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0105 ROUTE 149 - Health
105 ROUTE 149,MARSTONS MILLS N4V 1 61 1998 BORTOLOTTI CONSTRUCTION, INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 ti 508-771-9399 508428-8926 FAX: 508428-9399 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A A CERTIFICATION Property Address: 1106- v&eh Date of Inspection:1116V9 eIns tor's Na e: er's Name d Address: j CERTIFICATION STATEMENT* I certify that I have personalty 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 V*ms. The System: t/ Passes, Conditionally Passe Needs Further: ation'B Local Aproving Authority Fatls � r Inspector's Signature: Date:--,,/ 9 � The System Inspector shall submit a copy of this inspection report i6 the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design now 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)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. 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 taiilc 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 broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health) - 1 - X r 1� ksUBSURFACE-SEWAGE DISPOSAL SYSTEM:INSPECTION FORM � . G PART A `• 'I i � : '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 pipes)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)-DETERMINE&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 aseptic 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 coliforrin 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 CUR 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`ari overloaded or clo g9 SAS or oesspool 6 "Liquid depth in'cesspool is less than 6"°below`invert or`available volithi is less than 1/2 day flow. ' 'R uid' m m `more tlian'4 times n the last ear NO due•to'clo ed or obstructed eq •rePu,. ..p g Y BB pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE;DISP'OSAL 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: . Tfie'system ismithin 400'Feet of a surface drinking water supply a The system'is within 200 Feet of 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: _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. .-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. J.,/The system does not receive non-sanitary or industrial waste flow. _fhe site was inspected for signs of breakout. .. _ All 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- spected for condition of•baffles or tees,material of construction,,dimensions,depth of liquid, 0epth of sludge,depth of scum. 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- A � 4 � ' � `��st�.�C �q�F"Tt,`q '4a�ri2k,''ar"�.�,•�'yri F i i SUBSURFACk SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART B CHECKLIST'(continued) ZTho 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 BE5A)T.1�iTIAL1� Design Flow: gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readings,if available: Last Date of Occupancy COIVLMRCLAiJINDLISTIAL � r, Type of Establishment v� Design Fl Lgallonstday ,Grease T� ^ra��Present: (yes or no)., Industrial Waste Holding Tank Present. A!V Non-Sanitary Waste Discharged To The Title V System; ` Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERATFORMATION c PUMPING RECORDS and source of information: Ae System Pumped as part of inspection: If yes,vo ume pumped: '` gallons Reason for pumping:. TYPE OF;SYSTEM: Septic'Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy hared System(If es,attach pious ins ion records, if any) Other(exp ain): � S TE AGE of all components,date installed(if known)and source„of information: PRO �. S age odors detected w arriviirat the site. -4- " s SUBSURFACE;SEWAGE DISP.OSAL:SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): t/ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: ��t� r. `ype: Leaching pits,number:_ Leaching chambers, number Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments:(note condition of soil,signs of hydraulic failure level of ponding,condition of vegetation, etc) a A61 (31'12 AK0, 44' LAZ&&&& oaa4e;2tZ2- QK A 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: Ind_icat_ion 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.) PRIIVY:_Lj� Materials of construction: Dimensions: Depth of Solids Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)- -6- SUBSURFACE SEWAGE,UISI'OSAL SYSTEM INSPECTION FORM . S "PART C GENERAL.INFOR M ATION (continued) ± SEPTIC TANK: Depth below grade: Material of Constnwtion` ✓concrete metal FRP Other (explain) Dimisions:),2.5'I&'X S' Sludge Depth: �' Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments:(recommendation for pumping,condition of inlet and outlet tees or atfles,depth of liquid level in relation to outlet invert tructural integrity, vidence of le age,etc. 7oe A Af GREASE TRAP: ( C'O7�`t'rt,9 A Depth Below Grade: Material of Construction:_ oncrete_metal . FRP_Other (explain) Dimensions:?, ' X Scum Thickness:. Distance from top of scum to'top of outlet tee or baffle: Comments::(recommendation for pumping,condition of inlet and outlet tees dutpifflejr depth'of liquid" level in relation to.outlet inVerf,'stp3pural integrity,evidence:of'leak. "e: TIGHT OR HOLDING TANK:.C Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Floc: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alann and float switches, etc.) DISTRIBUTION BOX: 7 Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) _"PUMP CHAMBER: t () _._Pump is`in working order: Comments: (note condition of pump chamber,condition of'pumps and appurtenances,etc.) j I xtSUBSURFAC' SEWAGE OISPOSAL.SYSTEM'JNSPECTION 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 C� 1 1, i s. DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of Determination or Approximatiop 01 U � TOWN OF BARNSTABLE LOCATIONk& j yXjf ,}j SEWAGE # VILLAGES ASSESSOR'S MAP Cz LOT INSTALLER'S NAME PHONE NO.6jfy � � SEPTIC TANK CAPACITY 2,000 LEACHING FACILITY:(type) / (size) 10t;0 "t�_ NO. OF BEDROOMS PRIVATE WELL O=PUBLICWATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 66, 13,LDC� H � f /.� �. �-� LOCATION SEWAGE PER�lj O. VILLAGE I'Y1 INSTALLER'S NAME & ADDRESS P h1 Abe- fi r, X ye 0 U I L D E R OR OWNER DA T E PERMIT ISSUED _/ DATE COMPLIANCE ISSUED t. - ` o g y i I ASSESSORS MAP N0: �^cx� No PARCEL NO: — ��� F�s...:....c.:?......... .--•- -------------••-- THE COMMONWEALTH OF MASSACHUSETTS OAR® OF HEALTH u�w. ....... oa, ........................................ App iratinn for Bi-spnaa1 Works Tnnitxnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair I-'J"'an Individual Sewage Disposal System at: PUR.STo ��..4..CA.: Ylftlee!S_l--..... ----------------------•---••------.......------•--•-----•---•---------•......---...•--......------ Locatio dress ; or Lot No. Owner• ddress a �Q K v� Xl'l�t�` c�. �' . � 11 �,� _.3. a 6:x 1.°--.. w c....... z Installer Address Pq Q Type of Building Size Lot...- . j_. Oi.... . feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) ............... No. of ersons......_.............._..____ Showers — Cafeteria p., Other—Type of Building _____________ p ( ) ( ) Q' Other fixtures ---------------------------------- Design Flow_._.... .�.........................gallons per person per day. Total ily flow_-__ a ions. t� Septic Tank—Liquid capacity..51�=_gallons Length.. ....:....... Width._..__.._._. Diameter__..______. Depth.(a._...._.._.. Disposal Trench—No. .................... Width.................. Total Length.................... Total leaching area...........3------sq. ft. Seepage Pit No.......I----------- Diameter-Cb-_---_.-___- Depth below inlet-----4.�......... Total leaching area-_$/3......sq. ft. Z Other Distribution box ( ) 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---- ........... ----------------------------------------•--•----.._.........---••-------------------•....................................................................... ODescription of Soil.....T:a-..... ..........................•----------------------------------------••-•----••--------------•----..................... x U --•---------------•----------•--•------------------------------------...----------------------------.....-------------=----......------------•-•-••-------•••----------------------••-•----------------- w -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U 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 HTHE, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issue, y t board of hea r �c( -'') .... � Date G. y , [ /e . Application Approved By---------------------------------------------- -------------- ............ ........................... Date Application Disapproved for the following reasons:....................................................... . ----------•-------------------------------------------------•------------•--•--..............------------------------------------------------------- ------------------- Date Permit No..................... Issued-.........-------- :..�_��.L % No ----------- RZ7.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .............. . ...........OF-........................................................................................ ApplirFa#inn for Bispoii al Works Tnnstrur#'inn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair V-1)"'an Individual Sewage Disposal System at: .......... Locat°. Address or Lot No. r f- �0 C { +� 1—, 1 r�?.r."1 -•....................................•---------......----•-........... .... _ - ... ---•---- Owner• Address a Installer Address d Type of Building Size feet U Dwelling—No, of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) pa,, Other—Type of Building ___________________•._____- No. of persons............................ Showers ( ) — Cafeteria ( ) QI Other fixtures .._....--•-•-•-•-----•-•-•-•-•---- ------- W Design Flow......�..�_.-.��...........................gallons per person per day. Total daily flow.... .8 ...............gallons. Q: Septic Tank—Liquid capacity_I1�1-:..gallons Length....r.......... Width0............ Diameter__---------- Depthlo.._.......... W Disposal Trench—\?o. .................... Width.................... Total Length.................... Total leaching area_._....._...........sq. ft. x Seepage Pit No------1............. Diameter/6.............. Depth below inlet..-±°.............. Total leaching area_�.1_3.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date............................ -•------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----N. --------__. GZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water... __._.......___. a --------•---•--•----------•-•••-------•--•-•---••-----•-•..........•--------•---••---•-•---------------•-..-•-••----•..........._••.... ----------•------•-- DDescription of Soil.... •� I�-f• .�....-----•---•--•.......---•-•-•--••••-------------------••-•------•-------••--••-•-----•---•-•---•----••----•---------•--- x 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 TAT'." of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Peep issu54 by board of h _ Date Application Approved B PP PP y........................................_.....-•---- ----- . -------•----. ..---•----... ----------------------t f �r . Date Application Disapproved for the following reasons:---•-------------------•---.....------------------------•-----•----------------•-------------------••--------- ---------------------------•-•-•---•---------------•-------...----------------------..........----------.._..........---••-------------------------------------------------------...--------------.....-- • ate - l Permit No......- � ..._ ...•---_.... Issued - ! ... .._.............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 0.17 HEALTH (, ...................... .................. Trrfifiratr of faniiiph anrr THIS IS—TO CERTIFY, hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by--------- ......--===�n.EIZ.%.....L---- ...1= `.....-•-------------- ---------------------•--.......------...............---------...•...------------------------------... ----- ----- Insc ller has been installed in accordance with the provisions of T i T i �of T State Sanitary Code as described in the application for Disposal Works Construction Permit `o..___.- .......................... dated......-_._1_, �'_��'.�___._._._.__._._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................�._......li-I.tr.....-----------...-•---•--.. Inspector.......................)..:\�'D........................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD,,._OF,, HEALTH ...........'.(0.................................... 7E<DV . ......... No✓;:..�... (_/ FEE. 1f .. Disposal nrkg �TuT--strati an rrmit Permission is hereby granted------.::`- ��'------....'-�`-=----......C. ........••-•-•-••-•--•-•.............••-----•••-.............-•-•-••----......_-••------- to Construct -( ) or Repair ( ) an Individual Sewage Disposal System at Street TM 11 as shown on the application for Disposal Works Construction Permit No.'"-150... Dated..... _ ':.L.C' s...- -- Board of Health DATE---------- ..i...... ...1-7--> `�, FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS a YR�^'+�^,: iwa,�w... atawalm�aWJYWiYmkFr+*.w.+nau .. - ..q.avac.Rnunnw'naw.R'1tim»1�+« N . N a Ta! N ` FLC)WS Ar 3E1 .,�� is ►� � �lt U1v> 0 'i1�JCY CatT t>.tob SYo `� F3��tLt �*sG � 7 �Lt R. ,.�� ,trl Ut�C}_17.� n5 c T'1.0« 8 n Zr O N1 A.t,OV 1E A t _ A 10','�-,4 S 1= 5'7aF7,t- T-I-:. Low 8 . M XIS7 I til F F C4US TED AS A PROPOS'E'D T�/0 STORE E>UILDIKIG WITF-1 '� cS l S'1 r�T_~i' G4Q'n�. STvI'�� C ►0 aF�CH <v LU01� I sCLU1�i JG A F-ULL P RSEM /o �� pt-r WITH C. 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