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Home My WebLink About0071 GOOSE POINT ROAD - Health 71 GOOSE POINT RD, CENTERVILLE -� A= 252-042 No. 42101/3 ORA LFIC-, almd&1903K ESSELTE 10% ® O O O __ y �-- No. 26 — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Xkgool *pgtem Congtruction i3ermit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: Location Address or Lot No. -7 Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. .6kc. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) �' '� t'a ✓`� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss e by the�Board of Health. Signed \_C�`� �`- � i Date Application Approved by Application Disapproved for the following reasons Permit No. / ? Date Issued t 2 No �n ��.. Fee ; �, t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Migpotai Op5tem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. I� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 00 MGM Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title rc Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issn by thh's Board of Health. Signed 0-X- 1 � Date Application Approved by Application Disapproved for the following reasons a Permit No. /z - 7d Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS T ER that the On-site Sewage Disposal System installed( )or repaired/replaced on 3 by e r�o— 1)6e_'K, for Q Y k c.-e. as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: t No. O Fee b 1 ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS if 1=igpoga1 *p.5tem Congtration Permit Permission is hereby granted to to construct( )repair On- ite Sewage System located at :7 h#°�- 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. ' All construction must be completed within two years of the date below. Date: ,!y Approved by�_� _- A ; a -r CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL I WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) D -� �'1 hereby certify that the application for disposal works • .; P �Y construction permit signed by me dated Kara a Z4 ..}t 9 b , concerning the `•'g ` ✓�.. property located at m -J - - cei'v i;�, meets all of the r' i following criteria: • There are no wetlands within 300 feet of the proposed septic system ► ,! A • 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 . �• Ar" , •. There is no.increase in flow and/or change in use proposed 4 ; U l. • . There are no variances requested or needed. t; , • ter, SIGNED ` ' "', 1�" "\u .C,Qti,_ DATE: j LICENSED SEPTIC SYSTEM 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]: »I , t! 4 CPR p e, t 37` y Dose- CA CC;aL"r\j ; . TOWN OF BARNSTABLE LOCATION 7 r SEWAGE # a w O VILLAGE 9� A 'V%` E. MG ASSESSOR'S MAP&LO'I INSTALLER'S NAME&PHONE NO.C,A6 t'�Jdl`,2� 99S . 4,77- 0 SEPTIC TANK CAPACITY LEACHING FACILITY: (type)710%' (size) NO.OF BEDROOMS 3 BUILDER OR OWNERST16ce rAar�i 1J PERMITDATEI —I' - 16 COMPLIANCE DATE: F� J 9� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility aU + 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 oJJpchiqg facility) . Feet Furnished by �T S/ i a,qq a - s o TOWN OF BARNSTABLE LOCATION GV'7-�'5&e ;�k_• �A SEWAGE # VILLAGE CVSN j\S� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY hoc) (off LEACHING FACILITY: (ty ) - (size) N 00 Q NO. OF BEDROOMS �n n BUILDER OR OWNER w\ PERMITDATE: COMPLIANCE DATE: 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 of leaching facility) Feet Furnished by � g At ayv Ac 3� BA 33 � e � 4� :SESSORSMAP Na - ARCELNO' Commonwealth of Massachusetts Executive'Offic6 of Environmental Affairs John Grad - D.E.P. Title-V Septic Inspector Department--of _- P.O. Box 2119 Invironmental Protection Teaticke.t, MA 02536 (508) 564-6813 VARIam F.Weld 6"Mor -- — Trudy toxe ne - - - 8ntary,EOEA _. _David B.-Struhs Commissioner _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ��CEHV�� _ PART A' CERTIFICATION - Property Address: �� } `�� 2C1 ��` JAN 9 1995 Address of Owner: Date of Inspection: ,��-\\G (If different) HEALTH DEPT. Name of Inspector: TOWN OF BARNSTABLE Company Name, Address and Telephone Number: 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: _ Passes _ Conditionally Passes _ Ne ds Further Evaluation By the Local Approving Authority _ ails Inspector's Signature: ✓ I Date: D4GQ, The System Inspector shall submit a copy 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 floe of i0,000 gpd or greater, the inspector and the system owner shall submit the repron to the appropriate regional office of the Department of Environmental Protection. The original should be sent to me system o�+ner and copies se+•,: to ti)e buyer, if applicable and the appro.ing INSPECTION SUMMARY: Check A, B, C, 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. y B] SYSTEM CONDITIONALLY PASSES: 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 conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Whrter Street • Boston,Massachusetts 02108 a FAX(617)SWID49 a Telephone(617)M-SM Printed on Recycled Paper i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i - PART A - -CERTIFICATION (continued) Property Address: Owner: � Date of Inspection:(i2�- B SYSTEM 1 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 pas Board of Health): s inspection if(with approval of the broker-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: 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 ENVIRON VENT: I hP �c(em nd> d >PUII( ldnh dl)U SUii dUbOf pllOn sy'iiCfli aliU ii "n iilli1- -00 fcci iu d 56-"c:c surface water supply. > tc The s\s P ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. "i e system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The s>;tem 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. DI SYSTEM FAILS: L have determined that the system violates one or more of the following failure criteria as defined in + for this determination is identified below. The Board of Health should be contacted to determine what willNbe,necessary o corr� 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. (revised 8/15/95) 2 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION (continued) - Property Address: Owner: - Date of Inspection:. - W\ A� . - . D] SYSTEM FAILS (continued): 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 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, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flo,.ti• of system is 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 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 11 of a public water supply weili 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 8/15/95) ` 3 P _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B _ _. CHECKLIST - - Property Address: Owner: ctio ` Date of Inspen: Check if the following-have been done: t_ _ K ping 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 volumes of water have not been introduced into the system recently or as part of this inspection. ��P4� s built plans have been obtained and examined. Note if they are not available with N/A. e facility or dwelling was inspected for signs of sewage back-up. s_,-?he system does not receive non-sanitary or industrial waste flow '-'(he site was inspected for signs of breakout. uAll system components, excluding the Soil Absorption System, have been located on the site. t 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. L1- _The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b\ non-intrusive methods The i; +HPrP irn r p�+nP'` were DPOvided with information on the proper maintenance of Sub Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION - — Property Address: ., C�� U - Owner: - Date of Inspection: _- \\ y FLOW CONDITIONS RESIDENTIAL: Design flow: - allons _ Number of bedrooms: - Number of current residents: Garbage grinder (yes or no):!.41> ._ Laundry connected to system (yes or no): eS' - Seasonal use (yes or no):�� _ Water meter readings, if available: Last date of occupancy: COMMERCIALIINDUSTRIAL: Type of establishment: Design flow:_ allons/day Grease trap present: (yes or no)_ Fndustrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RE RDS and source of information: �. AcoA System pumped as part of inspection: (yes or no)lj�(,_, If yes, vCM? e pdr-nred gallon., Reason for pumping: TYPE OF SYSTEM t✓peptic 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) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C . SYSTEM INFORMATION (continued) Property Address: Owner: .Date of Inspection: SEPTIC TANK: ll _ (locate on site plan) Depth belowgrade: -- Material of construction: Lconcrete _ metal -FRP—other(explain) Dimensions: O VA. ' 1 `r - - Sludge depth-: " 't Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:C� Distance from top of scum to top of outlet tee or baffle: �0`1 Distance from bottom of scum to bottom of outlet tee or baffle:_Q Comments: (recommendation for pumping, condition f inlet and outlet tees or baffles depth of liquid level in relation to outlet invert, structural integrity evidence of leakage, etc.) ^ '�� C o i GREASE TRAP;_�\)(locate on site plan Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum tnrc? Distance from top of scum to top of outlet tee or baffle: Dioa^ce from bottom nt crtim t^ hottom of ou!let tee or battle 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 8/!5/95) 6 SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM `, ART.C SYSTEM INFORMATION (continued) - Property Address: - Owner: Date of-Inspect' iolf-\ - TIGHT OR HOLDING TANK:{1\ (locate on site plan) Depth below grade: - - - - Material of construction: concrete _metal _FRP.—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BO\ \ (locate on site plan' Depth of liquid level above outlet invert: Comments: (note it levei and distnbuuu;- i� eyudi, e,,ic,1ce Gl sGi�d: Ca,f?v.Er, 2 deuce G( lea-age Into Or out Of box, e?C. PUMP CHAMBER��\{r (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address..�� _- - Owner: Date of:Inspect 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: _ -Type: - leaching pits, number: c� C G_\ - leaching chambers, number leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: l Comments: (note condition of soil, sign of h draulic failure, level of ponding, condition of vegetation,etc.)__ Q�.(1 CESSPOOLS: fl\\RT (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;rounu'.-.a:c- 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: (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, etc.) (revised 8/15/95) 8 SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM_ - - PART C (STEM INFORMATION .(continued) - - Property.Address: Owner;. . Date.of Inspection: SKETCH OF SEWAGE_,DISPOSAL SYSTEM: include ties to at least two-permanent references landmarks or benchmarks _locate.all wells within 100' f;� F P4 3Z 0 c DEPTH TO GROUNDWATER Depth to groundwater: �!� feet method of determination or approximation: V (revised 8/15/95) 9