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HomeMy WebLinkAbout0087 OVERLOOK DRIVE - Health 87 OVERLOOK DRIVE, CENTERVILLE A'�--188122 i y� NoP213LOR HASTINGS,MN f TOWN OF BARNSTABLE LOCATION �`i 7 OL�1'��®/� �l• SEWAGE # 0001"'1-7 VILLAGE red Pezyl ' /ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /5`00 LEACHING FACILITY: (type) Z—.0-0,0, l (size) /a?•� �(�3 >C,2� NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: a S-at COMPLIANCE DATE: ,f. 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 L 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 �':On 7 ��a r 37 d �s .17 O �y' o .ter. TOWN OF BARNSTABLE " LG^AiION �Dnz-),e SEWAGE# VU-LAG �0 lle- ASSES R'S MAP&LOTiaa AME&PHONE NO0. D14161�1 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Ca) (size) NO.OF BEDROOMS_^ BUILDER O �Ctrlk- 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 byT1(TwliuY 13 �v d- No. _ Fee V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migogar *pgtem Con!5tructfon Permit Application for a Permit to Construct( )Repair( )Upgrade(►/)Abandon( ) L/Complete System ❑Individual Components Location Address or Lot No. 4e Owner's Name,Address and Tel.No. Assessor's Map/Parcel /�yp��,p� //!I 1le Installer's Name,Address,and(rTel/No./l/ / Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(111�� Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 A I gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 52W (�c Type of S.A.S. Z—' 90 0 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1)1�-/e ca7 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 bx t ' B of Health. 1 Signed ate O Application Approved by Date Application Disapproved f the following reasons Permit No. Date Issued c (� Fee J� THE COMMONWEALTH OF MASSACHUSETTS ,� v 'wEntered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zlp# iration for Migogal *p!tem Cone;trurtton Vermtt Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) V Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 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(14� Other Type of Building�/ eee2fNo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3.3.l gallons. Plan Date Y Number of sheets Revision Date Title Size of Septic Tank t Type of S.A.S. Z --$-!�O A Description of Soil le,It 34K1 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: t. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b thi B afd of Health. _. Signed , 1 x. Date a /0, Application Approved by T TROICIA- ./ l ,, Date 12 a Application Disapproved fo the,following reasons v Permit No. — Date Issued (o�� U THE COMMONWEALTH OF MASSACHUSETTS '",og`� BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER dFY that the On-site Sewage Dis osal System Constructed( )Repaired ( )Upgraded(l/) Abandoned( ys�` at ���� �, y '/G// l� 4, ,eeonstr/ucted in a cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 }�"ted lz7 Installer Designer / The issuance of this permit shall not be construed as a guarantee that the isystern will function as designed. Date Inspector �::kr d --------------------------------- No. s Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mtgoof *pMem Con5trurtton Vermtt Permission is hereby granted to Construct( )Repair( Upgrade Abandon( ), System located at 7 2W/"'L ; ,��, ' A� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Cos ction ust b completed within three years of the date of th s e it. Date: % Approved by y NOTICE: This Form Is To.Be'Used-For the Repair Of Failed Se -tic Systems.Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAI, WORKS CONSTRUCTION PERMIT(`VIMOUT DESIGNED PLANS dvlro�4fc.,eb-y Certify that the application for disposal wor'ys cons -uction permit sided by me dated /Z$/al concerning the propert-y located:,at $7 © f�LO®,� ,QjQ. meats all.or the following criteria:. ne fa:Ied system is conner.-d to.a rtsid aGcl 1we11L1g oniv: mere are no co_ mmer"al Or oLii1� /'ases associated writh the dwell.11 g. —ne soil.s c`zssne as.CLASS i and:ae _=o;-ri - � c on ace is .e ;n'rr or :�tu,i :o._ irLautes ac l -I=are no wetlands whhin 100 =mot of me omoesta-C=V.0 717szem :Here are no pri�are wells wi'. .1-40 :of the proposed septic r�>here is ne inc7tase in flow and/or.c:and_ iL se proxsed. !.rlere`re no V^S.c^nC^eSlleS�ed or I2erae� �!Ile bortom oI the proposed leaching acuity will not br ixatea'less ;ran nve __t 3i cve the zA=-i=adjusted,,oundwater able z!varior- (Adjust the ound�ater.tabie.using tbe:timator tII=,od when applicable], - Lhe S.a S.wi11 be lo:..atcd with.=10 fe_:of al-ty veseama we:lanc s, the DOCom of the propose.1 leaching facility will not be located less than fou-teta(14)f=above the nta.;u-num adiust-d g oundRater table elerarion, - Please complete the following / A) Top of Ground Surface Election(using GIS information) q 7. B) Gz:W.Elevation <J. ;the MAY-Ega G.W. Adjustment D rI'rrR NCE BE i�A and B SICKED : yam/ DATE: (SY'trh prapcsed plan-of sysz=on baaj. O (� C �7,: Vr a� r sB "'rybd3 `4 f1.x ir;z i:ac F ; yet' F f s+- rs itc- ` a a t--�"R- ;,x r s �d �,� .: T01NT OF BARNSTABLE > r, �. c {y3.1 ,iY�rFt �'-rah�t LOCATION...' SEWAGE # µ r .' VILLAGE �P�t2�� L�.. ASSESSOR'S MAP & LOT f ;< 1. INSTALLER'S NAME&PHONE SEPTIC 'TANK CAPACITY !SOD 11!5�4C LEACHING FACIL=: (type) Z—S�OOyAI e-04,y! (size) /�?•� �C�3 � NO.OF BEDROOMS -- -- - BUILDER OR OWNER JC&!' PERMITDATE: COMPLIANCE DATE: it :•. It fll s Separatton Distance Between the Maximum djusted Groundwater Table to:the Bottom of Lenching:Fac�lrty.. Feet Private Water Su 1' Welland Leachin' Facili wells exist PP Y ,g ty (If ah' on site or within.200 feet of leadhing'facility) '— Feet ! Edge.of Wetland and Leaching Facility(If any wetlands exist t within 300 feet of leachi'n faeili �- Feet �' ' g. ty), , Furnished by j. df a.` i t ... 4 .9 Jr LC3 �s C'�#W, BORTOLOTTI CONSTRUCTION,INC.765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508 771-9399 508 428 892E FAX. 508-428-9399SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMPARTA CERTIFICATION Property Address: erf� r�� Date of Inspection: -a(�-q� Inspector'sNaine: Owner's Name and Address: G 7 6ef CERTIFICATION TAT MENT• ' , I certify that I have personally°inspected'the sewage disposal system at this address and that,theinforma- tion reported below is true accurate and complete as of the time of inspection. The inspectionwas'per formed based on my^training and experience in the proper function and maintenance`of on'-site-sewage disposal rtems. The System: Passes Conditionally Passes Needs Further Ev luation By tl Local Aproving Authority f k Fails Inspector's Signature: iDate: 7�(a The System Inspector.shall submit copy of this inspection report to the;Approving authority wttlun thir- ty(30)days of completing this inspection. If the system is a shared system or has a'design flow of 10,000 gpd orgreater,fthednspectouand 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 1M ARY• A)SYST PASSES: Ihave not found any information which indicates that the system violates any'of the failure criteria as defined in 3.10 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more'system components need to be replaced or repaired:,The system,upon comple- tion oftthe replacement or repair,passes inspection. Indicate yes'.nor,'wriot determined(Y,Ni OR ND).Describe basis of determination In all instances. If not determined",explain why not. . . § The septic tankiis metal,cracked,structurally unsound,shows substantial'infiltration or exfiltration,or tank failure.is imminent. The system will pass inspection if the existing sep- . tic tank is'replaced.with a conforming septic tank as approved by The Board+of Health. Sewage backkup or breakout or high static water level observed in the-distribution box is due ,'kr to brokewor 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): -1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)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 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 ;"3 the,system is failingAo protect the.public health,safety and the environment. s s 1)SYSTEM.WH.L PASS DNLESS BOARD OF HEALTH DETERMINES THA77HE - SYSTEM!IS NOT:FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: t 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 THEBOARD OF HEALTH;(AND PUBLIC WATER SUPPLIER,IF,APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNERXTHAT PROTECT THE PUBLIC HEALTH AND SAFETY-ANWTHE?t ENVIRONMENT: {, ` The system has a septic tank and soil absorption system and is within 100 Feet to`a'surface T water supply or tributary to a surface water supply. The system has:a septic tank and soil absorption system and is with a Zone I of a public z water suPP Y 1 well. The system has a septic tank and soil absorption system and is within 50 Feet of a private r, water supply well. The system has a septic tank and soil absorption system and is less thaw 0;Feet but�5O 0,t Feet or more from a private water supply well, unless a well water analysis for:,coliform m' r fro m llution fro indicates that the.well is free po bacteria and volatile organic compounds '., {' =the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or'less f: i'i ?it•5>ppm D)SYSTEM FAILS: 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'r 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. r, ..Discharge.or.ponding of efluent to the surface of the ground or surface waters due to an _> overloaded or clogged SAS or cesspool. "" ` 4`�. �`"' Static:liquid,level in the distribution box above outlet invert due to an overloaded or clog- , ct .:ged SAS or,=sspool:; ; Liquid,depth in'cesspool.is less than G"below invert or available volume is less than 1/2 leequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). "Number of times pumped -2- f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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: ' ° ° 'h The'following'criteria apply to a large system in addition to the criteria above: The design flow of a 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 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,am pped Zone ll,of a public water supply'well. 11 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. a SUBSURFACE SEWAGE DISPOSAL OS L SYSTEM INSPECTION S CTION FORM PART B CHECKLIST Check if.the,following have been done: ;; .• ;.•., , _Pumping information was requested of the owner,occupant,and Board of Health. _,,--None of of the system components have been pumped for atleast two weeks and the system'has been receiving normal flow rates iduring that period., Large volumes of water have;not been introduced into the system recently or as part of this inspection. " •,.:F, °+:'- k""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. _�Z he system does not receive non-sanitary or industrial waste flow. The site. was;inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on site. vTbe;septic tank manholes,were uncovered,opened,and the interior of the septic tank was�in-' spected for condition of baffles ortees,•material of,construction,dimensions;depth.of liquid, d "th of sludge,depth of scum. �e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- ` A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner and occupants, if different from owner)were provided with information on ty ( P , the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL• V Design Flow: gallons,.Number of Bedrooms: Number of Current Residents' Garbage Grinder: Laundry Connected To System: *S Seasonal Use: O WateuMeter Readings,.if. ailable: Last•Date of O.ccupancy;3e-ea CX. w il- k:>jhCo- /'p1& COMMERCTAIJINDUSTRIAL# 146 Type of.Establishment , '�:,,,i,}, - 5. Designflow.f° * �lons/day k Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary:Waste Discharged To The Title V System: Water,Meter Readings, If Available: _ Last Date of Occupancy: ~' OTHER:,Describe) Last Date of Occupancy: GENERA INFORMATION / PUMPING RECORDS and source of information: / a GjYI System Pumped as part of inspection: If yes,vol a umped; gallons Reason.for;pumping:t TYPE,OF=SYSTEM ` .r,. : .; . ;Septic Tank/DistributiowBox/Soil Absorption System - Single Cesspool Overflow.Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AP ROXIMATE AGE ofall components,date installed(if known)and source of information:-, rE Sewage odors detected when arriving a the site: k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: A10 Depth`below grade:` Material of Construction: concrete metal FRP Other' (explain) Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom 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.) t GREASE,TRAP: 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: 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.) TIGHT OR•HOLDING TANK . v t Depth Below Grade: -Material of Construction:_concrete_metal : FRP_Other,(explain)' Dimensions: Capacity: gallons Design Flow: Rallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:AU 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,etc.) PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 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: Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,numbe.r: 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, etc.) CESSPOOLS: , Number and,,configuratton:a2- 6 Depth-top of liquid to inlet invert: Depth of solids layer: t:Depth-,of scum layer: Dimensions of Cesspooh Materials of construction• ^ " t�ndication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comme ts: (note condition of soilk, signs of hydraulic failure evel of ponding,con 'lion vegetation, e .) o- fo ` ` � � p Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -6- 'I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. v 7e 1 DEPTH TO GROUNDWATER: Depth to groundwater: / 7' Feet Me od of Determination or�pproxim don: I �^l®�' S. �A D►� -7-