HomeMy WebLinkAbout0363 SKUNKNET ROAD - Health ;63 SKUNKNET RD, CENTERVILLE
A= 1.70-115
(/ ,L TOWN OF BARNSTABLE
LO::ATIONC41L)�� V'i L�(e SEWAGE # G$%66�
VILLAGE3 3ska1 kNt-f' e®(aR ASSESSOR'S MAP & LOT rJ" /
INSTALLER'S NAME & PHONE NO. UQ C� kpL,►J S0 tJ 7 7 5-a7)6
SEPTIC TANK CAPACITY 1 000
LEACHING FACILITY:(type)� (size) 4AAZ AN6
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER (V\Q_
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: :7 1 l 1 N S
VARIANCE GRANTED: Yes No
9
1
(Al
��
No..l.. .. F>±a...3. ...Q0.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABL.E
Allp irativit for DivVitiitti Works Tnnitrnr#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
363 Skunknet Rd Centerville
..................................•-•------••--------....:----•----------------........----------- --------------------•-----•--•-----------------------------......------....._......---------------
Mr. Finn Location-Address or Lot No.
Owner Address
a W.E.- - Robinson Septic___Service____________ _ P.O-.Rox 1089 Centerville
Installer Address
UType of Building Size Lot--- --------- ----------Sq. feet
�.. Dwelling—No. of Bedrooms--------3----------------------------------Expansion Attic ( ) Garbage Grinder (no)
aOther—Type of Building ----------------------_---. No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures .....................................................................................................................................................
Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter..........--.... Depth................
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................ --------------------------------- Date.------...--------------.....---........
a Test Pit No. I................minutes per inch Depth of Test Pit......--.-.--------. Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.....--.-------.---. Depth to ground water........................
------••---------------------------•-•--•--•-----•----•-----------•------•--•-•-•--------•----------.........................................................
0 Description of Soil....... and......----•-------------•--•------------------••------------.....----------------------------------------•--------•----------------------------------.
x
U -------------------------------------------------------------•--------------......------............--------------------------------•--------- --------------------------------........................
W
x .................. ------------ ------------------------------------------------------------------------ ------------.........--------------------.....------------------------.....-•--------•---- .
U Nature of Repairs or Alterations—Answer when applicable...additional___-preCat_--- tonepaciced.......
-leachpit---off___ex_ist ng___d-box______
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance ha;been d b the board of health _Signed .._....ea. ------------- / !� 6DaceApplication.Approved By ...... - � P "'' �1.......
. ,....
Application Disapproved for the following reasonr: ....................----....................................'----'---........._...---- ........----------
Permit No. ...... `- Issued L.....�1..��.. .........
Dace
_�--- ———————————— -- --------------
, -� / �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun fur Di ipmial Wor1w (funtitrurtiun rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
363 Skunknet Rd Centerville
•.....................•----..........................-•-•--•-----------.........•-----........_... ------------•-------•-----------••----...--•--•---------....•-----...--------•----------•--...•---
Mr. Finn Location-Address or Lot No.
Owner Address
W W.E. Robinson-_-Septic___Servic2______.__•__-•__ P.O.Box 1.08g---Centerville --_
Installer Address
UType of Building Size Lot... ......... ..........Sq. feet
Dwelling— No. of Bedrooms........3_--------------------------------Expansion Attic ( ) Garbage Grinder (no)
aOther—Type of Building ---------------------------- No. of persons.---------_--_.---_------- Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------- -----------------•--•----••---•--••--•-•-----................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity...........gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter........--.......... Depth below inlet.................... Total leaching area..................sq. ft.
`.Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------`---------------------------------------------------- Date........................................
04 Test Pit No. I................minutes per inch Depth-of Test Pit.................... Depth to ground water...--.-----------------.
44 Test Pit No..2................minutes per inch Depth of Test,Pit.-.-...._.-.-_.__--. Depth to ground water........................
9 ...............................------- ..............=......=..............................................................................................
ODescription of Soil-----sand----•-----•---•--------•------------------------x -----------•---------------------•---------------------------•--------------------
V ...........................
W
x ............. --------------------------------------------------------------•-----------•---------••---•-------------------------------•------------•-----••---------------......---------...--...-•----
U Nature of Repairs or Alterations—Answer when applicable...additionalpecast _stonepacked_-_ r __ _•____,
leachpit off existin.
-_---
----------------------------•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been is >�d b e board of health.
.. tt � l
Signed --- -- --t-----d- l� ( -
-----------------------------------........----....... .............. �ce.-- ------- .
el
Application.Approved By ---- -------- !���. - .-`�y�.....- _ =%..... .��...�y///7 ..................�f ^.; ..
L:� ( Dare
Application Disapproved for the following reasons: - ........ ..................................................
..................................................... .--....... .........................................................- --......._....Dare....._ ........................................
.................... ............... ..are..^^'^"
............ /` "''�' ,�^� c'
Permit No. .........._'b--.... L%. Issued / ">�f-'�� `� ". �'' .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
U ertifi ate of Camplian e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X)
(k byWE �---R�obinson.--.Septic Se _.._..----------------------------------._----.......------------........._........_............. ......
--- --
----- . . . ....._installer
at ... 3.63 Skunknet._.Rd....Centerville-_---------------------------------- -_--------------- -------- ------------.-------_......._......------.---------------....-
.._..- .....
has been installed in accordance with the provisions of TITLE of The State Enviro mental Code as described in_,-_...-
the application for Disposal Works Construction Permit No. �'a' ._-/�Q.edated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT'BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................... ...- f - ...`.. 15....._... -------------- Inspector ------------......- r
THE COMMONWEALTH OF MASSACHUSETTS
r BOARD OF HEALTH
TOWN OF BARNSTABLE
FEE.._30. .00•
No..............•---• ...----•---....----
Ru penal Workii Tunutrurtiun "rrutit
W.E. Robinson Septic---Service
Permission is hereby granted................ ...
Ito Construct ( ) or Repair (X) an Individual Sewage Disposal System
363 Skunknet Rd Centerville `
at hIO.. Street Q ! tG ........1 ......
as shown on the application for Disposal Works Construction Permit N- ___.---_....-- a-t�ed_, 3._....
' .... Board of Health
DATE....... -------------------, •-----"'}7•----
FORM 36508 HOBBS R WARREN.INC..PUBLISHERS
Town of Barnstable
Department of Health, Safety, and Environmental Services
• e�x�vsresre.�,� Health Division
"I
367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A McKean
FAX: 508-775-3344 Director of Public Health
July 5, 1995
Richard Finn r
363 Skunknett Road o E ..-
Centerville, MA 02632
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 363 Skunknett Road, Centerville was
inspected on June 14, 1995 by Troy Williams a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Hydraulic failure of leaching pit
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen
days of receipt of this notice.
You are also directed to bring the septic system into compliance within thirty (30) days
of receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health d
ASSESSORS MAP NO:
PARCEL NO: 1�S
4-o4- (.c,? TOWN OF BARNSTABLE
LOCATION S kdd,- le� SEWAGE #
VILLAGE 4 _ ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY l v
LEACHING FACILITY:(type (size) C 'XG
NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATER �ub
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
3'
3 3s
y16�,
J(pit
3�
[Installer letter]
T0: �i �'G� yli�J (Date)
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you localted�at �i"�r1 ,:�f"P % as
inspected on � rAo�sa Massachusetts licensed septic
inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the followin.
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of
receipt of this notice.
You are also directed to bring the septic system into compliance within thirty (30) days of
receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 3 3 -5KJ N ktVe�f Rd , Ce1, J�'e.✓ui
Owner's name Date of Inspection R ' ��� '�� r
y l s QCC�[IN/ D
PART A
CHECKLIST J U N' 19 1995
Check if the following have been done: H'TMDEPT.
TM Of @AMSTMEE
Pumping information was requested of the owner,
Health. occupant, and Board of
.� None of the system components have been
Pumped forand the system has been receiving normal flow ratesaduringtthat weeks
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 i
/ available with N/A, f they are not
�L The facility or dwelling was inspected for signs of g sewage back-up.
_A/— The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
he
The septic tank manholes were uncove
re ,the septic tank was inspected for conditioneofdbaffleshe.orinteri tees,or of
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has bee
n determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
Provided with information on the proper maintenance of' SSDS.
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORK
PART B
SYSTEM INFORMATION /
FLAW CONDITIONS
If residential
number of bedrooms
_. number of current• residents
ND garbage grinder, yes or no'
5 laundry connected to system, yes or no
,1`4° seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
93 = o263/ oaoYo llni�,S
e-cl Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
AJ-
✓G-c. ate. U h 7—
Na system Y pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type,- of system
_V Septic 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. Source of
information:
aS � , /� b >`a itic�
Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
` / SYSTEM INFORMATION continued
SEPTIC TANK: V
(locate on site plan)
G i
depth below grade:
material of construction: concrete metal FRP other(explain)
dimensions:_ ,S )C J k 6 / d o o q Igo
S sludge depth
distance from top of sludge to bottom of outlet tee or baffle
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
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evi ence of leakage, recommendations for reps rs, etc. )
a
G O✓ �1 ✓u y t✓ v
YJ t oZ i o J t✓ O ✓ vA, c� v ✓ ca .�
l o
- �� O J t ✓ .�v pit r),/ 4-
DISTRIBUTION BOX:
(locate on site plan)
A So , e 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, recommendation for repairs, etc.)
S•� L f S J L r'Ga I a d O u c_ w, � � I J
(fin w�<< 1 �S u .•, ) c.n.�[.✓ �c. }'•-,� �r � 6 �� ALio.� � n� �JG � •
i N U Gr
_PUMP CHAMBER: /1 /4
(locate on site plan)
pumps in working order, yes or no
Comments :
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORN
PART B
SYSTEM INFORMATION continua.a
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 and number
leaching chambers and number *' w a She
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure,
c level of ponding,
ma
co dition of vegetation, recommendations for in enance or reps etc. )
c� 2 �. v, rs1
6 c✓ i H S✓ v L �o -ter G.i or ,em s
--
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 groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation,, recommendations for maintenance or re
pairs,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, recommendations for maintenance or repairs,etc. )
' 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE E=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
a`
3e�6„
3�
36
3,5
y1 '6 Off
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or ap r, cimation:
.-(� JMu"
/ " 5 �aw Lc 1 ., of o� 11
r v M C.,L
N
i
SQ88QRFACE SEWAGE DISPOSAL SYSTEH INSPECTION FORH
PART C
FAILURE CRITERIA t
Indicate yes, no, or not determined (Y. N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
YStatic iquid level in the distribution box above outlet- invert?
L ,,� rt.
�
Liquid depth in cesspool <6" below .invert or 'availablevoluiae< 1/2 dad
flow?
Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
. Al within 100 feet of a surface water supply or tributary to a surface
water supply?
.L within a Zone' I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
1L within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private w
at
supply well with no acceptable water quality analysis? If thee we'll
has been analyzed to be acceptable, attach copy of well water analy.
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEK INSPECTION FORH
PART D
CERTIFICATION
Name of Inspector w ; , �,� �,, S
Company Name
Company Address t(c p/C/ 9C.,S S /�. L7
Sd-=1 _t_at.{nn .cta tement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of 'the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303 . Any failure criteria not evaluated are As stated in
the FAILURE CRITERIA section of this form.
V I have. determined that the system fails to protect public
lth
the environment as defined in 310 CMR 15.303.. The basis for athisand
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature S
Date
Original to system owner
Copies to: -
Buyer ( if applicable)
Approving authority
3 3
l O CA I',t:ON - S EWAGE PERMIT NO.
.077
4, IV
YILLA-C.E:
INSTA: I.IER'S NAME L ADDRESS
e UIL0ER 0R OWNER
DATE PERMIT ISSUED
- 1I- VS
DATE : COMPLIANCE ISSUED 4 -
0 Lad-
30�b � 3s"
7
•f I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 363-8kunknet Rd Centerville
Owner's name Mr. Finn
Date of Inspection 7-11 -95
PART A
i
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
None 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.
y 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 site was inspected for signs of breakout.
Y All system components, excluding the SAS, have been located on the
/ site.
Y 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.
l//The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
v/The facility .owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS. i
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
_3 number of bedrooms
_ number of current residents
✓ garbage grinder, yes or no
laundry connected to system, yes or no
1/ seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
ah/Z - ► . o4a
V System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Types of system
�/ Septic 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. Source of
information:
� v(sf a ! ti.:w S is , �; �� �6C j o b o
Sewage odors detected when arriving at the site, yes or no
i
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade: ��
material of construction: concrete metal FRP other(explain)
dimensions: (,, — F- - 4 5` 7 �
sludge depth
�2 distance from top of sludge to bottom of outlet tee or baffle
6 scum thickness
iV distance from top of scum to top of outlet tee or baffle
C_ 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, recommendations for repairs, etc. )
�..s . A% e.4 -A. I --/) —5 !C A zi42 L el R r
DISTRIBUTION BOX: ✓
(locate on site plan)
(� 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, recommendation for repairs, etc. )
/✓ O
PUMP CHAMBER: !/ V
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chambe condition of pumps and appurtenances,
recommendations for maintena a or repairs,etc. )
to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
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:
j a a !O 5 r 1 T_5 I /�/�-i��� �• '7 �� Qj �i FJ,R
Type /
leaching pits and number S
leaching chambers and number
leaching galleries and number
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, recommendations for maintenance or repairs,etc. )
All O
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 groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,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, recommendati s or maintenance or repairs,etc. )
I
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
G\L
1
b
V �
J
61 e4
Al
DEPTH TO GROUNDWATER
0 4- depth to groundwater
method of determination or approximation:
�Ls tj c
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
y Static liquid level in the distribution box above outlet invert?
Iy Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
/y Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
ay within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
_L within 50 feet of a private water supply well?
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 analysi
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
I _
--TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 363 Skunknet Rd Centerville
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Mr Finn
PART D - CERTIFICATION
NAME OF INSPECTOR W.E. Robinson Sr
COMPANY NAME W.E. Robinson Septic Service
COMPANY ADDRESS P.O. Box 1089 Centerville MA 02632
Street Town or City State ZIP
COMPANY TELEPHONE ( 508 ) 775-87-76 FAX ) -
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems.
Check ne:
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature L e!�' r ZV Date
One copy of this certification must be provided to the OWNER, the BUYER
(where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doc
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L,3-C T 10N - SEWAGE PERMIT NO.
VILLAGE
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INSTALLER'S NAME A ADDRESS
i
e U I L D E R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED �_ � _
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Z�P-V7us - LAr__
OF.................... t ------•--•----..................
Ap iratiou for Dhgp i ai Works Tomitrurtinat 1hrutit
Application is hereby made for a Permit to Construct (�or Repair ( } an Individual Sewage Disposal
System at: 4 ' 343
....t ........................`�:�7.---- K V�. � c � 1�� �. �J t tz\1.I�:t LE..............
-
-Location-Address or Lot No
er Address
�. .... .................
Installer Address
UType of Building Size Lot___���,� ...Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtares ....................................
Design Flow............ ... .................gallons per person per day. Total daily flow........�3 .................gallons.
W ....Septic Tank—Liquid capacity�&842.gallons Length.5q]P.. Width................ Diameter---------------- Depth................
W Disposal Trench—No..................... Width-------------------- Total Length....... .......U. Total leaching area-____-__-.___-•--. ft.
�t Seepage Pit No._..._.._.t---------- Diameter.....U......... Depth below inlet........... ..... Total leaching area_Z-*-_V . ft.
Z Other Distribution box (A Dosing tank ( )
aPercolation Test Results Performed b - _t-- ____ ................ Date........................................
a Test Pit No. I----L_2__minutes per inch Depth of Test Ph__- ..... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
0 Description of Soil......... 2.. �✓1NID 441' ..._..
c.,
W ---------------------------------------------------------------------
VNature of Repairs or Alterations—Answer when applicable.-----------------------------------------------------------------------------------------------
--•------------------------•---•--•-----------------------•----------------. -----------------••••••---•-----------•--------•••----••••--•••••••••---------•••••--••---••••-•-••---•--...------•---••••
Agreement: r
The t ersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the prow; of fITLL 5 of the State Sanitary Code— The un4ersigned further agrees not to place the system in
operatic un ' a Certificate of Compliance has bee i su d b t f health.
�_ Signed----- - -- - --- ---•------ .............. ..........................
•."--•. ..5-
- ------------ - - - -
D e
A cation Approved By....... `� - - - ••�....
_7l�Zv..... 1/Date
Application Disapproved for the following reasons:-----•---------•----------------------------------------------------------------------------------------------
.............•••-•••--•--•---•••---•-•-•-•••---.....•---•••-••-•-••••••••--••---•••--•--......-•••-•-•---'••••-•-••-•---•-•-•-•---••-•-••••••-•--•-•------------•----•---••-••-•••----------•--••--•-•---
Date
PermitNo....... ..�....--.�L�9------------- Issued_.......................................................
Date
Fizs....... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� �� k--Z "i F_�-t_
ApplirFatilin for Disposal Worki i Toustrurtinn rruti#
Application is hereby made for a Permit to Construct (V/)/or Repair ,( ) an Individual Sewage Disposal
System at:
.................................._L
Location-Address
o.
nerAddress
Le
Installer Address
UType of Building `� Size Lot._'2,,_4?J_0...Sq. feet
Dwelling—No. of Bedrooms-------____............................._...Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons..................._........ Showers ( ) — Cafeteria ( )
d Other li res -------- ----------------- .........
--r-•-
W Design Flow______________ f:' /________.__....._______gallons per person per day. Total daily flow__._._.___.;.................................7lgallons.
WSeptic Tank—Liquid capacity;/�_GG'_. _gallons Length.-'-- __ Width................ Diameter................ Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length______.................... Total leaching area__.................. q, ft.
� Seepage Pit No_________ ___________ Diameter.._...�__.._.__._ Depth below inlet....................
Total leaching area____.�__,,,�.'_sq. ft.
Z Other Distribution box (,f) Dosin tank ( )
'�' Percolation Test Results Performed by� �.._�� _ t �5�-'C:_••___•__-__•_ Date....................
Test Pit No. 1...... '___minutes per inch Depth of Test Pit.......12-_._._ Depth to ground water........................
(Z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------------------------------
••--------•-• .•-• •---------------- -
Description of Soil =------------•-.-f-=-`J —' �hr G %
U ........................................................--�--•-
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
.-• -•---•-••-••.............••-•......--•••--•-•----•••-•-•---•••--------•-------••---•----------•-••-•-----------...•••••---...•-•-•••--•--•••••-••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
r1�-•
the provisions of/'t T r".c,. 5 of the State Sanitary Code—The un,4ersigned further agrees not to place the system in
operationAon
tiii�ate of Compliance has be i su d b t f health. _
Signed..... _ .: _ -.:. _ _ �
_.. ..
,
Application d B .,PPy-•-•----• •-•._..,. r : =•------......•--•-••...................... -• • •-=- ---:_Applicatived for the following reasons--------------------------------------------------------------...............................
Date
----•-•-•--•-•------•----•-••-•--•--------------•--•---------------------------------•----•-•-------...---------------••-------------------------------------------------------------------•------...--
Date
Permit No. .••--••------• Issued.------•-•---••---••---•.......................................................
` 1! c,
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH A
...........................O F..... .. .`.:. :. .: ............... ..............
(Inrtifiratr of Tuutpliana
TH S IS TO CERTIFY That the Individual SeK�ge Disposal System constructed ( Repaired ( )
-
b)-••-•-- �:� ".::., 1_t° . ` ---------------------------- ---------------- ------�... ---------------
at �e -- —..-- --_*r L� �K ��!_! Instals' j--------- i/ i�.. � ..
has been installed in accordance with the provisions of TI`I'I-,.:,, 5 ofrThetState Sanitary Code as described yin the
application for Disposal Works Construction Permit No_____________` __:__:__.�_ __.____. dated___..___`:, ,s,---l l
-.Z
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO].TRUEDAS A GBJARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ............. `. :- g-��--.--•--.....-------------•------------- Inspector--•-•--- ---•----•-------- •--•------•----THE COMMONWEALTH OF MASSACSETTS
BOARD,-'' F HEALTH
..........................................OF... yl z� ._...__...._......._._..
...e., a FEE........................
Disposta ,r Works Tons#rnr#ion utit
i Permission s hereby granted---• t -�r/� t _ .��" ' .-----...•••••......:......................
to Construct or Repair ( ) an Individual Sewag is sal S3>tem
w _
.................
Street
as shown on the application for Disposal Works Construction Permit No... :_..:_:=::`?-Dated.._____tis�:__ !t �="
.- -.--..-. • x '" f
.............
nn).,-DATE. /7� ..................................
Board of Health
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