HomeMy WebLinkAbout0015 OLD FALMOUTH ROAD - Health �a
15 OLD FALMOU,1'I,-i< 4
_ _ A= 079 to\%A01
• BORTOLOTTI CONSTRUCTION, INC. /
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM /
Address Prop Q tE; Q
Date of Inspec} ` Map arcel Owner
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PART A — 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 AT LEAST TWO WEEKS AND THE SYSTEM"HA§BE Y
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN IIyTROD`�1 ED-
THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. j r
✓AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH= /A.
HE FACILITYOR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP.
✓THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. 1f�
✓ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. cS'
THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TA SPECTED
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUI
DEPTH OF SCUM.
i,�THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
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
No of Bedrooms No of Current Residents Garbage Grinder
Laundry Connected to System 14 Seasonal Use
NON RESIDENTIAL:
Calculated flow
WATER METER READINGS,IF AVAILABLE:
FGALLONS
Pump'ng Records and Source of Information: // I
SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS
Reason for Pumping:
TYPE OF SYSTEM:
Septic tank/distribution box/soil absorption system
Single Cesspool Overflow Cesspool Privy.
Shared system ('If yes, attach previous inspection records, if any)
Other(explain)WWC/0/7
Approximate age of all components. Date installed,if known. Source of information.
1ld 'et' e.." QD l�
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE?
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B SYSTEM INFORMATION (Continued)
SEPTIC TANK:
Depth below grade: 0 /11 Dimensions: ��S X / f XX-"
Material of construction: _Concrete Metal FRP Other} CO
Sludge Depth p Distance fron)Itop of sludge to bottom of outlet tee or baffle
37
Scum Thickness i Ji Distance from Tpp of Scum to top of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffle
Comments-
�
- s
DISTRIBUTION BOX: &0 DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:
PUMP CHAMBER' 0 Pumps in working order?
Comments:
SOIL ABSORPTION SYSTEM (SAS):
IF NOT PRESENT,EXPLAIN:
TYPE: — 600
Comments:
OY7Q
o dim e ,
CESSPOOLS: G 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 — SYSTEM INFORMATION (Continued)
..4
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL WELLS WITHIN 100'
70
5'
DEPTH TO GROUNDWATER: l DEPTH TO GROUNDWATER
METHOD OF DETERMINATION OR APPROXIMATION:
S y ve vUh
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.)
Backup of Sewage into Facility?
Discharge or ponding of effluent to the surface of the ground or surface waters?
Static liquid level in the districution box above outlet invert?
Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow?
Ay 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?
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?
/V Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools &privies only, not the SAS)?
/y 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
INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS
COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399
CERTIFICATION STATEMENT
I
i
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 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 ARE AS
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
FORM.
INSPECTOR'S SIGNATURE:
DATE:
ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(d applicable),APPROVING AUTHORITY
TOWN OF BARNSTABLE
Lf�-}AT70N lie e14.�l� ®. SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT&79-0/7-00/
INSTALLER'S NAME PHONE NO., 9�-1 l��7 OitkST �
SEPTIC TANK CAPACITY �fJDCJ
LEACHING FACILITY:(type) size)
NO. OF BEDROOMS PRIVATE WELL O UBLIC WA�TER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 40`'
VARIANCE GRANTED: Yes NO
49
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No.. .__ IIVVff Fics.�Q...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tonstrurtiun 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair l') an Individual Sewage Disposal
System at:
o ,2D /yes
tion-A res o Lot No.
/._ � ......................... Gam - .................................................
._-......---•--------.
Owner ress
Installer Address
Type of Building Size Lot��DZV_��Sq. feet
�-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Ga Other fixtur s -----------------------------
W Design Flow................
. per person per day. Total daily flow............... _0 ...............
WSeptic Tank—Liquid capacity/ .gallons Length................ Width................ Diameter__-__-__•__••-•• Depth................
x Disposal Trench—No..................... Width.................... Total Length................ Total leaching area--------------------sq. ft.
Seepage Pit No.--_____ - Diameter.__... P� �____. ,�Q_..... Depth below tnlet_____.�________ Total leaching area.................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.--------------•------------------------
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
t� ------------------------•-----------------------------
Q-�. -
O Description of Soil------. �..----- - ` 0 5E
U ...... ..............................................................------------------................---•-- ----•-------
W
U Nature of 4/1 Repairs or Alterations—Answer when applicable__-:_,,�I00-------
:_��l�O
............. � � '` s---------------
----------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant b n issued th oard of healt .
Signed .. -- ...-
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A lication A roved B --........ - ------ —----. ---
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Application Disapproved for the following reaso ----------------------------------------------------------------------------- ------ ------------------------------------------
................................. ------
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Permit No- ------- --- --------
----- --- --------- Issued f� ��t-
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No.. ... 0..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tonstrur#inn lirrutit
Application is hereby made for a Permit to Construct ( ) or Repair (/>-�) an Individual Sewage Disposal
System at:
L-cation-Address or Lot No.
--.... ----•--------•..............•. --•-----•-------......��.--•---......------.
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►W-a `i r� '�!Ji�.�a 1 j/ Own.D7'�5T ' dress si`1.r./�! PLC.. .
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Installer Address
d Type of Building Size LotC- �_ f 7-1 Sq. feet
U Dwelling—No. of Bedrooms............... ....._._..__._..__.._Expansion Attic ( ) Garbage Grinder ( )
Other a —Type of Building ---------------------------- No. of persons............................ Showers
( ) — Cafeteria ( ) ,
Otherfixtures --------------- -----------------------------------------•------------.........------ -----------------•------ -- . ...
W Design Flow.................�� .............gallons per person per day. Total daily flow................ .............gallons.
W Septic Tank—Liquid capacity......._Ggallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No.____-_------------ Width.................... Total Length............ Total leaching area....................sq. ft.
f--
Seepage Pit No.............-------- Diameter------- ..... Depth below inlet-------4........ Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
1
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
..-
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ------------------------------------------------------------------------------------•.....----------.........................................................
0 Description of Soil------. .......... -------
V ....... ------------------------------------------------------------------------------------------------------------•--------._...------------------------------•-•---------------...
W
x �- ------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.-----,---------- �Da
-----------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance h b- n issued b the board of health.
Gl ram/
Signed ---- '�'�v U -. 7,0
..Application Approved By (. ------..... ° -2- . !I_-GCrt/-------------------- �;- �a e /�
.Application Disapproved for the following reasoV----------------------- ------------------------------------------...---........--------------------------...-------------------
------------------------------------ ....---.---------
I Dare
Permit No. .... -�l!/----------------- Issued d........��:.--...-......
Uace r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer-#ifiratr of CootylittnP
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ........................................... ;4 Q --------1_J- kz- -. - --_
Installer
at ...................................
------------------------ ---- 5 aC /- lJ UT/. 4-.. t� <.-. $
has been installed in accordance with the provisions of TITLE 5-of he S e vironmental Code as described in
the application for Disposal Works Construction Permit No. ---- ""--� dated -----------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE _` ..---'' ! ... C_ Inspector...�.,:.....r'—!'...._. ...................��-c...7=./�r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No....l..�
r �..
Disposal Works Tontr ion 11
rrntit
Permission is hereby granted................ �07Z.......... ................................
to Construct ( ) or Repair (A) an Individual Sewage Disposal System
at No------------------------� ----- --_.aj i� - 1�✓l/U%a.�'�---- �) -Is"/
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Street 71n
as shown on the application for Disposal Works Construction/Pe� it No.__,__!l.__-.?h! ate ______ .� .
-----�o------- .--........... ...... �
l // Board of Health V
DATE -�fD/.-9- ---------------•-------------------• C�
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FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH ,
/.. ....._....OF..........
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy at- _
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L dares r I of Nv.
------ ............. ... • --....... .---•-
W r r f
I s ller Address
d Type of Building Size ....Sq. feet
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�-, Dwelling—No. of Bedrooms._ __ ..................._____.___Expansion Attic ( ) Gar age Grinder ( )
per-, Other—Type of Building ---------------- o. of persons_-___--�-------------
Showers ( ) — Cafeteria ( )
a4 - -Other fix ures ------- ----------------- -
is W Design Flow- --------------- _0------ __- Mons per person per day. Total daily flow-----------------
-G� Septic Tctnk�—Liquid capacity_r.�allons Length................ Width------------ __ Dia eter................ Depth...._.----.-----
Disposal Trench—,%o_ ___________________ Wi th...._.._._.._ ._. . tal Len . o leaching area--------------.-----sq. ft.
Seepage Pit No__4............. Diameter.-/.O��-�owXt.... 1 leaching area sq. ft.
z Other Distribution box ( ) Dosing tank ( ) ��/ �17
W Percolation Test Results Performed by--------------------------------------------------------------------------
Date---------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..-.-.-_.----.-.--.-.__-
rXq Test Pit No. 2----------------minutes peer inch D h of Test Pit.................... epth to ground water . _.__.._.._.__.._.-_.
a ,�J f ( --- ----
Description of Soil----------------Cam• .,"___
V ----------•---••-•----••---•------------------ '------ ------•-------------•------------- •--------•------•- --------------•------------ ----------------•----------•--------
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 Article XI 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.
'gned.......... .•. .4--_-----•-----------•--------------------
Dat ^ice
Application Approved By-------- -- -- --- Z-
ate
Application Disapproved for the following reasons....._____ _ ___________________________ __ .... _ ��_�......... _____
--------------------------------------------------•--- -------- . .........--••-- . --- -- ---------- ----- � � 71
Dat
PermitNo......................................................... Issued.......Z----1
! _ S
No..... __. Fes$... ......""`�'�•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
�-
Applirtttinn -fur i,ipviittl Workii Cnnnitrnrtion Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at
ai l ,,� .....---...
�w > --..-----•----- .K
Locati -Addres r Lt.No.
/_111M�i_ .... .....X......... ... .... ..... ........ . ... . .. ............. ..... .. .. ................. . .
I ller Address
Type of Building Size Lotor ,04.6..__Sq. feet
Dwelling—No. of Bedrooms ............................Expansion Attic ( ) Garbage Grinder ( )
aq Other—Type of Buildingp ( ) ( )No. of soils Showers — Cafeteria
a' Other fixtures ______01L�_
_____
W Design Flow_________________
.. flow---------------
WSeptic Tank Liquid capacityallons Length________________ Width..___..._... .. llia eter_..._.__.._____ Depth._.._.__._.___.
x Disposal Trench— o.----•---- Wi th �otaLen o leaching area sq. ft.
Seepage Pit No.. ........... Diameter_ > .. ow l t. '��_.______.. 1 leaching area
...- ------_---.sq. ft.
Z Other Distribution box ( ) Dosing tank.(. ) ®" ► �/�
Percolation Test Results Performed by_.-,_- ---------------------------••-----....----•-------------•---...... Date--------------------------------------a
Test Pit No. 1...-------------minutes per inch Depth of Test Pit.................... Depth to ground water-..-_-.__---_--.__--. -
44 Test Pit No. 2----------------minutes pjr inch D ,th of Test Pit.._........__._.___. Depth to ground water_. --------------_____-
_ ---
D Description of Soil -- • ......
x _., -------
t e "
.
U Nature of Repairs or Alterations—Answer whena___ -------------------------------- --------- ------------
licable.-.--------------------------------- -
Agreement: -
The undersigned agrees to install ,the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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.
at ."w'
Application Approved By...... "` -- -•-•"•• ' 't g -•D- "J
ate
Application Disapproved for the following reasons:-------•- ------------•--------- -
-- ---- Dat
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0,q HEALT
OF. C% ��
�••••• ..
rrtiftr of f�nrut anrie
THI S TO CERTIFY, Th t e divnual Sew e Disposal S t co tr c ) or Repaired ( )
by .... .•. . ..-• .............................
------- --- -----------
Z Installer
at r.__ t...... .,� - -- ----------- ' •• ._. ... �
has een install e in ccordance with the provisions of Article X1 of-The State
fTheState Sanitary Cod as descr' ed iu the
a application for Disposal'Works Construction Permit No............... ....... dated_^'�_. _ ..__7
---
THE.ISSUAN E OF THIS-CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA_N EE•THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
nDATE..................................................... .......................... Inspector: ------•---------------------------= ------- ......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
.......... -.OF....... . . •.........................
No...... "` FEE-- -_----.
�i�p>or�ttl �?r.� _C�u nr• ' at �'rrtnit
"
77
Permission i 'hereby gr nted....... t
* to Constru ( r )�ndi i . abl e ispo. ystem
atNo."" . - -----•-- %------------------------------- -......................
•+"� - treet .+
as shown on the lication for Disposal'Wo�ks Construction Per i o.______.___ D t
Board Health., d o f H I DATE-------_------ --- X..........:.------------------
FORM 1255 HOSES &, 1+A RREN• INC.. PUBLISHERS _
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