HomeMy WebLinkAbout0047 WEST VIEW LANE - Health 47 WEST VIEW LANE,'CENTERVILLE
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UPC 12543
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MASTING9.MN
No. l 78�o Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for Migpool *pgtem Congtruction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. / Owner's Name,Address and Tel.No.
Aq
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
3660
P_A /—_ 17A
Type of Building:
Dwelling No.of Bedrooms 13 Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �i y gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
r
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� 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th s Board of He h.
Signed R S Date /0
Application Approved by
Application Disapproved for the f owing r sons
Permit No.T — J -7 9�6 Date Issued
~No.'7� l 79f�
Fee, _
THE COMMONWEALTH OF MASSACHUSETTS ,
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Migaal *pgtem Cougtructiou Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No..
S p
A AJ /-e 17A
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
Nature of Repairs or Alterations(Answer when applicable) A01 �.
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 provisionQed�by
5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issis Board of Huth.
Signed J Date /0 —
Application Approved by
Application Disapproved for the aowing asons
Permit No. 1 g 6 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
F THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repai ed/replaced(4-1 on
G ��C 1AW- by L ,�`' o�z/,00 for
as has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated /D-
Use of this system is conditioned on compliance with the provisions set forth w:
,/ r
a�
__�_.._ ���.. ter.. ..dam• a_,—ea--. t�e.�..:varv-�.scs•'�:+, .�9. _. .-`--.;: •ctt�es..�.:.:.
No. — F e
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
�Bigpoga-1 *pgtem Construction Permit
J Permission is hereby granted to ; P 1%,�Ix_,,
to construct( )repair(---)an On-site Sewage System located at 6, of(&J 1-4XAe
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.
'pi �{ Date: ^� Approved by
r L1
}
Pao
Q
I
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated x2 ;e'l�9S- , concerning the
property located at f 7 meets all of the
following criteria:
There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE: /2 � S
LICENSED SEPtlC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER C--
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
2
R. r
r + (OCTCommonwealth of Massachusetts Rry
Executive Office of Environmental Affairs �' 2 1
Department of re s 199>5
Environmental Protection ,�,� N
q
Wllllotin F.Weld
r3oremw S
Teudy r^,oxe
grace EOE1
David 0.Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
s{ Ut�� G>9 e �
Property Address: �� �E'- y 4174v Address of Owner:a RS me
Date of Inspection: /p-/g- 9.7 of different)• PARCEL NO:, 63 �
Name of Inspector: Tr /7o2I'y
(.'ompan Name, Address and Telephone Number:
J Vv402 (/V S p fr c 3
�k- 12a( i�i.�.eh/-
ti�ERTIFICli2i�i
AY STATEMENT accurate
l have personally inspected the sewage disposal system at this address and that the information reported below is true,
n
certify that d
and complete as of the time of inspection. The inspection was performed based on my training and experience in the groper u on a
maintenance of on-side sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_�F'ails
G Date:
i;v;per?c—'4 Signature:
flee :system Inspector shall submit a copy of•this inspection report to the Approving Authority within thirty (30) days of completing this
red system or has a design flow of Io,000 gpd or greater, the inspector and the system owner shall submit
;:nspection. If the system is a sha
h�_ 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.
li4, FPEC'TION SUMMARY:
Check A, B, C, or D:
A; :>YS'fEIM! PASSES:
_ 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.
i's, ;YSYGM CONDITICVAL�Y 'PA35ES.
ired. The system, upon completion of the replacement or repair,
One or more system components need to be replaced or repa
passes inspection.
in ain
Imitate yes, no, or not determined.(Y, N, or ND). Describe basunsound,
of
hdeterminationow substantial nfilcatration oreAttration or tank failure n�)
_ The keptic tank is metal, cracked, structurally
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
appruved by the Board of Health.
1
(revised 8/15/95)
One Wlnter Street • Borrion,Nlassaehusetts 02108
• FAX(617)SW1049 • TNephone(611)292-55M
rD Printed on Recycled Paper
c
: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ,
Owner:
J'•
Date of Inspection: f,
B] 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 tka 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
r
_ 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
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF,-HEALTH:
he Board of Health in order to determine if the system is failing to protect the
Conditions exist which require further evaluation by�t
public health, safety and the environment.
f`
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DET MINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SA AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 eet of a surface wate
Cesspool /IN
is within 5 feet of a bordering veg aced wetland or a salt marsh.
2) SYSTEM WILL FAILS THE ARD OF HEALTH (AND PUB C WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUING N A MANNER THAT PROTECT T PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The systemptic tank and soil absorption system and is withirr\100 feet to a surface water supply or tributary to a
surface waly.The syste.meptic tank and soil absorption system and is within a Zone I of a public water supply well.
The systemseptic tank and soil absorption system and is within 50 feet of a private water supply well.
The systemseptic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply wes a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free fron/pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm• 1
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 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 dogged SAS or cesspool.
t� Discharge or ponding of effluent to the surface of the ground or su waters due to an overloaded or clogged SAS or
A;-
cesspool.
(revised 8/15/95) 2
r
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 41 ��'S-�v��Ce� G•.9�e � ><z/_
Owner: M"'e/eow
Date of Inspection:
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.
An portion f cesspool or privy i within 100 feet of a surface water supply r tributary to a surface water supply.
_ y port o o a cessp p vy s c a pp y o t bu ry a
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 II 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: '7 U-)es�
Owner: t"Le.)2 2v ce
Date of Inspection:
Check if the following have been done:
=Pumping 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.
&+s 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 system does not receive non-sanitary or industrial waste flow
_site was inspected for signs of breakout.
system components, excluding the Soil Absorption System, have been located on the site.
Mhe 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'fhe size and location of the Scfil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_f-T'he facility ovsner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
y t
• , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �"j ��� { 1 e w
Owner: M v 22L C42
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: stall ns
Number of bedrooms:
Number of current residents: O
Garbage grinder (yes or no):-4LU
Laundry connected to syste (yes or no):
Seasonal use (yes or no):7
Water meter readings, if available:
Last date of occupancy:.e-&4w,--�f
COMMERCIALII NDUSTRIAL:
Type of establishment:
Design flow:_gallons/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 occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source o�mation:
Al"'W•e l v w A,/
System pumped as part of inspection: (yes or no)_
If yes, volume pumped Qallons
Reason for pumping:
TYPE 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) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth_ low grade:
Material of c ruction: _concrete _metal _FRP_other(e lain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom utlet t affle:
Scum thickness:
Distance from top of scum to p of outlet tee or baffle:
Distance from bottom of um to bottom of outlet tee or baffle:
Comments:
(recommend on for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, idence of leakage, etc.)
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FR other(explai
Dimensions:
Scum thickness: `
Distance from top of scum to top of outlet tee affIe:
Distance from bottom of Zetc.)
out
tee or baffle:
Comments:
(recommendation for puf inlet and outlet tees or baffles, depth of liq 'd level in relation to outlet invert, structural
integrity, evidence of lea
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locat on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
if not determ' to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, nu
leaching trenc , number,length:
leachi ads, number, dimensions:
rflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, con of vegetation,etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: IG
Depth of solids layer: 73-
Depth of scum layer: O
Dimensions of cesspool: 7 7 u L cL1
Materials of construction: it/1
Indication of groundwater:�(bN�`�— L ,
inflow (cesspool must be pumped as part of inspection) M I Y
Comments: (n t ndition of soil, signs of hydraulic fatlur , level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on sit p a
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of h ra I of pondin& condition of vegetation, etc.)
(revised 8/15/95) 8
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4 7 CV e-S�-v W L-4,N
Owner: 1'0 P.Ro a)
Date of Inspection:
S
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
C�SS�6L
DEPTH TO GROUNDWATER
1
Depth to groundwater:�feet L�
method of determination or approximation: �f.� 7
(revised 8/15/95) 9
S
No. /V I �U f� Fce
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
T[PpIicatton for Mt!6paal *p6tem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
47 wens-f-t/�.Qcc> 4Wt
Installer's Name,Address,and Tel.No. U Designer's Name,Address and Tel.No.
iga ti r, A4
Type of Building:
Dwelling No.of Bedrooms 1— Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow y gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or terations(Answer when applicable)
ov _
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 provisionsaf 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issti d by th s Board of H h.
Signed - Date tU
Application Approved by .5
Application Disapproved for the f owing r sons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS,
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site.Sewage Disposal System installed I or repairgd/replaced(4-fon
f4gVt- by or— iJ,v /po for U/?,CdUJ
as has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated i'0- 25--
Use of this system is conditioned on compliance with the provisions set forth below:
No. 17
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mie;paal *potem Con!5tructton Permit
Permission is hereby granted to LJ U> ���K�
to construct( )repair(—•)an On-site Sewage System located at ? e �!/
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.
p Date: l(2 Approved by
�`