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Home My WebLink About0034 CAP'N JAC'S ROAD - Health 34 CAP'N JAUS ROAD W BARNSTAB E j A= 194 052--0 a d 7Ail" ,J e R BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop Date of Inspec} M 9� arcelDS2 Owner�!-. ,,, dilY - WOO 6- PART A — CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: LIMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. ONE 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 COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. C-1 S-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WI N HE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. ,,_THE SITE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. 2 � ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. - %, , '996 (/THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SE NK TED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH UID,DE SLUD DEPTH OF SCUM. THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING IN A APPROXIMATED BY NON-INTRUSIVE METHODS. THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL �Je No of Bedrooms .S� No of Current Residents Garbage Grinder Laundry Connected to System Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: GALLONS Pumping Records and Source of Information: A/ SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS Reason for Pumping: TYPE OF SYSyEM: ./ Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes, attach previous inspection records, if any) Other(explain) Appr mate age of all components. Date installed,if known. Source of information. e- ;92/s-sw*�n SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? "4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below g� a:� Dimensions: , Material construction: —4,,,,edncrets Metal FRP Other} Sludge Depth Distance from top of sludaVo bottom of outlet tee or baffle Scum Thickness // Distance from Top of S/c/um to top of outlet tee or baffle 2- Distance from bottom of Scum to bottom of outlet tee or baffle Comments: / oa /0,0, Vol DISTRIBUTION BOX: f/Comments: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT PUMP CHAMBER: Pumps in working order? Comments: SOIL ABSORPTION SYSTEM SAS : IF NOT PRESENT,EXPLAIN: TYPE: aA 2 n CasoL ♦J' Comments: CESSPOOLS: Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Materials of construction Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — USTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES.LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' V- DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If'not determined",explain why not) Al Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? A Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? J✓ Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? C� Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? ! Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools &privies only, not the SAS)? 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,amonia nitrogen and nitrate nitrogen. '! PART D — CERTIFICATION I INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 Ii i CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION !REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: I HAVE NOT FOUND ANY INFORMATION TON WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED AREAS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS i FORM. INSPECTOR'S SIGNATURE: DATE: ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY