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HomeMy WebLinkAbout0030 PREAKNESS WAY - Health (2) 18 PREAKNESS WAY, MARSTON MILLS YOU WISH TO OPEN A BUSINESS? j For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town [which you must do by M.G.L. -it does not give you permission to operate.) You rnust first obtain the necessary signatures Or this form at 2100 Main St., Hyannis. Take. the completed form to the Town Clerk's Office, "I st Fl., 367 Main St., Hyannis, ti1A 02601 (Town Hall) and get the Business Certificate that is required by-law. g DATE: 1 I a0 3 Fill in please: 14, APPLICANT'S YOUR NAME/S: CL Gl• I VIjgli I'D BUSINESS I YOUR HOME ADDRESS: 19 pf- 1n 4- _ (,&) W, u ryf. ,50Q HN id(4 TELEPHONE # Home Telephone Number .5057 • '1'4 0 0 a a y NAME OF CORPORATION: j NAME,OF NEW BUSINESS o550' �G�, TYPE OF BUSINESS u,*'d 0a IS THIS A HOME OCCUPATION? ✓ YE O c J ADDRESS OF BUSINESS I ,e elC.n,t.�w r MA.P/PARCEL NUMBER D� 1 (Assessing) When starting a new business there are several things you must do in order to be in with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST, GdTO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual hasLbeerii-hf r Tftf the permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: . 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature' COMMENTS: op� ti »s '29 co t \ to IJB,Lf' -)10 'SF! aT�o 60. ~ L—oT g �� 38 0 3\x IV q O °0 °0 \ joB # 85-309 CERTIFIED PLOT PLAN PREPARED FOR: LOCATION: PREAKNESS WAY W . BARN . SCALE: 1=40 DATE: 2/ 12/87 REFERENCE: LOT 80 PB 420 PG 99 LEBEL SOLLOWS DEV . I HEREBY CERTIFY THAT THE BUILDINGS SHOWN -ON THIS PLAN IS LOCATED ON THE GROUND AS .SHOWN HEREON: BUILDINGS CONFORM TO SETBACK REQUIREMENTS OF THE TOWN WHEN CONSTRUCTED. OF �1gsf9� ARNE yGs t H. down cape engineering OJALA N 1 .o g2B3,yg � rT\/TI GnlrTnlP'PAC TOWN OF BARNSTABLE '°LOCATION SEWAGE # — I6 VILLAGE*,, ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. - -� �i SEPTIC TANK.CAPACITYci } LEACHING FACILITY:(type) e� (size) 00 �NO. OF BEDROOMS PRIVATE WELL O B C WATE BUILDER OR OWNER DATE PERMIT ISSUED: j (107 DATE COMPLIANCE ISSUED: -/ S 7 VARIANCE GRANTED: Yes No ,/ ' s 0 y� L-®-� ' �� 0 f I OPY THE COMMONWEALTH OF MASSACHUSETTS �--• BOAR® OF HEALTH ......P. 1^1......OF..... j` J ..4 S./--�11�L�.................... Amifiratiun for Di�puua1 Works Tunutrurtiun r an it Application is here ma for a Per t to Co Duct ( ✓ror Repair ( ) an Individual Sewage Disposal System at: T �J f"�'�" a l `-Z.. s s...... .. `. ........---•C e v'"!!�----'.........................•------- ......... _0----- - - -- -- - Location-Address or Lot No. s, 3:._.lz.��� ...... i..............................................� !�3 2 j,� �nos S •-- ---'----.. .. Ow r Address aG c 2 � �cSt �S � �"�V-/J1� .............................. ._....----------•---.................._................_-.........-"............•............... Installer Address Type of Building Size Lot.2 c 9 .......Sq. feet � Dwelling—No. of Bedrooms............`3............................Expansion Attic�--�� Garbage Grinder--�j'� p`4 Other—Type of Building [ . a"'?..._. No. Of Dersons.... fie.....__; A Showers (-_ -,Cafeteriff-T—) 04 Other fixtures ---- _ - -- =_a ....... Deign Flow......... ..... S _ -- r' ga_l-l�on.�s..W allons er n y WSePtic Tank—Liquid ca..acit !0!� allons Lngh �_ Width-__5 ..... Diameter................ Depth-5' .x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....,.-------- ...sq. ft. Seepage Pit No---------!_._____---- Diameter......�.?°... p 3c.s..... Total leaching area..4�__1�..tsq. ft. Depth below inlet.._.... Z Other Distribution box ( ✓f Dosing tank Percolation Test Results Performed by.....17__�_ Date... 1..� ..fir......... IV4 Test Pit No. 1__.....!�t.1_4ninutes per inch Depth of Test Pit...... .3....... Depth to ground water.....Ia._L_._'�'.. (i S f3 Test Pit No. 2...... ..Z minutes per inch Depth of Test Pit-----/..9....... Depth to ground water____--_?-_-t........... oZ/2o/e-7 <-z=--- ---------------------------------�---�------. .. .....................................................1.:s.--.-t-..... Description of Soil > ' ' ..�..... ---•••� -•---•----•--•----•-•--••--••'--•'-------•---•--------'-----.. '-- x U ----------------------- --------- ----------------- •-------------------- -------- . .------------ ------------------------- •------- ------------------- ••----------------------------------------- W --•-••-----•---------------•••----•--•--'-•--'-••-----'-•••---------•---•-----------......--'------- -----------------------------•-'----•-----•-•---------•'-'--'----'---------'---•----•............•- UNature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------------•--•-----------------•---------•------•----•------......_.....---•-----------------------------------------...----------------'-------•-------•-------------.......---•---•---- Agreement: The undersigned agrees to install the aforedescribed Indiv' ual Sewage Disposal System in accordance with the provisions of iI'I U 5 of the State Sanitary Co he u ned further agrees not to place t e sys m in operation unte of Compliance has been s u th of health. ned. •-•-• .. . '--- ' -------'-"--'-'............................ �'-•... G j ,2 D e Applica n Approved By-------------------------- .:.. .._._.. •. ------ � Date Application Disapproved for the following reasons----------------•-------.........-------------------------------------------------••-'--•----••-------....---•-- .................'-"-'------------'-.............••-----'-'-.....---------••-•'-•---"-••-•-'.......-'---•---•---'---•--'--'•--'----------'-'---•-•--•-••'-•-----'-----------••'-•----••----•....-'--'- L) Date PermitNo.---'-'.... ........................................................... Issued........................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR , QUALITY ORIGINAL (S) I m DATA No.. _ .... r Fxa............._............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6 v✓f✓ !-� '7 iz S i L ..... ..... .--.. .....OF..... ... ---- --- .-- ---..................._........ Appliration for Disposal Works Tous rurtion "motif Application is hereby made for a Permit to Construct (1-'or Repair ( ) an Individual Sewage Disposal System at: L^ i �, tom^ , -............................................ . .. .. ,7 t .r .. ✓. . / c Location-Address or Lot No. � s . Owner r Address W .. . .. l '.. 7. -- .. --/....................................................................... Installer Address d Type of Building Size Lot. .`!... ........Sq. feet Dwelling—No. of Bedrooms...........`3.............................Expansion Attic-( ) 140 Garbage Grinder (•^) Other—T e of Building .............. No. of persons..___..._4........_.._..... Showers — Cafeteria' d Other fixtures ---------------------------- = ....................... W Design Flow...........................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacityr_"41 gallons LengthiAW... ". Width..... ?_~Diameter................ Depth:- �-- ".. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No........L----------- Diameter.._...1. ....... Depth below inlet..3i ..... Total leaching area...2_`.4 sq. ft. Z Other Distribution box ( ✓) Dosing tank-(') Percolation Test Results Performed by._..! ..':..: ......................................... ._:._'.... Date...`A Z.................... 1.4 . : Test Pit No. I....5...'....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.._L.z......... . Phi Zw�/'S y C Z C,lZ . S- CD 2 T ----- ............... !S4— • O Description of Soil........................= =' x U ---------------------------------- -.----------------------------------- ------------------------------------ •--------------------------- -------- •------------------- .....--------------- ----------------- --------------------------------------------------------------------------------------------------------------------------------------............................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•--•------------------------------------•-•--------•-----------------------......---.........---......-•---------------------------------------------------------------------------------•--•--- Agreement: The undersigned agrees to install the aforedescribed Indiv ual Sewage Disposal System in accordance with the provisions of T ITLE 5 of the State Sanitary Co&1,The u./ rel,#ned further agrees not to place t'e sy tem in operation un ' to of Compliance has been, S44 by tll�. rd of health. ,�'� .............................................. - �- Zto Appli>ppi oved BY Y � ................................................. Z �' Date Application Disapproved for the following reasons:-------•-------------------••----------•--------------------•---------------------------------•------••-••----- --------------------•---......•--•----•-------------------•--•----•-------•---••....................................................................................................................... Date PermitNo..---...... .......... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ✓.....OF..... ............. :,/ _................................................. Tertif irate of Toutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (1--)or Repaired ( ) - •.....................•----.................----•---------•---......................._..----••-•--------•--- --- Installer at 3 0 k � ✓VU has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as de• ribed in the application for Disposal Works Construction Permit No--------- : ___ .... dated-....... _ .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION(SATISFACTORY. DATE....................` ._�'_l.._ ..- t ---•------•---------_.. Inspector....... THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH No......-.A-_ ....) FEE........................ Disposal Workii 'onotrion rrutit Permission is hereby granted.....' '...:.../`....... _­".......� to Construct (�or R_`1 epair (�) an Individual Sewage Disposal System at No.---L ' = " r r � 7 ) '- -----.-••- ...-•••..............•---•-•-••---•-•------•--...-.--- -----•------------••-•-••••------•---••---------•-----------•---------------•••---•....... Street 7 _/U� as shown on the application for Disposal Works Construction Permit No.-O.... ,___._.../.__ Date ...................................... Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON 1�I 1 J f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A CERTIFICATION O l�f 18 Preakness Way cT �' Property Address:Marstons Mills,Ma $ �9 Address of Owner: +� moo" 9� �, (if different) Date of Inspection: 21 September, 1999 Inspected by: James Holler �f I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Holler &Son Construction LLC Mailing Address: P. O. Box 702, Marstons Mills, Ma 02648 Telephone: (508) 420-0280 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ®Passes ❑Conditionally Passes ❑Needs Further Evaluation by the Local Approving Authority Ej Fails Inspectors Signature t-,o Date: 0 9' The system inspector shall so it a copy of this inspection report to the Approving Authority within 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 olfice.of the Department of Enviromnental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: ® I 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: Comments: B) SYSTEM CONDITIONALLY PASSES: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not detennined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. ❑The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank:was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is itmninent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (Continued) Property Address:18 Preakness Way,Marstons Mills Owner:Kathleen Nele Date of Inspection:21 September, 1999 B) SYSTEM CONDITIONALLY PASSES (continued) ❑ Sewage backup or breakout or high static water level observed in the distribution box is due to broken 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). Describe observations: ❑ broken pipe(s)are 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 HEALTH 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS 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 the SAS is within a Zone 1 of a public water supply well. ❑ The system has a septic tank and soil absorption system and the SAS is with 50 feet of a private water supply well. ❑ The system has a septic tank and soil absorption system and the SAS 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 18 Preakness Way,Marstons Mills Owner:Kathleen Nele Date of Inspection:21 September, 1999 D) SYSTEM FAILS You must indicate either"Yes"or"No"as to each of the following: ❑I have detennined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this detennination is identified below. The Board of Health should be contacted to 15.304. detennine what will be necessary to correct the failure. Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded 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 clogged SAS or cesspool.` ❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow. ❑ ❑ Required pumping more than 4 times in the last year not due to clogged or obstructed pipe(s). Number of times pumped ❑ ❑ Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. ❑ ❑ Any portion of a cesspool or privy is with 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 1 of a public well. ❑ ❑ Any portion of a cesspool or privy is with 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 coliforn bacteria,volatile organic compounds,anunonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes"or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: ❑ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No ❑ ❑ 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 E 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 Property Address: 18 Preakness Way,Marstons Mills Owner:Kathleen Nele Date of hispection:21 September, 1999 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health. ® ❑ 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 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. ® ❑ The site was inspected for signs of breakout. ® ❑ All system components,excluding the Soil Absorption System,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 battles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location or the Soil Absorption System on the site has been determined based on: ® ❑ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. ® ❑ Existing infornation,Ex.Plan at BOH. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address: 18 Preakness Way,Marstons Mills Owner:Kathleen Nele Date of hispection:21 September, 1999 FLOW CONDITIONS RESIDENTIAL Design flow: 330 gpd/bedroom for SAS Number of bedrooms 3 Number of current residents:2 Garbage Grinder:No Laundry connected to system:Yes Seasonal use:Yes Water meter readings,if available (last 2 years usage in gpd):No Sump pump:No Last date of occupancy:Currently COMMERCIAL /INDUSTRIAL Type of establishment Design flow: gpd Grease trap present: Industrial Waste holding tank present: Non-sanitary waste discharged to the Title 5 system Water meter readings,if available Last date of occupancy .OTHER: (describe) GENERAL INFORMATION PUMPING RECORDS and source Owner System pumped as part of inspection No Volume pumped: Reason for pumping: TYPE OF SYSTEM ® Septic tank-/distribution box/soil absorption system ❑ Single cesspool ❑Overflow cesspool ❑Privy ❑ Shared system(y/n)(if yes,attach previous inspection records,if any) ❑I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components,date installed(if known)and source of infonnation:20 Years,Owner Sewer odors detected when arriving at the site:No SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address: 18 Preakness Way,Marstons Mills Owner:Kathleen Nele Date of inspection:21 September; 1999 BUILDING SEWER (Locate on site plan) Depth below grade 22" Material of construction❑Cast Iron❑40 PVC ®other Distance from private water supply well or suction lineN/A Diameter 4" Continents:(condition of joints,venting,evidence of leakage,etc. ) Sound condition,original piping to tank is"orangeburg" SEPTIC TANK (locate on site plan) Depth below grade 14" Material of construction®concrete❑ metal ❑Fiberglass❑Polyethylene❑other If metal list age is age confinned by certificate of compliance Dimensions: 1000 Gal Sludge depth: 10" Distance from top of sludge to bottom of tee or baffle 20" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 3" Continents: GREASE TRAP (locate on site plan) Depth below grade Material of construction❑concrete❑metal ❑Fiberglass❑Polyethylene❑other Dimensions Scum thickness Distance from top of scum to top of outlet tee or baffle Date of last pumping Cornments: (recontinendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leak,etc.) .I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address: 18 Preakness Way,Marstons Mills Owner:Kathleen Nele Date of hispection:21 September, 1999 TIGHT OR HOLDING TANK: ❑(Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade Material of construction: ❑concrete❑metal❑Fiberglass❑Polyethylene❑other(explain) Dimensions: Capacity: gallons Design flow: GPD Alann level: Alarm working?❑ yes❑no Date of previous pumping Conunents: (condition of inlet tee,condition of alann and float switches,etc. ) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:Zero Continents(note if level,and distribution is equal,evidence of leaks or solids carryover,etc. ) PUMP CHAMBER: ❑ (locate on site plan) Pumps in working order: (yes or no) Alarms in working order:(yes or no) Conunents:(note condition of pump chamber,pumps,and appurtenances,etc.) i' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(Continued) Property Address: 18 Prealaiess Way,Marstons Mills Owner:Kathleen Nele Date of Inspection:21 September, 1999 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 One, 1000 Gal leaching chambers,number leaching galleries,number leaching trenches,number&length leaching fields,number&dimensions overflow cesspool,number: Alternative system: Name of technology Comments:(note condition of soil,signs of hydraulic failure,ponding,vegetation,etc. ) CESSPOOLS: ❑ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer Dimensions of cesspool Material of construction Indication of ground water inflow(must be pumped as part of inspection) Commments:(note condition of soil,signs of hydraulic failure,ponding,and vegetation,etc.) PRIVY ❑ (locate on site plan) , Materials of construction: Dimensions Depth of solids Comments:(note condition of soil,signs of hydraulic failure,'ponding,vegetation etc.) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(Continued) Property Address: 18 Preakness Way,Marstons Mills Owner:Kathleen Nele Date of hispection:21 September, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM Include ties to at least two permanent references,or benchmarks,locate wells within 100'and where public water supply enters house. OF Stu t�sF Ai 3I,- b`� z�( Z 28, -Ott it A 3`c o O9 ZD i` i fi A4 33` — oej —9 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address: 18 Preakness Way,Marstons Mills Owner:Kathleen Nele Date of hispection:21 September, 1999 Depth to Groundwater feet Please indicate all the methods used to determine High Groundwater Elevation: ❑ observed from design plans on record ❑ observation of site(abutting property,observation hole,basement sump) ❑ determine it from local conditions ® check with local Board of Health ® check FEMA maps ❑ check pumping records ❑ check local excavators,installers ® use USGS data t Describe in your own works how you established the High Groundwater Elevation. (Must be completed) TOWN OF BARNSTABLE LOCATION /Il" /�p/�/1rod.c( Q.IJ SEWAGE # VILLAGE ASSESSO 'S MAP & LO ry ,TJy$PEC NAME&PHONE NO. SEPTIC TANK CAPACITY ZQQQ �r /A-`a LEACHING FACII.PTY: (type) �.C�' LII (size) 60 dG NO.OF BED 3 BUILDER OWNS PERMU DATE: DATE:— s2 N4 px- r, Separation Distance.Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) n` Feet Furnished by 4A {R- t� I � \ V-'-_ � �� o� � , . ��° �-� �� .- �,� o �� � 9" i �� ��'C�'' y�, �„ t vim, Q$ T ov AU G 22 BORTOLOTTI CONSTRUCTION,INC. '�yFeg9Ns 139I 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 �r/109MAkr 508-771-9399 508-428-8926 FAX: 508-428-9399 A 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E ti PART A C/E.R,TIFICATION Property Address: W Date of Inspection: Inspector's Name: Owner's Name an Address 0/ 7 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 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 Eval 'on B e Local Aproving Authority Fails Inspector's Signature: Date:_ a`t/Z7 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 approving authority. INSPECTION SUMMARY: A)SYSTTM PASSES: �// I 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. The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exftltration,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 broken, 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 • ;.t ��"'_4 � PART A CERTIFICATION (continued) 1 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 r 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 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- ING IN A MANNER THAT 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. 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 ti"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year hM 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. 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 a large system in addition to the criteria above: 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 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 I1 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: `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. wl"'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. _4The site was inspected for signs of breakout. ZAll system components,excluding the Soil Absorption System, have been located on site. 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- I` 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 FORM - _ PART C = . SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: (/ Design Flow: allons Number of Bedrooms: 3 Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readings, if ayailable: Last Date of Occupancy:�Q COMMERCIAIJINDUSTRIAL: �Q 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: GENERA NFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection:X(i If yes,volum pumped: gallons Reason for pumping: TYPE Of SYSTEM: t/Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): APJ?ROXIMATE AGE of all components,date installed(if known)and source of information: Sew ge odors detected when arriving at the site: ICJ -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: t/ Depth below grade:�� ,, Material of Construction:11_ concrete metal FRP_Other (explain) Dimisions; ,,5_'Y(o',y5' Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 33 � Distance from bottom of scum to bottom of outlet tee or baffle: boa e- Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid 1 el in ation to utlet invert, structural integrity,evidence of leakage,et . Q- Q• /0 / �� 9 r 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 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:_z2Q Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments (condition of inlet tee,condition of alarm and float swit0es,'etc.) DISTRIBUTION BOX:Je!!:� Depth of liquid level above outlet invert:/Z Comments: (note if 1 el and distribution i a ual,evid ce of solids carryover,evidence of eakage 'nto or out of box,etc.). Vr 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). (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: Leaching trenches,number,length: Leaching fields, number,dimensions: Overflow cesspool,number: Comments: (note condition of soilIII , signs of raulic ailure lev I of ponding,condition of vegetation, etc - ' 4 ii CESSPOOLS: Number and configuration: Deptli-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: Materia sl of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - ti 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. 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