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Home My WebLink About0153 WINDING COVE ROAD - Health 153 WINDING COVE RD.,M. MILLS A=057 050 0 s . o so �o 1998 w BORTOLOTTI CONSTRUCTION,INC.. , 765 WAKEBY ROAD,MARSTONS MILLS,MA 02048 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPiCTI! ON FORM PART A / CERTIFICATION �3 L(� E Property Address: Date of Inspection: Inspecto ' ame: Own s Name and Address: I certify that j 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 (s%ems. The System: :Passes ,w Conditionally P es �.; Needs Further at on the Local Aproving Authority Fails Inspector's Signature: Date:- ��y/f The System;Inspector shall submit a copy of this inspection report to the Approving authority within thir- t 90)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. $ISPECTION SUMMARY- A)'tsz( PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 3 to CMR 15.303. Any failure criteria not evaluated are indicated E < 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 deterntination in all instances. If "not deternti*",explain.why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or iexfiltration,outank 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 - E ry TI 46 tit 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: 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 WELL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM I3 NOT FUNCTIONING 1N A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENTS: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is witidn 50 Feet of a bordering vegetated wetiand 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 absorptions system and is within 100 Feet to a surface water supply or tributary to a surface water supply. i The system has a septic tank and soil absorption system and is tm+ifh 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 defliied in 310 CMR 15.303. The basis for this determination is identified blow. The Hoard 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 thap..6"below invert or availabic volume is less than 1/2 day flow. _. 1 ed or obstructed due to Required pumping more than 4 times m the last year NO i' clogged pipe(s). Number of times pumped .'.i -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 portio of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water su7ply 4W with no acceptable water quality analysis. If the well has been analyzed i to;be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compoupds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM)FAEL 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 healtif and safety and the environment because one or more of the following conditions exist-..°.y. , The system`is within 400 Feet of a surface.drinking water supply The system'i"s'wtlun 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. a.> M~ .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 t CHECKLIST Check if following have been done: --�-�Nipping information was requested of the owner,occupant,and Board of Health. . _p one of the system components have been pumped for adeast 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. Yset plans have been obtained and examined. Note if they are not available with N/A. � facility or dwelling was inspected for signs of sewage back-up. e 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. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in petted for,conditi6n of baffles or-tees,material of construction,.dimensiona,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- :-, r ? :4i 4,1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART B CHECKLIST(continued) y e facility owner and occupants, if different from owner)were provided with information on Th ty ( P the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYST19M INFORMATION FLOW CONDITIONS Design Flow: (� lions Number of Bedrooms: 2 NmR r of Current Residents: c r Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readings,if ilable: Last Date of Occupancy: CnMMERCIAI.l RDLISTRIAL:'�(� Type of Establishment: Design Flow:__gallons/day Grease Trap Present: (yes or no)____. Industrial.Waste Holding Tank Present: , Ton-Sanitary Waste Discharged To The Title V System:_„ _ Water Meter Readings,If Available: Last Date of Occupancy: g OTHER Describe) Last Date of Occupancy: X GENERAL INFORMATION c 6PING RECORDS,and source of informatipw System Pumped as part of irispecdon: /( If yes,volume pumped: ons 1, Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soii Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection rv;ords, if any) Other(explain): ROXIMATE ACE of all qpponent.s, install (if known)and so ce of information: SewijFq e odors det ed when arriving at the site: -4- e SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM t ,t PART C . . GENERAL INFORMATION (continued) SEPTIC TANK:_ Depth belo.:grade:— Material of Construction: --' concrete metal FRP Other (explain) '- Ditnislona:yR,S�/o'X Sludge Depth: ii Scum Thickness: 71 Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: �3 Comments;(recommendation•for pumping,condition of inlet and outlet tees orb es,depth of liquid level in relation t outlet invert''stru tural integrity,evidence of leaks e,etc.) ' /dt ' G AS TRAP:) Depth Below Grade: Material of Construction: concrete metal FRP—Other (explain) - — — — Dimensions: - Scum,T'hickness: 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: Depth Beloyv Grade: Material of Construction:—concrete—metal—FRP Other(explain) ''11imensioq: Capacity; gallons Design Flow: t;allons/day Alarm Level: ' Cq*ments: (condition of inlet tee, condition of alarm and float switches. etc.) `7 DISTRIBUTION BOX: Depth of.liquid level above outlet invert: Comments:;(note if l el and distribution is equal,evidenc of solids carryover,evi ence of l ge into or out of x,etc.) PUMP.CHAMBER . Pump is in working order. . Comments:(note condition'ot°ulmp chamber,condition of pumps'and appurtenances;etc.) 5- F i , J -r p,;. � . .��; 4 � �.�a;,i Jr, •� t�., w p. 'tc � •t". .. a .pub-.'� .. ,t ' �C'►" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) , SOIL ABSORPTION SYSTEM(SAS): y� (L.ocate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: ,hype: Leaching pits,number: / Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Co ts:(note condition of I, si s of hydr ulic f i ure level pondin ,co dition of vegetation, etc.) GZ 1 C �1d • ESSPOOLS: Number a d 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: Io.flow(cesspool must be pumped as part of inspection) Comments:(note condition of soilk,signs of hydraulic failure, level of ponding,conditiowof vegetation;- etc.) N. 'PRIVY:_z2� Materials of construction: Dimensions: --,— Depth of Solids: Co..iments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetaoiaA,. etc.)' -6 i.: i T � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q 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 a qq . DEPTH TO GROUNDWATER: Depth to groundwater; Z/ Feet Method of Determination or pp ximatio : ��'/��'� /!> G(•J� ' D R'/Z-1/" u -7- No. E:-(o. --- �- F�s.... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH • ,�........OF.......... Appliraiion for Ehiip a al Workii Tnnitruriiun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System I� at � � 1� � .....----.. ... . ...... �tr -. -- 2 .- ............. tio re -- Lot N tiVjTf� Jl VTPhh O ner / Adddress ISsta� 49)w / Address Type of Building Size Lot.p%`-'.'._7!.....Sq. feet Dwelling—No. of ......... ..........................Expansion Attic (�l Garbage Grinder PL, Other—Type of Building .........................:.. No. of persons..................---------- Showers ( ) — Cafeteria ( ) Q' Other fixt res ...................... . . W Design Flow.................. ► ......._ gallons per person per day. Total daily flow.........7-Y.C�_.....................gallons. WSeptic Tank-�Liquid capacity.f .gallons Length................ Width---------------- Diameter................ Depth................ xDisposal Trench—No..................... Widt�s...-__._........_._ ----Total Length......../__..._..... Total leaching area----:...............sq. ft. Seepage Pit No--------1_._._..__.. Diameter--__-Y•°-�... Depth below inlet.....CO........... Total leaching area..a /....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •------------------------•---•... --------- •-----•--------- O Description of Soil l� '' W&4-- � l '------ `=14.....A .-S -_---------- !-. _ V ..--•-•--•-•--•---------••••------------•-••----••-----------•------------------------•----------------------------------------•-------------------••----•--------------------------••-----------•------- 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 iITI 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is d b the boar of health. S' --•��-- . ------. ---- -•----------Da.t.e........•..... Date Application Approved B ------ _7: 7 PP PP Y..... Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- --------•-----•------•----------------------------------------------------•------•--....---•----------....------------------------------------------------------------------------------•-•-•----._...... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........OF....... ��0 �N• i'►7 �. •...........................�� 7v Trdifirattr of Toutph aurr TFjf,$ IDS TO 1RTIF /That the Individual Sewage Disposal System constructed ( <or Repaired ( ) by �{-._. ..... --------- .--- ----•------• --- ----- -- -- - I 'sc ler at...... �� t` ..--. .. t_ ►_ � ..z/.._., h� e I�'� 171 s has been installed in accordance witli the provisions of T �9flThe State Sanitary Code as described in the application for Disposal Works Construction Permit No... .................................. dated._""._7_.f.7='� _ ---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................` Inspector.................................................................................... NO.._.....:L_G .... Fim.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF........ . .. ..4 ........................ Appliration for Uiipnlia1 Work Tom3trurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemata? .......WA......................... ..... tX� .� .7...&_146...... ...... L ation-Addres Address e yf .............................•-.-- Address Q Type of Building Size Lot _....R: ......Sq. feet. U Dwelling—No. of Bedrooms.............I............•.............Expansion Attic ( ) Garbage Grinder ( j '4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria Q+ Other fixtures --------------• -••--•---•--•--•-----------••-.• -- W Design Flow.................`............._gallons per person per day. Total daily flow----------IJ .....................gallons. WSeptic Tank f Liquid capacity ..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area..........._........sq. ft. Seepage Pit No.......I............ Diameter.._fosing Depth below inlet....6............ Total leaching area.,2Q.1....sq. ft, ZOther Distribution box ( ) tank ( ) •-' Percolation Test Results . q,` Performed by.......................................................................... Date........................................ aTest Pit No. I.................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.....:.---.--_-----___. Pd •. ... •••• _... ......................................... D Description of Soil ,A .i k P � � '"' . tit` A ............... -------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------•--- 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 TITL: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i d by the board of health. Sine --•• -•••---•-•--•-- z - Date Application Approved B Ff ----------------------- PP PP Y i� Date Application Disapproved„for the following reasons----------------•---------------------------------------•------•----------------------------------------------•-- .;. ' Y Date PermitNo.................--..................................... - Issued....................................................... Date THE COMMONWEALTH OFWASSACHUSETTS G- yy BOARD OF HEALTH �� ....... .........OF..... :4 %luntif iratr of Tumphattrr THIS I T0. RTIF , hat the Individual Sewage Disposal System constructed ( �r Repaired ( ) �"0 1S -•---. .fit .. .•---•-----------------------------------..................................................................................................... by_....... l� �'?- Insta ler /, ,�a! e. at.._� t� tk � q , — 'arJ - �t; has been installed in accor ance 1 the provisions of T _fi% ` f The State Sanitary Code as described in the application for Disposal Works Construction Permit No._.._ :_.._ ,� ............... da.ted__an_7m/7V-*.7 ,.--------------- THE ISSUANCE OF THIS CERTIFICATE SHAD NOT BE CONSTRUED AS A GUARANTE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.., DATE............................................................................... Inspector..:-----------------------------................................................... THE COMMONWEALTH OF MASSACHUSETTS , BOARD F HEALTH j .... F O.g) ...... ... .........0 F.... E se Elisposa rkii n Y dart antti Permission s reb granted......` 4... ----....... .� = ��----------•----------------------------------•-•-----•---•------ to Cons, uct � !?► � = tlY �P d i j at D---`� 1-- �''��;•_1"t�:�?.�1�_ Street as shown on the application for Disposal Works Construction Vo Dated.._...!�"l_!.__'`��............. 1Y-'.ay. t ----------------- ---------••-......-•...........------ d of Health DATE-------------------------------------------------------------••-•-•-•---------- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS "` ' ��:�.�� :'.n,��L�-!'' - '� Est=...��c�M !f� � •^ � j . 1 } 41 1 i' P/f ' l ` '� P G.P.D. : �.PD. TAN L 1)C-St6J -125 G.P.D. E10 f J L �i.�l Lam(' FLOW t 33D &FID. / .FNo 1 �• ` ZZ f /G•C'.f.GO�oTl �QT� tU � ti t J• Ort I � �Q dR • l , RIOHAPD jl- A. N,yi SAXTcR ?'Cv3 c• ,1 ti zu c , ( TEST �(ZS''lq Tot rioo s too.• , S. .� f�vsr �.ii n• 7Tn Win � s .4�Pi�f6c � , .• ' �-� :.. !..U.ti241 •Poe ." ttyK•`1Co�a : :;":. _.�_ " ; . _ E 4 PIP,& C� � tw• Got.. ��.r� •• ':_ i SU�`OCC:, t►iK - / TANK t P,7 6 r r [pijrj' wos++ISD - - -;� ZZ,. GGIZT,��=ter THAT T1.1G roU}y0'�-CIc IJ S�la�v►J t PL4►,.1 RL�c�E►.1G�` -i. ` t-1C.z l;=4tJ Gc+1�LPL�lS W �YK �'►-��: 51DE.LI►-�� Aug :�'rL'./•C� • �'GCcst��wc��TS OF T►+� .:_'..,... : OT' � .. , "raViLi r, I%I- -,'IST� a�LG LDS t'ai� L/�, �ir�i iJ (p :•1 1 . B A XTC1Z. t2CG1S tt_2CD "wo SUZV&YoR ' 'T--W,S t V L,At-`4' -1-S "OT•7 1L'A-,GV 0T 4 Aal 05TECV1l.1.G. -,a, ti(AS'Sr. - .t�%1�:J i./�t�� l /J�.��LY `�• \t1�:: U��•.jf�'{Ij '�l1�CJ�LD i r. - . .6 t' s TOWN OF A.RNSTABLE ✓ A. LOCATION 2&2eSEWAGE # VILLAGE ASSESSOR'S MAP & LOT d 7/ b� V6Pr5-,,7ZjeS NAME&PHONE NO. 4 SEPTIC TANK CAPACITY (24 LEACHING FACILITY: (type) (size) NO.OF BEDROO S V. BUILDER O O ; PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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) Feet Furnished by 6,—v? q/ nn� d'� o �v q9