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Home My WebLink About0023 SASSAFRAS LANE - Health �23 SASSAFRAS LANE, MARSTON MILLS BORTOLOTTl CONSTRUCTION, INC. 9 45 INDUSTRY ROAD, MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:.9 3 / 0/ z 2 24&a _ Date Of Inspection Inspector's Name: Ow{er's Name and Address: 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 Inspectioln was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site.Sewage Dis- posal Systems.Tie system: 1/ Passes' Conditionally as s Needs Fur er v ati y the Local Approving Authority Failure �Q Inspector's Signature Date: 7 TheSystem;Inspector all submit a 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 Offie 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. A) SYSTE PASSES: I have not found any Information which i udicates 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. j 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 exfil- tration,or Tank Failure is iimminent. The System will Pass Inspection if Existing Septic Tank is Replaced Mith 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 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 i I j t < 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 _ Obstruction is removed i C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: j 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. i 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 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 invertdue to an overloaded or clog- ged SAS or cesspool.' Liquid depth in cesspool is less than 6"below invert on 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 (continucd) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. within 100 Feel of a surface water supply or tributary to Any portion of a cesspool or privy is a surface water supply. is within Any portion of a cesspool or Privy Any Zone 1 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 FAU S: 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 of more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply' The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any,such system shall bring the system and facility-into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the,local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CIIECKLIST Check if thefollowing have been done: pumping information was requested of the owner,.occupant,and,Board of Health. �/N— one of they system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of wate�'h�ve not been introduced into the system recently or as part of this inspection. ✓As4milt 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 uon-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. %� The eptie tank manholes weir uncovered,opened,and the interior of the septic lank was in- apoctedfor condition of baffles or tees, material of construction,dimensions,ikpth of liqui4 r '` -depth 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: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CIIECKLIST(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 RIMMENTIAT.- Vol, Design Flow: _gallons Number of Bedrooms: Number of Current Residents: Gad age:Grinder: NO Laundry Connected To System:(�� Seasonal Use: 'it'O Water Meter Readings,:if ailable: O Last Date of Occupancy: COIi MRRCIA1,414DURTRIAr., PM Type of Establishment: , Design Flow: aallons/day 'Grease Trap Present: (yes or no) Industtial 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: GENERAL INFORMATION PUMPING RECORDS and source of information:& . .. ;., -System Puni*,as,part of inspection:-,� if yes,volu pumped: sallons Roma for pumRmg: 1'Yp"A,.S.YSTEM: <: Septic TauldDistribution Box/Soil Absorption System Single Cesspool, Overflow Cesspool Privy Shared System(if yes,attach previous inspection records, if any)- APE of all co vents,date installed(if known)and source of inforniation �9 } Sewage odors detected when arriving at the site: IZ,(r - --- -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: i t&A r Depth below grade: Material of Construction:ti/concrete metal FRP Other (explain) — Dimislons: R.S'Y&'X S' Sludge Depth: / Scum Thickness: / Distance from top of sludge to bottom of outlet tee or baffle: L/ 01/ Distance from bottom of scum to bottom of outlet tee or baffle: / OF Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid f level in relation t outiet inve structural integrity,evide ce of le ge,etc:.) ' �i ' W GREASE TRAP: A.)O t Depth Below Grade: Material of Conslniction: 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: A)v Depth Below Grade: Material of Construclion:_concrete—metal FRP—Other(explain) Dimensions: Capacity: gallons Design Flow: gallonstday Alarm bevel: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note' eve[and distribution is equal,evi ce o solids carryover, evidence of leakage into or out of box,etc. PUMP CHAMBER: A d ...... Pump is in working order:' _ Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) -5- �I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: n . Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: _ Comme ts:(note condition of soil,si ns of hydraulic failure le I of i iJ pondin ,condition of ve elation, V A J CESSPOOLS: A)0 °F Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(Cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition ofyegetation, etc.) PItIVY:�� Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include des to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 2V ' 0 DEPTH TO GROUNDWATER: / Depth to groundwater: / Feet,/ Meth of IDe rminadon or Appro 'matign /Y" i�il//� J`Cd� / 445, -7- 2-3 TOWN OF BARNSTABLE LOCATION e-a7 SEWAGE # e9_ 316-7 VILLAGE Aj 692VA;1,If66-5 ASSESSOR'S MAP & LOT acl3 --068.- ,,INSTALLER'S NAME A PHONE NO. OV�S;'�' -771-9 �,SEPTIC TANK CAPACITY ,�D 1 LEACHING FACILITY:(type) s' (size) 'NO. OF BEDROOMS IVATE WELL O� BL1C WA ER BUILDER OR OWNER 6% -� 01JAY P"7"/' DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes —��No\ �,� i �� i � I 'M Kt No......91:. A 3 -o6 Fps. _.._`'•-------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH' p "' .................OF....._.. �� .!_._ �8 ................................ Appliration for Disposal Marko ontr ion �[ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syste>�at � /` •---- Loca'on-Address or Lot . No. ... tr__ �7..r.%- .................. -.....---- _/ .�ssr ?� '.......................... OwnerAddress ........................................ Installer Address Type of Building ize Lot_/S f.(/.M..._......Sq. feet Dwelling—No. of Bedrooms___ _ _____________________________Expansion Attic Garbage Grinder Other—Type T e of Building .............. No. of ersons....._....._..._.....__.._._ Showers (� yP g -------------- P ( ) — Cafeteria ( ) WOther ures -----•------•-•--••••••-••-••••-•-•---•........-•-••-•.•-•••...................................••-•••••-••--•---••-•--.................•••----••••••_•- d W Design Flow......__s�..............................gallons per person per day. Total daily, flow' _....3_J?__J0.......................gallons. W1 Septic Tank—Liquid'capacity/..gallons Length__..�•� th_..... Wid ___� .... Diameter________________ Depth_..___..__. x Disposal Trench—No.�................ Width.................... Total Length.................... Total.leaching area...................sq. ft. Seepage Pit No.R* - iameter.....f:0......... Depth below inlet..._?............ Total leaching area..�_.P__�....sq. ft. z Other Distribution box ( e Dosing tank ( ) Percolation Test Results /Performed by..��_ Ct* .=_... ___________________ Date___ . .......... W , , a Test Pit No. 1...........:....minutes per inch Depth of Test Pit...l__________.... Depth to ground water___A40............. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 ---- •----•••---•--- - ---•---•____________________________________•--------------•------------•--------•-•-----•----•-••-----------••-- Description of Soil__.: _.'_ C®�? ' 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 TITIE . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' e, by t e and health. ( <,�Signed_ �j ate Application Approved By.....•- -•-. '�/ ....... . ........ . -----• ... ----�.. .... D e Application Disapproved for the following reaso _•.................................................•___•___.._..________________________________._...:--------- ...............•••-•....._...._...-----••••••-•....-•....-••---... .................................I---....----•-•••••••-••••-• ••••• • ..................................Date - ---•---------------- Permit No...GJ....... ------ ---------------------- Issued..---. . -�----•---•-----------.... D s a l O O No.._....L i.. ... -� Fss.. .,,,? ....._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �+ r :..e._..._ ........ ................................ Appliration for Disposal urk� unstrnxiun Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst at,'___ ., L o on-Address or Lot No. Owner Address W Installer Address Type of Building Size Lot_£' ,_. .........Sq. feet aDwelling—No. of Bedrooms_-- Y... ___..Expansion Attic ( Garbage Grinder aOther—Type of Building ____ __ µ :�...___.... No. of persons____________________________ Showers ( ) — Cafeteria ( ) Otherfixtures .------••---------------------------------------------.-----.....------------------------------------..:R:----..._._..........-----......--•--......---- wDesign Flow______ ________________________gallons per,person per day. Total daily flow____..:. *?.......................gallons. WSeptic Tank—Liquid capacity a"."1 e��.__gallons Length_: __,�..___ Width.. % L�_____ Diameter________________ Depth_______-__. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. -__-- - F !° a a ... � Seepage Pit No.:��` �`""____.__._ lameter.____t!.ti______.__ Depth below lillet___.r° ........... Total leaching area._.�:: - _�s..__sq. ft. Z Other Distribution box ( Dosing tank ( ) aPercolation Test Results Performed by.._,f__Z _ . t?":": ��` ...................... Date... ........... Test Pit No. L___.. minutes per inch Depth of Test Pit _` Depth to ground water... .e __.............. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ._..------•-----------------------------•---------.....----._._........_.._..-----------------..._......-----------...........---•-•-------------------•...-. ODescription of Soil........................................................................................................................................................................ 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 TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.......... ._..._ ........................ Application Approved BY--• --•• -`=--•-`"v` ` '�? ff =t ` ==•-•=-= -•-......... -•------- Date Application Disapproved for the following reasons:� ----------------•--------•-----------------------•---•---------------...-•-------••------............._.» .......................................................... ....______________.___________.___________ _..___..___..._ r- r^ Date Permit No......1 r ) -.7 t 1 s --•---........» Issued.-------�.. _ ._r_)_... ----•------•---- D�, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N� r ! -, .r ?..E. ? :......................OF....r�e..�t.�z' -�!`.�`f.............................................. (9rdifiratr of Toutplianr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY.................................................................................................................................................................................................... r. Ins aller at...... = ?,.-`----- -" --• , ' " ..............�.....----<............................................................. has been installed in accordance with the provisions of TIT � "5 of Sanitary Code yl�c�} the application for Disposal Works Construction Permit No.______� __^_. -3 __a dated______________ /_+ .1/____...._.�__.____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........................I:�..J...�. Ll............................. Inspector................. = —.� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 17 t. ..........................................OF... ......._....._....._...---.._..----------------------------•-------......... No..... . .... FEE........................ . . - -� Disposal k J,n ^^trndi�r .rani# Permission is herb ranted______________ ___ ...::' !......._� __... 4.. Y g .._......---;,........--- ..............••---- to Construct ( ) Re air ( ) an Individual Sewage Disp�Isa�S}' /V at No........... - �� •-` ............... ..... ...../......�. � J ` L \ _.......V../d as shown on the application for Disposal Works Construction Permit No.. )J ............ / ......... ....... .. . .---•----•..................•--...-•-•----------------------._...-------.....----•....._•--•-----..._..» Board of Health DATE_----------------------••---------••------------............•--------.......... FORM 1255 A. M. SULKIN,.INC.. BOSTON i I { a. 9 3.5k ncr arFvtm4naly OPEN SPA CE ccwr rr co►�xs 2 car ,crr cavrr� a. ` A.2 4"ocko r 40 PVC E iTa1B • • N 28- 53' 40" E �: IVV�PT IWERT NVE�PT .+s 'j' mwusT - ELTTIIC TAAK Q . _ AL. }• ►h.�► • . :r 314-to iW 92.00 6 IL AL EL lo 10, PROFIL E OF — _____lam 2-1 SEP TIC S YS TEM SO/L L OG 1 VA T,E 7.20 • sG 5454 GENERA L NO TES rraT ALL PIPE 4,. SCH-40 P.V.C. REMOVE ALL UNSUITABLE 1ITAA1 F nTFRIA � LOT 26 LOT 27 �' N LOT 28 To COMPLY wrrN 3I0 cMt� I5=02c 17 4 T/L/S DESIGN DA TA AK VDT CF DEMOOMS 3 l ' TOTAL FLOW 330 � cn $0 FT. &OrTOM LEACh" AREA s'Q FT. I 93 t�► , 93 / MED SAND �4R6W� 30x harar� O • TOTAL LEAQFIIKKi AREA � � PEM"T11WV RA TE AMU* NO. WA TM VAWi,rylMW - - CAL Ct"TAMM S� Mom I � f 15.5 �SE� 5E (ICo i/ 15.5 f {r a PIT J PROP 00 �� 36 TEsr / NO TE: TOWN WA. TER A VAIL ABL E 20 ' z� • \ 92. - ` At OF Nit°2492.00 , , / E S1 TE PLAN j-� -� •-' t VV• Zc PAMA. No.32M OF LAND 11 ! ESS��P � / - r ��F su , / f BA RNS TA3L E RES ZONE 'RF" / ' FL OOD ZONE „C., i } i PLAN REF: 448/88 GA -I?A -M 4 k W1., y-.,<• F ISA .. E• � •,,� 7 ` ,�,A S . 1 I YANKEE SURVEY CONSUL TANTS 143 Rou T 149 tp,a BOX 265) E 20 /O O 20 40 MA RS TONS MIL L S, MA 02648 DA TE: 5 / 8 / 1989 SCALE: /" = 20' t 1142 27