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HomeMy WebLinkAbout0118 LAKESIDE DRIVE - Health 918 L,4KESID� � MARSTUNS DILLS _ C ,4-- 102-018 I r� I Rttly �j JUL D - x8PO 00 BORTOLOTTI CONSTRUCTION, INC. of 45 INDUSTRY ROAD,MARSTONS MILLS, MA 026481Q� 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: - Rate Of Inspection -711.,100 Inspector's Name: ` Owner's Name..and Address: ove f, ")"X„p 3 G o�c4� CERTIFICATION STATEMENT: 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 perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.TI system: Passes Conditionally/P ses Needs Furtlfe valu io the Local Approving Authority Failure Inspector's Signature Date: zlze� The System Inspector�hallbmit copy of this Inspection Report to the Approving Authority with Thirty (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 Approving Authority. INSPECTION SUMMARY: A) SYS.. + PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below: 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 yes;nor,or not determined (Y,N,OR ND). Describe bases of determination in all instances. If 'not determined",explain why not: The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or ezfil- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank 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 clue to broken or obstructed pipe(s) or due to.a broken,settled or uneven Distribution Box. The Svstem will pass Inspection if(With Approval of the Board Of Health): -1 - . . SUBSURFACE SEWAGE _DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled 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 HELATH DETERMINES.THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE 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- 1NG IN A MANNER THAT PROTECTS 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: . The,System.has a Septic Tank and Soil Absorption System and is with a Zone 1 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 from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than5 ppm. D)SYSTEM FAILS: 1 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 overload or clogged SAS or.cesspool. Discharge or ponding of effluent 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 - f 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. 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 co➢iform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS:, 'rhe following criteria apply to a large system in addition to the criteria above. The design flow of a system is 10,000 ggd or greater(Large Systein).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 315 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: 'Pumping 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. If 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. ;/The site was inspected for signs of breakout. /All system components,excluding the Soil Absorption System,have been located on site. i/The:septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected 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 Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. - 3 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B. 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 FORM PART C. . SYSTEM INFORMATION s� FLOW CONDITIONS RESIDENTIAL: Design Flow:330 gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: 1%ey Laundry Connected%To System: C&a Seasonal Use Water Meter Readings,if aYA ilable: Last Date of Occupancy: COMMERCIAL/INDUSTRIAL Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industriai Waste Holding Tank Presenti Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: ` OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source of information: , &-111Z � System.Pumped as part of inspection:_ If yes,volume pumped: gallons Reason for Pumping: TYPE, /OF SYSTEM:- Septic Tank/Distribution Box/Soil Absorption System -Single Cesspool Overflow Cesspool' Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): P ROXIMATE AG . of all components,date'nstalled(if known)and source of information: Sew a odors detected when arriving at the site:_ , -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C GENERAL INFORMATION (continued) SEPTIC'TANK: Depth below grade. . Material of Construction:_ concrete metal FRP Other` (explain) Dimensions:1 'S�.Yw'°XIS' Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 3 �� Distance from bottom of scum to bottom of outlet tee or.baffle: f� Comments: (recommendation for pumping,conditioin of inlet and outlet tees or baffles,depth of li ud level in relation to outlet invert,structural integrity,evide a of leakage,etc.) i� ° GREASE TRAP:/;�' . Depth Below Grade: Material of Construction: concrete(explain) metal FRP Ulhcr c. Dimensions: Scum Thickness: Distance from top of scum to top 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,etc.) TIGHT OR HOLDING TAN Depth Below Grade: Material of Construction:-concrete-metal, FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallonslday Alarm Levels Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:` 111 �eau��alevidence Depth of liquid level above outlet invert:Comments: (note if level and distributionf solids carryover,eviden of leakage into or gut of box,etc.) px PUMP CHAMBER ' Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) - 5 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS):_j,� (Locate on site plan,.if possible;excavation not required,but may be approximately'by.non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number Leaching chambers,number:—,9—Leaching galleries,'number: Leacahing trenches,number,length: Leaching.fields,number.,dimensions: Overflow cesspool,number.. Com gents:. note comdf n of s signs hydraulic.failure level of ponding,condition of vegetation,etc.)_.. CESSPOOLS:. 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 soil,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 hyddraulic failure,level of ponding,condition of vegetation, etc.) - 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. a DEPTH TO GROUNDWATER: Depth to groundwater: 6` _ Feet Method of Determination or App oxim tion: Wj'J;Yf2�z1 � - 7 - TO O/� _(F BARNSTABLE / LOCATION �� � �� A/- SEWAGE # tf �7 VILLAGE �'/Q'r�i' d15 zo�1CS ASSESSOR'S MAP& LOT ®Z`®/9 INSTALLER'S NAME&PHONE NO. �e��� �� �f ?�/�✓7�� SEPTIC TANK CAPACITY I,rQQ LEACHING FACILITY: (type) a rh 33 O (size) 31 A X A ' NO.OF BEDROOMS —3 Cy BUILDER OR OWNER L°L°4aAl PERMIT DATE: ..10131Zer— COMPLIANCE DATE: l - `— Separation Distance Between the: _ Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 5 Feet Private Water Supply Well and Leaching Facility (If any wells exist rV/Jqon site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) 40j; Furnished by -� ' g3 30 No. lF• .,.•.,, Fee — THE COMMONWEALTH OF MASSACHUSETTS rj PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for Miqual *pgtem Construction 3permit Application is hereby made for a Permit to Construct( )or Repair(P<)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. -f- o Y9 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Oho-LO- C-Ci nY tma cJ o �tT I Co nl�'�tA1 es•1 Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building 0L44'iO WCYL No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow -73 a gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repai or Alterations(Answer when applicable) i N s'`)XAA_- 1-�50 5.k S tpri c �5Cl/Gt,e+UnJlJe Date last inspected: Agreement: The undersigned agrees to ensure the construction a of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by s B and of althf Signed Date to 7l qn� Application Approved by o Application Disapproved or a following rea s Permit No. Date Issued ——————————————————————————————————————— No. Fee _ THE-COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH'DIVISION - TOWN:,OF BARNSTABLE., MASSACHUSETTS r. 01pprication for Migoml *p!6terit Construction Permit M. Application is hereby made for a Permit to Construct( )or Repair(P<)an On-site Sewage Disposal System at: ` Location Address or Lot No. Owner's Name,Address and Tel.No. Of- (A,46,S l b� J(!L" x F�1C B�l�T` `'mea 4+J tz /A A4S-r-0-IS ✓vl 1 LL S`, ✓/o- Ga &Yj* /o w d(J4 VI �Le. s 7— y9 ✓vim• c Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. CSl A�Cd)T I 1 C U!J t'77AJ C 74 t*J (3GAZA. W_l n C U 1M 1 7WC'1 fO+J -7(ej Why , D AA . ►^A 1 Ll--S V1/Y� 0e1-tou Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder 6-1 q Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design-Flow 33 o gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date ,F Title Description of Soil 1 Nature of Repair or Alterations(Answer when applicable) /N s" I0 �tJo� V Cj e_-r-e_ % ✓L .��o SciA.t c,�,��e p �-�,-�s%z� E , . r Date last inspected: Agreement: The undersigned agrees to ensure the construction aka of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is B and Of alt Signed Date a V Application Approved by Application Disapproved or t e following rea s Permit No. Date Issued ----------------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(PC)on b Va,4=—t.o 7 t7 for f✓-tAC6 t4T —/7FE 6¢A411 //^" 7 6.4 J1f5 i <C_ j&VQt- ,M t M l(A-& has b constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions rth below: No. /♦1 a�-U Fee 3a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miopogal *pttem Construction Permit Permission is hereby granted to :;&7OX:-�t-a t' 4l C4 r1S-77' Ca7404 to construct( )repair(t,6).an On-site Sewage System located at (A,4LES/,dI� 491t446 , a and as described in the above Application for Disposal System Construction Permit.The applicant re ognize his/her duty to comply with Title 5 and the following local provisions or special conditions. All constructio ust b com led within two years of the date below. J d e Date: 0 Approved by (� s 1_ r W �C4) O' O O b� �D r a� ,e �, -� ra i, CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated /`a�a 7141' , concerning the property located at 11T meets all of the following criteria: — There are no wetlands within thin 300 feet of the proposed septic system l/• There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility v There is no increase in flow and/or change in use proposed There are no variances requested or needed. SIGNED : DATE: 7 4� i� LICENSED SEPTIC SYSTE INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted].