?i l✓S�-{??iLG ._.--..... a ..:..• ........................................ ------•-• ------------....................--....... ................__-•--•- Installer. Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms...........3........:....................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .. --•----.---•---------------•--------.---------•------------------------•----.... W Design Flow............. ..��.__..gallons per person per day. Total daily flow........ . ........................gallons. R: Septic Tank—Liquid capacity.e d.gallons Length................ Width................ Diameter................ Dept h............ .... Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No.........if./... Diameter........tQ....... Depth below inlet.......?......... Total leaching area..................sq. ft. Z Other Distribution box (A Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....................... (4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....--.................. a ---••---------------------------------------------•---------•---•-•-•-•---.......------•......---•--............................................... ----•----- 0 Description of Soil..............•----...............-------••-•-•---•----........--•---•----...--------........----......---••--•----.................-----...._...._•-•-•......------.... UW ------------------------------------------------•-------------------•--------•--------••--••-----••---......---------•---------------••--•---------•-•------...............-------•--•-......._......... 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 Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beef,issued b the bo )d of health. � .�.�..` ................ ------•- ..................... ..........................-.... Application Approved By.......... ..... --.�,_ Date Application Disapproved for the following reasons-............................................-----••----•-------•--•------------•--------.......... -......_..__ ....................•---......---•-----•-------.......-----•------...---•-------...------....---•--...................---•-------•---........-----.....------------•----•------......._...-•-•--......._. Date PermitNo....................... ..------ _ Issued--------------------•------------•--....---.......... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... I'll rr#if rate of Tomplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.. .._... ... ...... -----------------------------.......----- - ............ ._...._ Installer at... .. has been installtd in accordance with the provisions of TITLE 5 of 'The State Sanitary de s described in the application for Disposal Works Construction Permit No.... a__..��: '_. dated---.�Q12..�7 ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. - A;�.4'�-� "J ..........................•-_----- Inspector............................................... ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��....... .Ocr/!1/ ...OF.....1�/i�/�i✓51` CG" �;i7`� No........ ---- a Fss................1.. ,f �i��ro�tt1:- ork� �on� �tr#ion �rrmi# Permission is hereby granted. .....................................................--- to Construct ( ) or jepair ( ) an Individu JU.if..�al Sew a Disposal item at'I �� __. �. 1. CL ``* f --•• �.,�s�"�- ' ............................. ......--•- street , , • L as shown the application for Disposal Works Co ,stru _:.. . ......... Dated.... . Z_ ....�r........ Board of Health DATE............. .. �.: _:. FORM 1255 - M. SULKIN.'INC.. BOSTON �''� BAXTER &, NYE, INC. . Registered Land Surveyors and Civil Engineers 7 Parker Road/Osterville, Massachusetts 02655/Tel. (617)428-9131 WILLIAM C.NYE,R.L.S.-President RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering March 9, 1987 Town of Barnstable Board of Health P.O. Box 534 Hyannis, MA 02601 RE: Lot 10 Tanglewood Drive, Osterville Installer: P. Lebel Permit: 86-628 Dear Board: In accordance with your request, I have inspected the installation of the above referenced septic system. The system has been installed as per the approved plan with respect to components, location and grades. Very truly yours, Peter Sullivan, P.E. Baxter & Nye, Inc. PS/bc. H OF Mq��9C PETERw SULLIVAN No. 29733 " 0 ONA L MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS jy Z..5 I^Al Z. E� -577 I 4�1 C-5 &0( i _ , Ar co"d Af xf Wv IVAN 33 fzl rEL 47