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HomeMy WebLinkAbout0735 OLD STAGE ROAD - Health 735 Old Stage Road Centerville P A = 191 171 Sm ome� UPC 10259 o- No.H�.�. 30R NAGTINGS NN 0 1 TOWN OF BARNSTABLE LOCATION � � Q 5 � 'r SEWAGE # VILLAGE r�7 /` l /�iP ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /©OD GP r'4 L LEACHING FACILITY: (type) 1hD© 04 (size) 6 Y'8 NO. OF BEDROOMS .3 BUILDER OR OWNER 2e jr L,4 S h P vc) PERMITDATE: 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 facility) Feet Furnished by TA1Fv aAaR-aJ, T 0V+ 1 � 1 � . �AC.K ar K005F r = COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . ELM DEPARTMENT OF ENVIRO ENMAML TION RECEE� yd DEC - 3 2002 TOWN OF ALTH DrEPT.BLE TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: �geth•enT' JZ. Larsr %) Owner's Address: ago ftejeLO gd. �.e2Y+rrn:li�I1 N-m ,� r✓►1!3- O!'7 v 1 Date of Inspection: Name of Inspector: (please print) RA,,yM oHd F• U+uHs .ry- Company Name: &yrny4s .CA dSc.4►pE [ �' T�Jc. Mailing Address: S'4?N OLD 51WCF -41 � � p egu7ro4�fv3�- Telephone Number: 5-Qs—"77 g—Z),P-LI 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: t/Passes •, Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: c2 Date: A 7 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 DEP,The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: '73 S' OL0 ST,4GE W Owner: 1 6 R.cT i_j4j-z, h 4W Date of Inspection: . 1 I—7 -®2 Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health ✓Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period ✓Have large volumes of water been introduced to the system recently or as part of this inspection? 1` A Were as built plans of the system obtained and examined?(If they were not available note as N/A) _IZ,*" Was the facility or dwelling inspected for signs of sewage back up? c% Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? _�_ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing information.For example, a plan at the Board of Health. CE47 1 p.40 no-r PL.4N 03T,4iA)ec1 _ A'boft Roap.4Ny 1)EPT. Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -735- aL/,-) 57`9-65 eel Owner: Qb c,c'T L >'S�✓R Date of Inspection: y-- BUILDING SEWER(locate on site plan) Depth below grade: 13-'' / Materials of construction:_cast iron ✓40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ' (locate on site plan) Depth below grade: 10 Material of construction: �rete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:` Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: /Pro Sludge depth: &.Wv Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 44y w»tef' Distance from top of scum to top of outlet tee or baffle: 41,01,o Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: •x►t 7tk .Per Comments(on pumping recommendations, inlet and outlet tee or baffle cond it on,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:,(locate on site plan) Depth below grade: Material of construction:—concrete_,metal_fiberglass_polyethylene_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: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: •7-3 ev f'F_N1'y'n I/i14- y"A - V�.3.2— Owner: W h-4,eT` LAt5114 w Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: t�Gd1.y,e,5 Aw\I) Type Teaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(]ocate 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(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: h(& _ Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): • Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE"bISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73 2_ 0? l> >'l1i cj& t=� Owner: 'n Rate of Inspection: I( — 1 Oa— SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water iS'av feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _V Checked with local Board of Health-explain: C-T 5 Checked with local excavators,installers-(attach documentatibn) Accessed USGS database-explain: You must describe how you established the high ground water elevation: aIS Z f� d �-c -7 y� .0 C9-. P G K 0 ov�f No..........---•T-----. Finc.... ............... THE COMW NWEA TH OF MASSACHUSETTS BOARD�QF HEA TH Applirotion -for M-4mial Worko Tonotrnrtion Vrrumlit Application is hereb 'made for a Permit to Construct or Repair an Individual Sewage s PP Disposal Y ( ) P ( ) a P S stem at :< % t Ce Location:A ess ( �= .. t o. Owner . A3jdre�ss 41-- Installer Address d d Type of Building Size Lot_._ ....... q. feet .A.- U DwellingVNo. of Bedrooms________________________________ _____Expansio�ttic ((Sf Garbage Grinder ______-____ No. of ersons__________________________ Showers ( ) — Cafeteria ( ) � Other—Type of Building _________________ p Q' Ott xtures Q ------------------------------------------------------ W Design Flow.__- _.. ___ ___ _________________gallons per person p r day. Total daily flow.............................. gallons. WSeptic Tank—Liquid capacitv.��'�-gallons Length---------------- Widtl=-:17777i..-.. Diameter................ Depth----------_-.. x Disposal Trench—No. .................... Width-.._--_-___--.____ Total Length------------------.. Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth belo .................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 97— 3 - J' — .7 -7 Percolation Test Results Performed by-------------------------------------------------------------------------- Date.-------------------------------------- a a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.........-._-..-_._..... LL, Test Pit No. 2................minutes per inch Depth of Test Pit.-______--.-.._--___ Depth to ground water----..-.._--__-.-._---.- P u--- rl ............r-- . � . ---•-----------•---•--•------------------- - Description of,Soil------_ _ -------- -�---•-- •--- ------- --•---------- -- fL-V - --- -- W /am x --------------------------------------------------------------------•------------------------------------------------ -------------------------------•-------------------------------------------------- V 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. Signe _- ------ --------••-•------------- k •---- Date Application Approved BY - ---------------•----- 7`".,c -7 --------- Date Application Disapproved for the following reasons--------------------------------------------------------------------------------------------•-------------------- -- ---- ----•-••-•-•-------•-•--•---------------------------------------.. ------------------ Date PermitNo......................................................... Issued......................................................... Date No......... ••.... r Ficim.............................. THE COMIJUNWEtLTH OF MASSACHUSETTS BOARD F H H Imo" f. t , pphrtttion -for Bhip a id Works Tuaaitrurtioaa Vrre niit Application is hereby'made.for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S C at* Location- ressoW -[ ....... -••-•• -� 5 tt��A j- Owner-• !� W . ..V--- ....4 .. .. • ••-•-•.... ••••. --•--------------+ K �-�-•e '"t.......---�--- Installer Address j U TypeDwellin gNo. of Bedrooms----------- '----------- ---------Expansio]�ttic ( Garbage Grinder �t of Build Size Lot--- feet ( � aOther—Type of Building -_____________________ __ No. of persons_--_"T................. Showers ( ) — Cafeteria ( ) dOth - xtures ------------------------------------------------------ -------------------------------------------------- ------ W Design Flow___ ......._.gallons per person per day. Total daily flow-__--______ ------------------gallons. WSeptic Tank=Liquid capacity� r _-gallons Length---------------- Width..... Diameter----............ Depth................ x Disposal Trench—No..................... Width.................... Total Length------------------.. Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth belo inlet.................... Total leaching area-__:..._-_.-.-__-.sq. ft. Z Other Distribution box ( ) Dosing tank 7 Percolation Test Results Performed by-------------------------------------------------------------------------- Date----•----------------------------------- a Test Pit No. 1................mmutes per inch Depth of Test Pit-------............. Depth to ground water....----_--__.._-.__... i L14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------_-.-_-_--_----- ' O n j1-• F tr Description f�Soil-----� ! �...... «. �/. i.. V ------ � ._- d � `� - dry .. W "`----------------- - - UNature 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 NI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued by the board of health S . tgn D Application Approved BY----- - �- ----- - ------ -•---- . ............0'`- -7--------- ,Date Application Disapproved for the f ollowing reasons:------=......................-------- --------•--------•--•------------•-•----•-----------•.................... ---------•---------------------------•-----------------------------•------------•-•-•---•-•••----•-••-.....------•---------------------=-------------------•-------=---------•--•------------•---------- - Date PermitNo........................................................ Issued.------------------------------....... ...-•--..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT lr ..............OF............ ...................... ...................... .. �rrtifirttte a1f f�lam�iittnr�e . .qr,_ ��„ �T 0 CER Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) n at _ has been installed in accordance with the provisions of Ar' o The State Sanitary Code as descrf in the application for Disposal Works Construction Permit No.-- .................. dated..-,.""'..�_�_?_':_-.4�_____._.._._. THE ISSUANCE OF THIS CERTIFICATE -SHALL NOT BE:,CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNlCTIOP! SATISFACTORY. , DATE -----------/ .a�-•------- Inspector---.- .. ---------------------------=--------------•••- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 F....... '4 No........... .. FEE------ .............. . witrurtion Vrrmit Permiss' e ereby granted-- ------------------------------------- -�---•--- ---_._...----- -- _------------------------------------------------•---•----- to Cons Repa' Ividual e D" eel at No..- ' Street � � r� �� ° �. O r as shown on the application for Disposal Works Construction P It N Dated---- ---------------------------- ------- y Board of Healt---------------------- ...............I------0h DATE.......................... ..................-------- - - - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ..r.: + 1 {3{ k O 4 ' �j N ov N ; C'-��1 - 8M TG-P C / �/ E'�t�' ) /O /lit./. X 5., E 3S - (U I`� j 1 ' P!T Zia �+� A'SeaA ✓ N D xt- Ai � TEST H oL E t , DES UZ- TS PIER 7-0W/VeEC0RDS Ev 2S•20 , � • ' r M//�//N/U/�J $ U/LD/NG .SE' TB9C;K .E' Equ/ /2EME"NTS r R ��:� !'/2Q.00SEU BEO/2ooMS 3 O/V .5N1.9L L � °' CONAoRM To /"I�JSS EwV/ 'ONMENT/9LVq . C 04'E" SL' i9Nd TOtn//V_ O HEALTf-1 RE' GUL -9T/ 0AlS. s. TOP of c/9L )D*e OFi ,� ,E Fo Un/tDt97-/ON Al O S C L E" � 1 2 f /MPERV/O US COVER .' /O• MfjNHOLEEr`COV E�2 TO EXTEND TO TO PREVENT W/TH/n/ /� OF P/ti//SHED GR,.gDE M/N/MUM I FROM /NF'/LTIeAT//VG /o'M/N/MUNI 57-o/�rE COVE,QS .. l�r D/ST. 6 � � �- COVER 4"cAST BOX 2/"wioE 4' /R. WRTEr R O ^I C M/N/MUM �_— -Y 3•n�i /. /GH FLOW 'LINE / O OT /4" 4 IFO OT H /Fao-r �Z, �PVASHED G [ L O N r /NVER7- j L EA C h/ Pe S7-0 n/E A 1 AJ VE,QT r P/7- Ct o A L L /IVVEQT CH Pf9 C /TY ( 4.9,2 OU/vD SEpr,(C 7-.9/VK I6•15 14, A76R7-/'4GH7—) /A/VE-AT //AVERT /A/V E k-r C-c��• r . Np GARBAGE Gre/NDE� r-,l-� �'f x rIFIED PL Or PL19AI L O C -4 T/ O,A/: (:Z--G-• V i t-1 � 2 7 "cs��/v�l�. Lis = �O 0 A TE•' S0 U 7w Y,0g12-A4 D417)6 .y+ �2EFE,2E �/CE.' f3E/�/G LOT -5- AS SHoklAi i o A/ -9 Iw. STfIBLE COC//VTy /E'EG /S�`,2y O.=' �EE'OS SEPT/ C TO BE q �! of/ C� i M o F /O' FR OM FO Df3 GEORGE T/ O/V A /�/D L E F' C H F' / TS ' o LOW,JR. y{ L E,9 C H / N G P/ T•S T O B E A /v//A/ 9F �o /MUM of / o' FR oM oo,ERTy 7 Qs-T y0�/ L E S -�? N D SEPT/ C TF� /V/C z CE,eT/ Fy T11,97r- TH � SURJ� U� ZDCRO F �� T/OA/• .SHOWN OAJ TN / S' PLAN TED ON 7-HF- G R 0 U/V D r9 S S HO W/V f-/EREoN - IqAJ D THA T / T 4 t 5 COA./F0 le-1-1 DATE T> 7TL E — — — — — — TO THE H U/L D /NG .SET B/19cft RE /RE- — — ''/E/�/TS O �" THE T' l-V Al O,C 5.7 } 5 _ _ �Df�TE ,BOf�.eD OF tiE� LTH 0. , 9TE RE LA SUlZVE' yOl2 fjPP�20VED AGENT