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HomeMy WebLinkAbout0317 SKUNKNET ROAD - Health 317 SKUNKNET ROAD, CENTER_VILLE _ A= 1 00 259 lie 0Q ('� S K v nJ JC N i�u` n LLIL w C,e� C033' 3 - Pod2 QlVJ --------------------- - Q c z,f, 2n n TOWN OF B STABLE LOCATIONe-T • SEWAGE #9 0 V,7-i,LAG S, ASSESSOR'S �� R MAP & LOTZ7a"R INSTALLER'S NAME&PHONE NO. C-&c1�6psa )AQI ,&S 417-2 SW SEPTIC TANK CAPACITY p 000 4 '�"V L LEACHING FACILITY: (type) I^. �� (size) IZA biha NO.OF BEDROOMS Z BUILDER OR OWNER 1:>Q-w e�ta3 �r PERMIT DATE: IA COMPLNCE DATE: 5 a /r� 97 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 2.d 4- Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A • Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin%racility Feet Furnished by e AA 1 35, gz /v v l� a "4dI /�A ■ \�, ) �(� No. !(J / / ` /1 C Fee a DD 3THE COMMONWEALTH OF MASSACHUETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplicatton for Mi$po5a1 *pmem Con5trurtton VErmtt Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: LocatiogQddress or Lot(No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. , Designer's Name,Address and Tel.No. c.G-r\t� -- ��_"j r;c(LS C-4,- \Nv • 5-e1&I:C_�LS` t opi5;- (IN . LQ3D V'Y a c-e YVtc .S Y; `M 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 NatureZf Repairs or Alter .ions(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 is d b h' Board of.Health. n � �'J 9/ p Signed Dated ` —/v Application Approved by ' Application Disapproved for the fo lowing reasons Permit No. f 7 I Date Issued S —-7 —`j /!�'i'1 ;l �e` Fee 1®�DONo. � t p'`V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ` appItcatton fOr MtgpogaY *pgtem Con!5trurtton Vermtt Application is hereby made fora Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. dr 1Aw '*�,,©K Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. t oig- (Z8 . lap VY)cc S`n` c-p 's-v YNn a. - 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 s w G ylt. C� tt 11 of airs r Alterations Answer when applicable) R.\ NC[J p P \ ( PP ) S--+� M Natu Re o Al t C Date last inspected: 1 � Agreement: t 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 i=bard of Health. � ,,.�/Signed j^� Date Application Approved by Application Disapproved for the fo lowing reasons Permit No. / — 1 7 Date Issued THE COMMONWEALTH OF MASSACHUSETTS I PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS (Certtttrate of Compliance THIS IS TO CE MY,that the On-site Se Disposal System installed( )or rep aired/replaced on 3 by v� i-D h-_ . �r�`crkS for a w Sht�.a ^—h t�c3 t�9 C1^ as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7/ dated Jr' " ^4'(o Use of this system is conditioned on compliance with the provisions se rth below: No. Fee 0.C THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Dt5pogal *p6tem C,on!5trurttou Vermtt Permission is hereby granted to � �� to construct( )repair T /t,)-an On-site Sewage 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. All construction must be completed within two years of the date below. Date: __57" —7 Approved by , uo �p,=tA6v' 6►RI ` 3�o G.P� ` 1 Fes/ a llo N AqS(y.Pt'. ___.. _ 'L$ '•:`� IC PIT u`•� P IMF. � , I • ' . �S . ; . + . . -� 1..GwM $tJt^li��K /1 UAI O t r.'e> •pal�� Fc-ow • 33D � � •• .9't S � � � 1 CIO j r ..BAXTE :;._.. --.r••_.• 1 -•r- . .. t . . � ..t •'( 1'1' _ ;� r Too tr'wv•lot,4 ' Tyr l000 ., �►M q8�6 �: . , I ,lug. . . . •I { r , w Foxe I ...w 1 PST 1 - •--1_--.-•..r_"r._�-•• w• +}• t j= Wil . - �..... ••-. .ST��Jrc ,LOB... . '. : I , � } qO .. .. : :�A � . . � I i . . ••. , : ; t.�tLTi�il`ssty i.��p Lb. t�•,M-. • E���gS•G� �..lo �sl..� • ; • • • ' .� • • • • � . . �,A1;.! •.Q,�FEtLE�.itE 1 GGRTIF�I S v�/1'rN Tp- SIUi`• .. Gap�CQut�E'�`'uTs �a Foa: Aura sr-- ub t6 �oT •pp,jEp NOV. to VISA, A �E loc. ..Iow,J 01= BAP�kiTA� ��� pL„pl{1. 1 8Q.1iCT�.R. t• b! �,pC,p,•rEb wl'Tul►•.l • "< Q 12tGiS�R�v 1.a►�.It7 ' SUev d4TF- ("i9" ; 1 J . . • p'STE�•V�t.Lr o AI�A►SS. e,ASCO '�'1-tts h�.n�-•! is �"1 0�IJG:. UFC Cr.,� �,l.��wu� l t> �5 j Commonwealth of Massachusetts Executlye Office of Environmental Affairs John Grad D.E.P. Title V Septic Inspector Department of P.O. Box 21,19 .Environmental Protection Teaticket, MA'02536 wuu.m F.w•Id (508)-564-6813 ooNmor Trudy Coxe tiacral,,y EOEA 1. 1 f d`LA David B.Strufut Commission SUPSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM NPART A CERTIFICATION `S Property Address: �� +—a-�` '�� �dreses of Owner. t 199 - Date of Inspection: (Ls qcP. (If different) b' Li Name of Inspector. 4jJ Company Name, Address and Telephone Number: "`N CERTIFICATION STATEMENT I certif,i,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_andexperience in the proper function and maintenance of on-site sewage disposal systems. The.system: Passes , Conditionally Passes W.(16 the local A rovin Authori - Nee s Furt r EvaluationBY PP g PARCJI;N04 a,ls Inspector's Signature: Date 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 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 cent tc:;ne system owner and copies sell; to tilt buffer, if applicable and the approving au,horit). INSPECTION SUMMARY: Check A, B, C, o D A) SYSTEM PASSES: f 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: BJ SYSTEM CONDITIONALLY PASSES: v 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 On*wlrtt•r Strom e. Boston,MasMehusa is 02108 • FAX(617)SWID49 is TN•phon•(817)21;124M 110 Pnntd on Naycld Pape, • s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' " PART A CERTIFICATION (continued) 2 C � Property Address: �J1, F Owne 11 Date of 1 0 BJ SYSTEM 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 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 ass ' _ Y eq P P 6 Y p�Pe P inspection if(with approval of the Board of Health): broken pipe(s) are replaced x' obstruction is removed _ .. CJ 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. f 1), , 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 FNVIR0111ENT; „ Ine sk"stem nd� a sepnL tank anu hul; d6borption sysieni and is vritl.ir. iUV (FE" to a 5,i-r—8 L�otL: SuNh,) v ii.,u its ,' tv u surface water supply: . The s%die^, hay a septic tank and soil absorption system and is within a Zone I of a public water supply well`. t` The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The s,stem 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' D) SYSTEM FAILS: e determined that the system violates one or more of the following failure criteria as defined in'310 CMR 15a303: 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. ,; N Y po.. or cesspool Backu o se p f. wage into faci1, ors stem com Went due to an overloaded or clogged jSAS Discharge or,ponding ofM1effluent to the surface of,the round or surface waters due to an overloaded or`clogged•-SAS or cesspool. (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prope ~Aress: ) �Jnk--tee.i'c-- Owner: Date of Inspectlon: ` � 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 flow 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 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 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 SURSURfACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propert Address: 3 Owner:. of Inspection: �1 S Check if the following have been done: . _I-Pamping 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. C �1s built plans have been obtained and examined. Note if they are not available with N/A. .1tThe facility Pr dwelling was inspected for signs of sewage back-up. L-1he system does not receive non-sanitary or industrial waste flow L-The site was inspected for signs of;breakout:` hCll system components, excluding the Soil Absorption System, have been located on the site., t/fhe 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. L--The size and location of the Soil.Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. if diffPrPni Grim owner' were provided with information on the proper maintenance of Sub- Surface Disposal System. . (revised 8/15195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C: SYSTEM INFORMATION Property Address: Owner` Date of Insop to } FLOW CONDITIONS RESIDENTIAL Design flow: 3 gallons ._ r Number of bedrooms: 3 1 1 Number of current residents: Garbage grinder (yes or no): Laundry connected to syste (yes or ndi; Seasonal use (yes or no): "! Water meter readings, if available: G Last date of occupancy: a COMMERCIALANDUSTRIAL•(\\(:� Type of establishment: . .... Design flow: gallorrs/day Grease trap present: (yes or no)_ Industrial 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 occupanq•: GENERAL INFORMATION .,L,. PUMPING R ORDS and sour a of i�niSormation: System pumped as pan of inspection: (yes or no) If yes, volume pumped gallons r , Reason for pumping: TYPE OF SY TEM _ eptic 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: k2x(o Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM W PART C. SYSTEM INFORMATION (continued) Property Address: S L000l - � - Owner:N:)��,, Date of Inspec3ion SEPTIC TANK:1,i r. (locate on site plan) s•..,. Depth below grade: 311 Material of construction: _j::eoncrete_metal _FRP other(explain) Dimensions: L TU S'-)'t W►4 L I 0 t t Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: q Scum thickness:_],_ Distance from top of scum to top of outlet tee or baffle: t Distance from bottom of scum to bottom of outlet tee or baffle: t( ( Comments: (recommendation for pumping, condition of• let and ouytlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) hL. 'Gt�C._ CY-\Cs a GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP_other(explain) Dimensions: Scum thickne», :a Distance from top of scum to top of outlet tee or baffle: Distance from. bottom N crwn in bottom of outlet tee or baftle: 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 PART C SYSTEM INFORMATION(cootinuc Prope Address: Owner: Date of Ins�e1�(1 (-11z TIGHT OR HOLDING TANKC�NC4 (locate on site plan) Depth below grade: Material,of construction: —concrete meta) FRP_other(explain) Dimensions: Capacity: gallons 47 Design flow: Rallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:le__� (locate on site plan) Depth of liquid level above outlet invert: Comments: (note vei and distriuurwr i>ryuai, e�id nce Gf solidi cartG,er, e%idence of leakage into or out of box; e!c:j� PUMP CHAMBER: \\7T _t (locate on site plan) u __.... Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of.pumps and appurtenances, etc.) (revised 6/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C k SYSTEM INFORMATION(continued) Prope Owner Date of Inspection: LS�� �� k2 , 4 SOIL ABSORPTION SYSTEM (SAS):_,L,,.-- ' (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: k ""T' leaching chambers, num_-ber leaching galleries, number,. leaching trenches, number'length: leaching fields, number, dimensions: ;a overflow cesspool, number. Comments: (n9te conditio of soil signs of hydrau ' failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: (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 ground„atc f, 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: pimensions. Depth of solids: Comments: (note condition of soil, signs of.hydraulic failure,,level of ponding, condition,of vegetation, etc.) (revised 8/15/95) l9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continNed) Prope dress: 3` Owner Date of Inspection: O� —1 IZs 1 q� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' LU 17 � g ` � a AP �56 gyp �P s� g DEPTH TO GROUNDWATER - Depth to groundwater:-Meet '' \\��^" J method of determination or approximation:V ci� C_nart (revised 8/15/95) 9