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HomeMy WebLinkAbout0207 CAP'N LIJAH'S ROAD - Health 207 CAPTAIN LIJAH, CE14TERVILLE A=193-129 No. 42101/3 ORA ESSELTE 10% a 0 0 0 9 -n— n �. _s 1?3 - ID 9 _ No. j L Fee d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for X45pozal *potent Construction Vertu Application for a Permit to Construct( (epair/Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Addpqs or Lot No. Owner's Name,Address and Tel.No. Asses�sor?Map/Pazcel ��J � � "" �P�bf't" LQ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(°l Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ':3 3 Q GA) gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature ti—IM&�av or Alterations(Answer when applicakle) ��-sL 1`�kl � A) jj 0 SIC; 1-0u S+ d 141 0 jSe-sqf_A49 Date last inspected: Agreement: The undersigned agrees to en ure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Titl 5 of he mental de and not to place the system in operation until Certifi- cate of Compliance has been ills d by is arc o Signed Date -� Application Approved by Date Application Disapproved for the following reasons Permit No. 7 r Date Issued .ti No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for i.5po!5a1 *pgtem Construction Permit Application for a Permit to Construct( repair(Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Add ss or Lot No. V t l-! Owner's Name,Address and Tel.No. Asseessso Map/Patce1�11�1 (7►� ' J NPSb/1• ^ 1— / 11� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J {/'�d' Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(1 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow (;A) gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil '.i Nature of Re ' or Alterations(Answer when applicable) NK t k o l�o� JA W S�o e. Ara S� d R>� i '' e►-t A Date last inspected: Agreement: The undersigned agrees to en ure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Till 5 of he nmental de and not to place the system in operation until Certifi- - cate of Compliance has been is d by is ar o Signed Date Application Approved by. Date Application Disapproved for the following reasons Permit No.T7 — . 13 '-0 Date Issued `7 THE COMMONWEALTH OF MASSACHUSETTS t BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired( t.�Upgraded( ) Abandoned( )by 4 at has been constructed in accordance with the provisions of Title 5 and(he for Disp sal System Construction Permit No. dated X Installer Designer The issuance of this permit shall not be construed as a guarantee that the syst,eer will fun//c�tio--n, as designed./'� Date '�— ��� 7 Inspector lZIA �r4 No. �— 1 3 *,., Fee THECOMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS 0iopogar *p!gtem C/on!5truction Permit Permission is hereby granted to Construct( ')Repair( L1 pgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Z / 7 Approved by . t a NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FORA DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) 0f l, Q,��r�, f'��e.�nil , hereby certify that the application for disposal works construction permit signed by me dated 0- q I , concerning the 11 n �,, located at �7 ��+� ��' A Qi Umeets all of the property -r-- following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14..feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNEDASEPTIC d DATE: LICENSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. j:ccrt I i e1 t CPtVITI \kA 1 66 yr. r ♦ -r TOWN OF BARNSTABLE LOCATION 7 �' n�`' SEWAGE # 97" VII.LAGE wK At C�1�F•w ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. � rl.Rt� I �•Lkrr✓ �3��1 SSg'':. SEPTIC TANK CAPACITY p0 D 0' LEACHING FACII.ITY: (type) [,.. �••r .�.��irn oK (size) NO.OF BEDROOMS BUILDER OR O R 4 � � PERMUDATE: al 4 _COMPLIANCE DATE: ' Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facili _ Feet Private Water Supply Well and Leaching Facility (ifanywellsexiA V Feet on site or within 200 feet of leaching facility) U Edge of Wetland and Leaching Facility(If any wetlands exi Feet within 300 feet of leaching facility) Furnished by o � aPP.�A 00, ..= TOWN OF BARNSTABLE o ! I'ION 007 SEWAGE # 17-13� VYLIAGE "`��' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �o�•w�� I , 1°ern. �3�'>��� SEPTIC TANK CAPACITY 100. LEACHING FACILITY: (type) LN, Li fXArse cA (size) 3a.� 1°a„X I` NO.OF BEDROOMS BUILDER OR OWNER . ° � PERMTTDA COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facili Feet Private Water Supply Well and Leaching Facility (If any w lls e ' tY� on site or within 200 feet of leaching facility) C) Feet Edge of Wetland and Leaching Facility(If any wetlands Feet within 300 feet of leaching facility) Furnished by y- � l�f � TS� owAz. Ovr-L L)otZ SUBSURFACE SEWAGE DISPOSAL BYSTEM INSPECTION •lORM Address of property ,'��)`�rr Owner's name i ; `J'l,�r� n._tom% Date of Inspection • •� Z7 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 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. VAs 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 site was inspected for signs of breakout. V/ All system components, excluding the SAS, have been located on the site. V The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for .condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based ion 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 SSDS. L t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents ..�� garbage grinder, yes or no 44.7laundry connected to system, yes or no V seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Typor of 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) Approximate age of all components. Date installed, if known. Source of information: Sewage odors detected when arriving at the site, yes or no . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: material of construction: concrete metal _FRP other(explain) dimensions: 9 4' sludge depth Y' distance from top of sludge to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: .(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on si plan) pumps in working order, yes or no Comments:, (note condition of pump chamber, condition of pumps and appurtenances, • recommendations for maintenance or repairs,etc. ) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 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: leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration 7 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, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, signs of .hydraulic failure, level of ponding, condition of vegetation,• recommendations for maintenance or repairs,etc. ) . . 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM PART H SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 2. f(,;0 �t DEPTH TO GROUNDWATER depth to groundwater method 'of determination or approximation: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . . Describe basis of determination in all instances. If "not determined", explain why not) i Backup_ of sewage into facility? Discharge or ponding of effluent to the surface. of the ground or surface waters? I Static liquid level in the distribution box above outlet invert.' Liquid depth in cesspool <6" below invert or available volume< 1/2 d. flow? 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? Lwithin 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 bordering vegetated wetland or salt marsh: (cesspools and privies only, not the SAS) ? ` within 50 feet of a private water supply well? 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 analy .for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL BYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector�� Company Name , iq-z�, Company Address V9 1....C,k, 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 recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maiitenance of on-site sewage disposal systems. Che one: 7c1 have not found any information which indicates that. the system fails to adequately protect public health or the environment as defined in 310 CMR 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 to: Buyer (if applicable) Approving authority q Lb C AT ION J.:�C,-S EWA G E PERMIT NO. V6lLAGE INSTALLER'S NAME A ADDRESS ,3 6u m s `7�'�OUTI71 e U I l D E R OR OWNER Ce,-27f,f DATE PERMIT ISSUED ,j- �1 _ F DATE COMPLIANCE ISSUED — �/— �5` .. -r 19� � -� � �` � �/ l ' � .. 04 AP JAAL /Qu0 rj 4F.4 41 it/O TE = - -- - ---- e x rstrn9 ground pro�r l e 1D ALL ,9 PDL/CA BLE Z. HO/2/Z SCAgLE / • _ /O OA-1 L/ E ,2T" SC ,9LE- / " = /O' /`7A/VHOLE COVERS TO tnJ/TH/A1 o -- o—o—o — Far-OPoS<"d c,round ProfrlF! /2~ p,� Frw/SHED GAaFALDE . SCHED. 40 P V. C. 02 �^ �QUALTb SEPT/C Cr—- /n/rnurr 14" Per- JCOO-f-) 2 of % �z~ ta�czshed sfon� � ---fir-TANK-.• � D/sr BOX . (ocJra. a , 6' Sump /tDoo GAL. 5E/-T/c T/9/V/C f 3�4 2 I a e c ° 7; e o o LC- Pr -T" ~`7- --- ZD E 5 G ti - 7-4E- S 7- O L _ L O G BED.e00M HOUSE DATE . _ '4-/D-12 TEST BY - J• D1��tf�-!�� ono d/sposer9 Gv ;TJVESS .� �' �r./�C D�l ,2.AP_rl 623 .E C ,FATE - MiA1.IlAiCN Tx,� P. Lof TEST HOLE/ 7'E ST HOLE q*Z uSE . /�c`�D G,9L. TAw*;� � `�S L E r9 C H Pj T: L.p.cj,-r �,r I� aurc.r^ n S/DELv,-9LL - S. F. tr •S � _ � ` G, P. 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