HomeMy WebLinkAbout0052 ASHLEY DRIVE - Health 52 ASHLEY DRIVE
A=172—089
Centerville
S M E A D®
No.H163OR
UPC 10259
smead.com • Made In USA
40).
Y77
No.__/-/::--2.-0 Fss.......2.)_
i THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF -
,��r �irtt iun fur 11iupuuttl Works Tanstrur#iun Prrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
system At:
51
__ .--- ................................................ ..... .•------•----------------------------------------------..............__........- ----
L oN Ydress or Lot No. ---
wa ...... ...........ner Address
..........••�------•-• `l ........1� 4X .............................•----------------..........:_.
Installer Address
Type of Building , Size Lot............................Sq. feet
�.� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of ersons____________________________ Showers
a YP g ---------------------------- P ( ) — Cafeteria ( )
Other fixtures ----------------
-•----•---------------------------------•..._.........._....---....._.._......•••-•--
W Design Flow............................................gallons per person per day. Total daily flow............................................
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............._...... Depth below inlet-----............... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(T4 Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ••-••••--•--••-•-•-----------------•••-••••••----•--•••-........--•-••--••....-------•......._..-•--._....----•--.._..•--------•-•--•-----•---•---..._......-
0 Description of Soil........................................................................................................................................................................
UW _.....•--------•-------•-----._...--•--•--•••••-•--•••--•--••-••-•------------•••-•••-----....••----•----••-••--------------------
Nature of Repairs or Alterations—Answer S..�erj applicable../ .PP......Ck....... .._.. __ Q ............................
��� �klwl
------------------------------------- ---- ..._.........._.Agreement:
The undersigned agrees to install the aforedescribed,Individual Sewage Disposal System in accordance with
the provisions of iITi LE 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 b e bo_ard of health.
SignedLt _._-•----•=---------•-------•--•---•--------•_______________________ ........................`7<
Date
Application Approved BY �'�`�`� �--✓ -----------------------------------
Date
��-. .1...
�C' V Date
Application Disapproved for the following reasons:....................................................................._..........................................
...__-•-•....................••-•--------....._....`.....---•------------•--........-------...........----.......-----.......---.....----•----•--•-•••-•-••---_._....-•--•----•••......_•-••-....._-_..._
Permit No.........., au
-/•- '��---------••------ Issued.--•................
...---•............. ......Dom
1
.�.r"`.M`�_ w'r4fie�,e�'s"n� ... '�� ,�y�i,v+"` ,.,� fyil� ;�jy'?'Me.,r_��` k�.w � �;�'��.a'�.�,,,�r.y.3„h•,.....n..r,,., ..
No:�: ,�r_- D I 'mac Fa$....... �"�_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF M
Appliration for Disposal orks Ku' strurtion rrmit
Application is hereby made for a Permit to Constr, ct ( ) or Repair ( ',fan Individual Sewage Disposal
Systemt ........... e ................ .......... ......... - ------• •_. _...-••-•--•-•--.
on Address v //� or Lot No.
.......... ...._.... _. --^- -----
_....- -• ._..._..._..._ .............._................
W
Address
ner
GU t G
a . .. ....._.._..- t ......................•------......---.....--•---•-----•-•-----•-----......
Installer Address
�q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms... .....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
d Other fixtures ...........................................
------•--------•---•-------------------------------------
-------
W Design Flow............................................gallons per person per day. Total daily flow........................_..._.._..._....._..gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Widt'K................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length .................. Total leaching area.....................sq. ft.
Seepage Pit No--------------------- Diameter.............--..... Depth below inlet.....I............... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date...................................... 1
Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water........................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ j
P�
ODescription of Soil........................................................................................................................................................................
U ------------
•-------
------------------------
----------------------------------------`......••-•--.....-•----------..... .....-•------------••---•-----•-••------•---•-•-----•--•---...---...----
W
...••--•---------------------------------------------------------------------------------------••-----------------------•------------ .
UNature of Repairs or Alterations—Answer wl n applicable1-A.2................................... ..... ........ ............................
------------------------------------------ f C k s` ''`' 1°vr' A r "?'°^''� ,o w,o .............................................
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 issued by,.the board of health.
mot l
Signed..... ..............................',•-------•----------•--•--•-•---
.
Date
Application Approved BY �,^',r• ,4, ------ ....... ......:.. .......... ..
Date
Application Disapproved for the following reasons:.................................... ................................................ ._......._...
••-•-•----------•.............•-----........---•-----------------........-------•-------•---•-------•-----------------••--•----...•-----•-•-•-....-•------------------•-••.....------•......._.........
Date
PermitNo..........--• •---. ----- ...........--.... Issued.--------••--•----•--------........:._............ ... -
M
Date
THE COMMONWEALTH OF MASSACHUSETT.S.
BOARD OF HEALTH
TOWN of YARMOUTH
Tntif irate of Tomphaurr
THIS W TO CERTIFY, d
, That the Individual Sewage Disposal System constructed ( ) or Repaire
by................ ........... .�L� --•--•------•-----......••.........--•-•-..._... .... .............. ._... •-• •••............_........
Installe
has been installed in accordance w h the provisions of TITLE of The State Sanitary Code as described in he
p I 5 s y t
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....... .........` .1. ....'�' r...�....................... 't. Inspector--- ._....._........ ... .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No... .
�f� �� 1'®•WIJ—off �`
...... .. FEE... ................
�i��o��t1 ork� Cno str�t#ion �rrmit
Permissionis hereby granted.............I........a - •-----•..--•............................................................................................
ato t Nonstruct ( ) or Repair (,,kT an Indivi ual Sewage Disposal System .
o.......... �� ....-A. .............._�� ..............----..............---------------•----•--........
hU Street
i
as shown on the application for Disposal Works Construction Permit No.?/::... -_ ated..........................................
..............................
of Health
DATE................................................................ ................
TROY WILLIAMS may~
SEPTIC INSPECTIONS
1.
Certified by MA Department of Environmental Protection cc", ` `` (508) 760-1819
a 6' a..
40 Old Bass River Road
South Dennis,MA 02660
-. Commonweaith of Massachusetts
c�op�
Executive Office of Environmental Affairs "`-
Department of
Environmental Protection
WNNam F.Weld Trudy Coxe
Govemor Y
Argeo Paul Celluccl David B.Struhs
LL Govrrrnor CortrrNrbrrr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
I J J CERTIFICATION G
Property Addrea 5,9 4.3 4 l e`i ✓r C�� ��ry� �I G Address of Owner.
Date of Inspeotioa /13 /76 (I[different)
Name of Inspecto , . y W- ( t"c.w r
Company Name,Address attd Telephone Number. /%jo rg iy+ S /� -S
Ss•e— Gl 6 o JG .
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
�83SE8
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date--
The System Inspector shall submit a oo6 of this inspection report to the Approving Authority within 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 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:
Check A, B,C,or D:
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.
Bl SYSTEM CONDITIONALLY PASSES: AI/141
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 5,2 /45 4 le-y
Owner. f ci t 1 f-t"
Date of Inspee.*' 5113/ G
BI SYSTEM CONDITIONALLY PASSES (continued)
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):
broken pipe(s)are 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
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A///y
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)
DETERMINES THAT THE SYSTEM IS FUNCTIONING 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 within 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 that facility and the. presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Address:
Owner.
Date of Inspection:
SA; 0&
D] SYSTEM FAILS: Nl4
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 effluent 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 clogged SAS or cesspool.
— Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
— 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
aoceptable 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. --
EJ LARGE SYSTEM FAILS: /61,,�'
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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:
— 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.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Sot �9S ICYOwner. F�L r�-e-
Date of Inspection: S 1
13 1� L
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
Y None 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 volumes of water have not been introduced into the system recently or as part.of this inspection.
As 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.
The system does not receive non-sanitary or industrial waste flow
,/The site was inspected for signs of breakout.
_ZA11 system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baIDes or
tees, material of construction,dimensions, 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.
V The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Addreas: 5a 1�5 4 11-Y
Owner. �� ( �G�
Date of Inspection: S//3/y
RESIDENTL&L- FLOW CONDITIONS
Design flow:dons
Number of bedrooms:-.13—
Number of current residents: iZ
Garbage grinder(yes or no):_LVo
Laundry connected to system(yes or no):�S -
Seasonal use(yea or no):-,6/o
Water meter readings, if available: -
Last date of occupancy: d o,-J,,o i t-d
COMMERCIA LAND USTRiAi•
Type of establishment:
Design flow:_—gallons/day
Grease trap present: (yea or no)_
Industrial Waste Holding Tank present: (yea or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Lest date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: -
/0..54- aJ— ,o L J- /O �r , ..J q s
System Pumped as part of inspection: (yes or no) /O
If yes,volume pumped: gallons
Reason for pumping:
TYPE qF SYSTEM
—� Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROIQMATE AGE of all compgnents, date installed (if known) and source of information'oku
�� /�/"�k -ZU�rJ G4 cl /Vts/tr gyp. ><' G�otr/< t1
s� b�. �5 36/y�
wage odors detected when arriving at the site: (yes or no) /VO
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Addreaw sa f I ey
Owner.
Date of Inapeotion: 51131176
SEPTIC TANK_
(locate on site plan)
Depth below grade:��
Material of construction:_Zbncrete_metal_FRP_other(..plain) '
Dimensions:_ ,e I
Sludge depth: R",
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thiclmess:__.,�/0 S C-_J h,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: '6/o f fJH,
Comments:
(recommendation for pumping, condition of inlet and outlet or baffles, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.) ��. _*'-e_ ��` v
- / ltiIL ��
�(i�.r-.t� .,.�D-S tit c��- i L, ,-�.L! dl c� � s� ✓�, � N
GREASE TRAP:_,�,,/l.9
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top 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 baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner. rU C I+�
Date of Inspection:
TIGHT OR HOLDING TANx_L/1,9
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(ezplain)
Dimensions:
Capacity- gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: w G
Comments:
(npt/e�if level/and distribution is equal,,/evidence of solids carryover, evidence of leakage into or out of box, etc.)
�p✓c,u� �e✓ � �,.��i ��//l..
6k
PUMP CHAMBER:_o
(locate on site plan) -- ,
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
01 TOWN OF BARNSTABLE
LOCATION /'Y,S e4.,,l SEWAGE W7'
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. '
SEPTIC TANK CAPACITY d '
LEACHING FACILITY: (type) � (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMUDATE: 5—tl,2,2 /P I COMPLIANCE DATE: 2 v
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 leaching facility) _ Feet
Furnished by` ) )
6
(
D /
o qO
ALLOT NO. : RESS.•_ f1�,�
OWNERS NATIE:
SEWAGE PERMIT NO. NE14: REPAIR: 4,--
DATE ISSUED: DATE DATE INSTALLED:
INSTALLERS NAME : oct
r
INSTALLATION OF: C �
WATER TABLE : FINAL INSPECTION BY:
DRAWING OF INSTALLATION ON REVERSE SIDE :
Ysl � `
�,`
1 w
/ 1 ��/{!
��s�/i✓''� !�
�� ��/�
�jct54r �
"`p /3� .. � Er�s��w�
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Jt,our (',�'.,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: c5a eq-5 ��y
Owner.
Date of Inspection:
SOIL ABSORPTION SYSTEM(SA.9): ✓
(locate an site plan,if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type: L7,
leaching pits,number: O7 — X6 L,-,
leaching chambers,number._
leaching galleries, number.
leaching trenches, number,length:
leaching fields, number,dimensions:
overflow cesspool, number:
Co nts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Sa ; ✓,., J-{j
e ✓ - ri.-J �. .��L
CESSPOOLS: ,C)
(locate on site plan)
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 soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:.r9
(locate on site plan)
Materials of construction:
Depth of solids:
Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: sa /-9 5 tk /,-y
Owner. /—�,L 1�G�, . 1
Date of Inspection:
s/i3 / 9L
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Indude ties to at least two permanent references landmarks or benchmarks
locate all wells within wo,
Feb.,
3;1
row¢�,ib.,...
28i
yo �
0_6oX —
w
DEPTH TO GROUNDWATER
[F
Depth to groundwater: — feet adjusted high groundwater level
r ,
method of determination or approximation
S L /,n G r� d rTI-d✓ti c�j� .t
9 =