HomeMy WebLinkAbout46R WEQUAQUET LANE - Health i
4612 Weq!.aquet Lane (Centerville)
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J17/11I1elllG®. '
UPC 10259
No.H1 3OR eta► '�
NASTINOS. UN,
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION q j wCtgapi-t 4- LafJ SEWAGE
VILLAGE f >;7,�,, •,//�' ASSESSOR'S MAP & LO'
INSTALLER'S NAME & PHONE NO. 19t.$ '77' `L
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)_
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC W
BUILDER OR OWNERQ
DATE PERMIT ISSUED: I -
C
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes NO
j
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3G ' r.
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=250021&seq=1 11/12/2010
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
WNBam F.Weld
Govemor
Trudy Coxe. �+
ls.. uy,EOEA
David S. Struhs
COmmin loner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,,
�O�,Q CERTIFICATION
Property Address: 4b R wf6X-)A&QeA- cart. CP.04* Address of Owner:
Date of Inspection: tC)-Lll-Q( (If different)
Name of Inspector: WilliAnN 12ebin5on
1.
Company Name, Address and TelephoriftWiOn
ic
43 Tomahawk tDr
CERTIFICATION STATEMENT Cientervitt ���
I certify that I have personally inspected the sewage depo"s3f'syQUWhis address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_V Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: uft,,z,tN't'1 1-Q01 Date: 10^ Sf-96
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 sent to the s\•stem owner and copies sent to the buyer, if apphcabie and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
�Zave
PASSES:
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.
B] SYSTEM CONDITIONALLY PASSES:
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)
l�/0 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)
One Winter Street a Boston,Massachusetts 02108 a FAX(617)W&1049 a Telephone(617)202-5500
Punted on Rwycled Praper
'.._
I •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B1 SYSTEM CONDITIONALLY PASSES (continued) 00
_ Sewage backup or breakout or high static water vel observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken,.settled of uneven tstribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pi s) are replaced
obstru ' n is.removed
distr' ution box is levelled or replaced
_ The system required pumpi g more than four.times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with appr of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C1 FURTHER EVALUATION 15 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, /NH
d the environment.
1) SYSTEM WILLNLESS BOARD HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILLT THE PURL HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cessprivy is w in 50 feet of a surface water
Cessprivy is ithin 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILLN S THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM ONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMEThe as a sepnc tank and sou absorption system and is within 100 feet to a sur(aLe wales wNN4 or 1111Jul41� W a
surface water supply.
_ The sv5te- hay a septic tank and sail absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system hat, a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
for c^sif^rm ha aria a
supply weii, unleb5 a nd volatile organic compounds indicates that the well is
wCn watc7 a1 aura.+ -
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
D1 SYSTEM FAILS:
I have 7or
a a system violates one or more of the following failure Criteria as defined in 310 CMR 15.303. The basis
for this is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the fail
_ sewage into facility or system component due to an overloaded or dogged SAS or cesspool.
ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DI SYSTEM FAILS (continued):
Static liquid level in th/men
ion box above outlet in ert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspothan 6" below inve or available volume is less than 1/2 day flow.
Required pumping motimes in the t year NOT due to clogged or obstructed pipe(s).
Number of times pum
Any portion of the Soion S em, cesspool or privy is below the high groundwater elevation.
Any portion of a cessp is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspvy 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 followin/beca
apply to larg systems in addition to the criteria above:
The design flowtem is 1 ,000 gpd or greater (large System) and the system is a significant threat to public health and safety
and the envibecaus one or more of the following conditions exist:
the thin 400 feet of a surface drinking water supply
thes within 200 feet of a tributary to a surface drinking water supply
thes located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
pu 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 6/15/95) 3
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: U6 R t#ts,QUA QOOrLAac CeAA
Owner: N-W
Date of Inspection: 0.4-4fo
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.
NA
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.
IE -
✓ The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
ZAII system components,Ai cluding the Soil Absorption System, have been located on the site.
ZThe 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.
ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility o-..nc. ;a-d occupants, if different frorr owne•1 were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised B/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: y6 Q (A)f QUA QST- LAAE, Cen4.
Owner: 8eu}1
Date of Inspection: 10_y_q(
FLOW CONDITIONS
RESIDENTIAL: -'
Design flow bw gallons
Number of bedrooms: &
Number of current residents:a'1
Garbage grinder(yes or no):,E&
Laundry connected to system (yes or no):_
Seasonal use (yes or no): NO
Water meter readings, if available: 3q t O—930-oc>
Last date of occupancy: 10-9b
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/ y
Grease trap present: (yes no)_
Industrial Waste Holdin ank present: (yes or no)_
Non-sanitary waste di harged to the Title 5 system: (yes or no)_
Water meter readin , if available:
Last date of o pancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as pan of inspection: (yes or no)LA
If yes, volume pumped ¢allons
Reason for pumping.
TVPF 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)and source of information: Iw Ast'ga
Sewage odors detected when arriving at the site: (yes or no) WO
(revised 8/15/95) $
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: y6 W&VA&ET sane. Cam:
Owner: 8E CA
Date of Inspection: 10-4-%
SEPTIC TANK:
(locate on site plan)
Depth below grade:,
Material of construction: _concrete_metal _FRP—other(explain)
Dimensions: Q,XSXS
Sludge depth:_.
Distance from top of sludge to bottom of outlet tee or baffle: ?L"
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 i et and o tletje�s or baffles depth of liquid level in relation to outlet invert, structural
viod
integrity, evidence of leakage, etc.) ; v/Q in
M •4
GREASE TRAP:J" onSiie,
(locate on site plan)
Depth below grade:
Material of construction: _con ete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top scum to too of outlet tee or baffle:
L1ictance from b cam n; crtim to hottOm of oti let 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.)
(revised 8/!5/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:pow Msk.
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: eallons
Design flow: eallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:AW1_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and d:stribL:"c- :z e%ide^.:e of se�!d< ca•���P�, evidence of leakage into or out of box, etc.)
PUMP CHAMBER: A )P—
(locate on site plan)
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
SYSTEM INFORMATION (continued)
Property Address:
�6 Q U/f QVAfSZET Lw * Cefd.
Owner: &c6k
Date of Inspection: (0-Ll'g
SOIL ABSORPTION SYSTEM (SAS):v
(locate on site plan, if possible; excavation not required, but may be74)proximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:LLp�p�O
leaching chambers, number:_
leaching galleries, 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,etc.)
� L_p:lr Shows no VS AS aF 4d&0hL fWuM At +pine og 14jes fan
CESSPOOLS: Uenk..
(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, etc.)
PRIVY: (�011e
(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, etc.)
(revised 8/15/95) 8
y r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: q
Owner: C41
Date of Inspection: jo..y_(J6
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DecK �1�
1000 fvs-t
SvS�em does �o� �A`'e -
eo�di+ice AT'r-'M OC 1A
D,K.b arqf� oP 4a T-'+ItW
Qr Liz`e
DEPTH TO GROUNDWATER '
Depth to groundf determination
�oxifee '/_ /&cL //41e ,//�
method of determination or approximation: /�lSi!([ �T /71�C
lrevised 8/15/95) 9
1
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t
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT Q4OWN THAT
nson Septic !'
43 Tomahawk Dr.
Centervkb%,WilliamE. 02
inS%, . Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in,310 CMR 15.340 and Section 13 of Chapter 21 A of the
General Laws. Issued by The Department of Environmental Protection.
101
April 20, 1995
Acting Director of the ' ' •ton of Water Pollution Control
r Hurd of Health
Town of Barnstable
Box 534
r, l, Fes$...... .:.-.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... .....an ...._.......
......OF..urns ..le....:.....
Appliration for Uhi ' vii al Works Tunfi rurtion rruti#
Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal
System at:
...1........ WrCi. ati �.Address
7Q S lk4G........................... ..`. ...%...........__.................or Lot___.........._.._.___..___.._.._._.._._.__...__
G �
Fl> �1 ....... ..-•.Owner---•--....•..........•................... 'S - .._pl�i._CK...h. ... . a�eNo.
e neats•-••----•-------------------------------
ss
'4..Q..C6 9--•----------------•----................................................ ur #�
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ............................ No. of persons----_----------------------- Showers ( ) — Cafeteria ( )
04 Other 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........................................
,aa Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-_---__-__---__-___-
a ---•--------•-•------------•••••-•-•-•••---------•----••---•-••-•--•.....--•----------•••--..-----•....................................................... .
0 Description of Soil........................................................................................................................................................................
---------------------------•------------------------------------------------------•---------------••--------....--------------------------------------------•--••-- ---------------
U Nature of Repairs,or Alterations—Answer when applicable:4sY 9'_ -----lgbo-.fa.__S5.0 �---Joao a.,46c�._.
Agreement: D
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
T A14'L^
the provisions of 'T T t E, 5 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.
Signed '�� -----•------------------------•-......••---• ---�-/3- �..........---
d= --
/ Date
Application Approved By. ---. ---------------- ll� ----
Ote
Application Disapproved for the following reasons:._.. ------------------------ ...........................................................
............••••••-•-••••-•---•-•......................•••-••--•-••••••-•--•----------•-•••••---•-------•---.............---------------•--•----••-•••-------------•--••-•-------••••......•------••--•.
/ Date
Permit No.......��.... --------------------- Issued l
Date
y.; No.A..1.'..nL. FEs...............-..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ...... . .....---.....O F...............-
Appliration for Uigpoual i gorkii &in,itrurtion rruti#
Application is hereby made for a Permit to Construct ( ) or Repair ("' ) an Individual Sewage Disposal
System at:
Location-Address _ or Lot No.
Owner _ Address
W ..................................................../ •...
Installer Address
d Type of Building Size Lot_-_----____-•--------------•Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
PL4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
F' Other 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..................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-________-------_--_--.
�T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-•__________--_-____.
P4 --------------------------------
•...
*---
-..........................
*---------------
----
-------------
-------------------
•-------------------------------------
0 Description of Soil........................................................................................................................................................................
V ••••--••---•----••----•••••--•--••-••-•--•...------•.......................••-----•••----••••-•-•-•••---...••---------••---•••---••---------......••---------•-•---••-•••••.........-•-•••------------•.
W
U Nature of Repairs or.Alterations—Answer when applicable______________'..______________ ._.!___._:_:.::.-.-:^-____ ._._!: %_:�_ _•________-
1 / , / r + i . t-t'
......--•---------•-----------•-•--•-••••••-•----••--••-••- .....•-••••-----------------------•••••----••--.........._..-•----•-•-•---------.....----------••-•-•-•••••-•••-••••••-•-•------------••..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS y g g p y
of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed = ---------------------------------•------ / ' /
Application Approved By.-6... ..---'� lr�'c.?�t/.... 9
j bat,
Application Disapproved for the following reasons-------------------------------------------------------••---------•-------•--•-----------------------------....--
....................•-•----•----------------•......----..._.......---------------.........--------...-•----------------•--•-----•--------------------......---------------------------•••-•------------
Permit No.------. ..............................................
.� ...��..�--------------------- Issued.-----�/_'_����,C�: Date
Date
f THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.........I...........................................................................
Trrtif ira tr of ToutpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (-U )
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at.....................................................................................................................................................................................................
has been installed in accordance with the provisions of TIT' of�he„State Sanitary Code `Ok c ibecj_in the
application for Disposal Works Construction Permit No--------------------•__•----, .......... dated_...__ '.Z./__/_��_ ._____......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMS WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector...........
...._ . ................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF....................................................................................
NO......................... FEE........................
Diupuatl Vorkv Tonuirurtion rrutit
Permissionis hereby granted............................-------------••----•---•----•--------------••---•••••-------•-••--•-••....•--•--•••.....-••••••--•........_....
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo.................................................................... --•-••••----....•-••-•-----••••-•-----------------•••.....---------•-•--••--......---- •••-
Street r
as shown on the application for Disposal Works Construction P,er.,m.�N.._......� Da d,_,.y_� _...- _!._._..
------------------- ---------------------------
�/�
.- - -. Board of Health
DATE. -- - •-•.... ...
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
TOWN OF BARNST ABLE.
LOCATION �6 GUe�oaa.a � 4- LcP/ SEWAGE #
VILLAGE 11-e ASSESSOR'S, Mc1P & LOT
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY��Gl�
LEACHING FACILITY:(type) /®�� (size) /owe zo; `
NO. OF BELROOMS PRIVATE WELL OR PUBLIC WATER cL
BUILDER OR OWNERn�t��
DATE PERMIT ISSUED: —
DATE COMPLIANCE ?SSUED- 1
VARIANCE GRANTED: ;des No ��
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