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HomeMy WebLinkAbout0088 HILLSIDE DRIVE - Health 88 HILLSIDE DR. , CENTERVILLE A=193.053 Slll J�,vsevc�o�o UPC 12534 No.2_ 1_ HASTINGS.MN TOWN OF BARNSTABLE LOCH`of4 VT 4 /y 0,z SEWAGE # VILLAGE ASSESSOR'S MAP&LOT ,O INSTALLER'S NAME&PHONE NO. /?Ji 0" `� g SEPTIC TANK CAPACITY LEACHING FACILITY: (type) r`}�" ��'7�� Z (size)j{> . NO.OF BEDROOMS' BUILDER OR OWNER CA.$ PERMTTDATE: :i�'/ ®y COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 acility) Feet Furnished by ��� -� '1 r, �.® -� �� a?C ` � � i � �.s� ^ � -S i p � � ''' 3 '� � �� e� �-�ov No. Fee f1/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppricatton for Migpogat *pgtem Construction j3ermtt Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Lg9on_ft11ss 1C1`e oDr . , Centerville , MA WTl1�r'sliaVi1210TandTel.No. Assessor's Map/Parcel 01� (7 811) 44 99—5 712 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service PO Box 1089, Centerville , MA Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. 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 Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable)N e W T it le—5 s e pt is inc . Tank. D-box and 2 leach chambers . 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 issued by thi Bo of eal Signed A e Date r Application Approved by Date Application Disapproved for the following reaso s Permit No. ' &27 Date Issued No. Fee $5 0 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PaiLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes1� 01pprication for �Digpogal *pgtem Congtruction ertnit�~ Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components L ion At s or,Lqt No ner's and Tel.No. H s .s 1C]a br. , Centerville , MA �I�1. � � Assessor's Map/Parcel ct 3 -- O S (781) 449-5712 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Serce PO Box 1089, Centerville, MA Type of Building: Dwelling No. of Bedrooms 3 Lot Size sq. ft. 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 Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) New Title-5 septic inc . Tank. D-box and 2 leach chambers. Date last inspected: n 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 issued by thi o of ealt . n Signed e Date Application Approved by 2 Date Application Disapproved for the following reaso s Permit No. ¢"" Date Issued ----------------- --------------------- THE COMMONWEALTH OF MASSACHUSETTS Connors BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm. R. Robinson Septic Service at 88 TTillside Dr. 'Centerville, MA h sqdated__�� constructed in accordance with the provisions of Title 5 and the forbisposal System Construction Permit No. eo� -' 7 Wm. E . Robinson Sr. Installer Designer The issuance of this permit shall not be construed as a guarantee that the s s 11 function s d sign/ed. Date Inspector No. .s — -------------------------Fee $50-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Connors Migposmt *pgtetn Construction Permit Permission is hereby granted to Construct( )Repair(X)Upgrade( )Abandon( ) System located at 88 Hillside Dr. , Centerville , MA 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 specialconditions. Provided:Cons tion in ompleted within three years of the date of t s pe it-- j Date: Approved by0 f NOTICE: This Form Is To Be Used For The Repay Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) - I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated 121 concerning the property located at 88 Hillside Dr., Centerville, MA meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in flow and(or change in use proposed. * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) _3 S SIGNED: . ��. � DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). *., �• p��, F �b c J�, � � o r v��l I f f w CO]MMONWEAI,TH OF MASSACHUSETTS 1 . EXECUTNE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF FNMONMENTAU PROTECTION ONE WINTER STREET. BOSTON MA 0210E 161 i) 292.550u TRUDY COS Secretan ARGEO PAUL CELLUCCI DAVID B. STR'-*HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Pr Address: Name of Owner Wm. Connors Hillside Drive , CemtervilIM4resll kOwner: 26 Elliot Rd,, Needham, MA Date of Inspection: ( —/1—7 Name of Inspector:(Please Print)WM.. E . Robinson Sr . 1 am a DEP approved system inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) nsoneptic Service Company Name: Wm. E . Ro bi Ma0ingAddress: PG BOX 1089, Centerville . MA Telephone Number: �T7 8 CERTIFICATION STATEMENT I certify that 1 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;se/waa disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 4ZJ Date: / The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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. NOTES AND COMMENTS 7 r R EC�EO r J U N 1 8 1999 0 TOWN OF BARNSTABLE S HEALTH DEPT. A%V revised 5/2/98 Page Iof11 £ 16 C� � ter.^tad on Recydrd Paper I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). "rop"Address$8 Hillsid.e Rd.. , Centerville , MA awe: Wm. Connors Date of Inspection: INSPECTION SUMMARY: Check A, B, C, of D: A. YSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES:, One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicat 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. 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 revised 9/2/98 - s Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corttinued) Property Address: 88 Hillside Dr . , Centerville , MA Owner: Wm. Connors Date of Inspection: j�-17 9 17 C. 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. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic,tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). I. 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Add,,,,: 88 Hillside Dr . , Centerville , MA Owner: Wm. Connors Date of Inspection: e 17 a1 D. SYSTEM FAILS: Y u must indicate either "Yes" or "No" to each of the following: f have determined that one or more of the following failure conditions exist as described 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. Yes No 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. 1 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. Lj iRGE SYSTEM FAILS: You mist indicate either "Yes" or "No" to each of the following: 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: Yes No 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 11 of a public water supply well) The wner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Pagc4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y PART B CHECKLIST Property Address: 88 Hillside Dr. , Centerville , NIA Owner: Wm. Connors Date of Inspection:Z/? I f Check if the following have been done:.You must indicate either "Yes" or "No" as to each of the following: Yes/ No J _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks anrF 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.. a/ _ The site was inspected for signs of breakout. {/ _ All 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 baffles 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. For example, Plan at B.O.H. e/ _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of,distance is unacceptable) f15.302(3)(b)] _ The facility owner (and occupants,if different from owner) were provided with information on the propermaintanaaca-0f SubSurface Disposal Systems. revised 9/2/98 Page.of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'rop"Address.88 Hillside Dr . , Centerville, MA owner: Wm. Connors , Date of Inspection: �"-/�-$ Cr FLOW CONDITIONS RESIDENTIAL: Design flow:-5:f 0 g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms (actual): Total DESIGN flowL�i d Number of current residents:, Garbage grinder(yes or no)&6 Laundry(separate system) (yes or noAod ; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (Yes or no): Water meter readings, if at/ailable (last two year's usage(gpd): Sump Pump(yes or no):/..O Lest date of occupancy: :I C MERCIAL/INDUSTRIAL: Type f establishment: Desigi flow: gpd ( Based on 15.2031 Basis f design flow Greas trap present: (yes or no)_ Industr of Waste Holding Tank present: (yes or no) Non-s itary waste discharged to the Title 5 system: (yes or not_ Water eter readings, if available: 1998 48 , 000 gal• Last to of occupancy: 1887 25, 000 ga . O R:(Describe) Las a of occupancy: GENERAL INFORMATION PUMPING RECORDS an source of information: System prumped as part of inspection: (yes or no)_ If yes, volume pumped: 6-6 gallons Reason for pumping: A,, 44 C AD- TYPE/OSS TEM tic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other Q 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 9/2/95 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ra PART C SYSTEM INFORMATION Icontinued) 'roperty Address: 88 Hillside Dr. , Centerville ,. MA Owner: Wm. Connors Date of Inspection: BUI DING SEWER: (Lot a on site plan) Dept below grade:_ Mate ral of construction:_cast iron_40 PVC_other(explain) Dist nce from private water supply well or suction line Die eter Co ments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: /p -V 16 4 Sludge depth:_ 1 Distance from top of sludge to bottom of outlet tee or baffle: 4�A Scum thickness: 6 d + Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: 1 J 'omments: (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.)f,A1r-6 / f l eti /e— , G SET RAP: (Iota on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensi ns: Scum th ckness: Distance from top of scum to top of outlet tee or baffle: Distant from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Comm. nts: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid ce of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 8 SYSTEM INFORMATION(continued) 'ropetty Address: 88 Hillside Dr. , Centerville , NA Owner: Wm. Connors , Date of Inspection: 9 TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (local on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimen ions: Capaci y:. gallons Desig flow: gallons/day Alarm resent Alar level: Alarm in working order: Yes_ No_ Date f previous pumping: Co ants: (co dition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) ��\\ Depth of liquid level above outlet invert: V I Comments: (note if level and distribution is equal, evil n e f s�carryover, evidence of leakage into or out of box, etc.) - PUMP HAMBER:_ (locate n site plan) Pumps n working order: (Yes or No) Alarm in working order(Yes or No) Com ents: (not condition of pump chamber, condition of pumps and appurtenances,etc.) Z14— revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 88 Hillside Dr. , Centerville , MA ' a Owner: WM Con ors Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:--2-- leaching chambers,number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Altemative system: Name of Technology: Comments: (note condition of soil, of hydraulic failure, leveI if ponding, damp soil, condition ofve at�y ion, etcl.) — �b A-!- d C '�i.'e7 -�/© �r�d c�G yJ' r+�t b i✓Z 7 10 CESSPOOLS:_ /J (locate on site plan) �,,�• // Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: J )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Com ents: ' (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY _ (locate on site plan) Mater' Is of construction: Dimensions: Dept of solids: Com ants: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revise-6 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icorrtinued) Nop"Address: HH Hillside Dr . , Centerville , MA , Jwner: Wm. Connors , Jate of Inspection: G�7_ `1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate.all wells within 100' (Lo-cate where public water supply comes into house) 1 i . k t 10 i i 1 J 11 rf-^ revised 9/2/98 Page 10of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rope"Address: 88 Hillside Dr . , Centerville , MA Owner: Wm. Connors Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater�vFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions V Checked with local Board of health i _Checked FEMA Maps Checked pumping records Checked local excavators, installers _Le6sed USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 .