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Home My WebLink About0035 WHITE OAK TRAIL - Health 35 WHITE OAK TRAIL, CENTERVILLE A 191042 UPC 12543 ti NO 'DOST CON'N�� MASTINGS.MN i Fee 40.00 No. THE COMMONWEALTH OF ASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS E C,. 01pplic tion for MizpooaY *pgtem QCongtruction Vermit Application is hereby made for a Permit to Construct( )or Repair(X )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 35 VMte C ak 'frail Lisa Bayitrtxi amtervi-Lle 7904742 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Pcbirsm Septic Servi( P.O. BOx 1089 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder 00 ) 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 sand Nat�lre pg Repairs or Alterations(Answer when applicable) lrstal l a 1,500 gal septic tank, d�c 9 '1'1t1e 5 leadtrarh. 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 Environmen 1 Code and not t place the system in operation until a Certifi- cate of Compliance has been issued by this oard of It Signed Date S�_Oz� Application Approved by Application Disapproved for the following reasons Permit No. Date Issued ——————————————————————————————————————— r '• ra fL�� 40.00 Fee -THE COMMONWEALTH OF ASSACHUSETTS� G�.'J> PUBLIC HEALTH DIVISION -TOWN OF BARN:STABLE, MASSACHUSETTS- � v i 0(ppYication for Migaal *pgtem Congtructton Permit Application is hereby made'for a Permit to Construct( )or Repair(X )an On-site Sewage Disposal System at: Location AAddresssoorr Lot N�o. Owner's Name,Address and Tel.No. 790-4742� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Food s i Septic Swdm P.O. B3C 1089 Type of Building: w Dwelling No.of Bedrooms__ 3 Garbage GrinderW ) 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 p irlstall a 1,500 cpl. septic tmi,, d-x Nat�� Re �r��tions(Answer when applicable) 55 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 Environme l Code and not t place the system in operation until a Certifi- cate of Compliance has been issued by this oard'of al ; � � Signed Date (� Application Approved by S Application Disapproved for the following reasons: . Permit No. Date.lssued `\ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH.DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Comphance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired replaced,(X )on b W.E. —ternseptic Servim for ?M F Wald as 35 Ot Atte �iYail -� has been constructed in accqgjance with the provisions of Title 5 and the for Disposal System Construction Permit No. -^Z04r dated,.. Use of this system is conditioned on compliance with the provisions set forth belo .—. �=. No. 91 '-2 �� `' tl Fee 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS x1i9pogal *pgtem Congtruction Vermtt Permission is hereby granted to W.E. rcdxmm septic servim to construct(` )'repair( X)an On-site Sewage System located at 35 tr+t im-oaak Tatil Qarbmrl k 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 mu t be com leted within two years of the date below. Date: Approved by ti CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, L��w.� , hereby certify that the application for disposal works construction permit signed by me dated 6 —A 6 9 4 ,concetriing tart property located at ICU 4 1 F� (�-b f`� �l �' �' m >t1l 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 I • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. ij t )i '. rix '`r 'J k 96 SIGNED: l Cz DATE: UMB LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. J { 1 } � t u .. � �� ,� � , '� 9 � � ��)L ti i i Commonwealth of Massachusetts , Executive Office of Environmental Affairs Department of Environmental Protection Vc William F.WeW ,. Trudy Coxe co Argw Paul Celluccl ILL Gowernor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 04 A- 77-,4 i PART A CERTIFICATION Property Address: Address of Owner. Date of Inspection: (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. 5 0 8 ) 7 7 5—8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT I certify 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 and experience in the proper function and maintenance of on-site sewage disposal systems. The system: - ��aasea _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority — Fails Inspector's Signature: 1 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 sent to the system owner and copies sent to the buyer, if applicable and the approving authority. IN ECTION SUMMARY: Ch A,B, C,or D: A] TEM 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.' B] TEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. In to 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 exfltration,.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. (rev sed 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-SM '10?Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION(oontinued) Property Address:.S /� ��- p,o.� T/,9i Ce tom/ Owner. L / /mil q>/1no za Date of Inspection: 5_; _9 L B] TEM CONDITIONALLY PASSES(continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pips(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 pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C1 FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require flirther 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. 2) 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 ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil 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 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 ppm. 9) THER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION(oontinued) Property Address: _3 S Owner. 1'1 J/f R 41,rnoyJ Date of Inspection: fAq-0 DI YSTEM 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 clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 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. El LAR E SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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!till compliance with the groundwater treatment program require nts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addrom 3 ,- U A i ;�e 0..9 k i/19; Owner. /S i3 /��9�/�yto✓�%� Date of Inspeotion:S L Check if the following have been done: ✓lumping information was requested of the owner,occupant,and Board of Health. _L�None of the system components have been pumped for at least two weeks and the system has been receiving normal now rates during that 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 if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _L,4%e system does not receive non-sanitary or industrial waste flow l Ae site was inspected for signs of breakout. �//ll system components,excluding the Soil Absorption System, have been located on the site. _VThe 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. The size and location of the Soil Absorption System on the site has been determined based on existing information or ZThe appro by non-intrusive methods. facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C `` SYSTEM INFORMATION Property Address: G VA k +,CA ( CC w F&xV1•f le- Owner. -- A (ZAI&I oOl > Date of Inspection: S/ag/96 - FLOW CONDITIONS RESMENTIA U Design flow: 011ons Number of bedrooms:. Number of current residents:_At*3 Garbage grinder(yes or no): /L-o Laundry connected to system(yes or no):_,'�r_ Seasonal use(yes or no): /L v Water meter readings,if available: Last date of occupancy: L—2'�—g COMMERCIAL/INDUSTRUL- 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 of information: System pum,14d as part of inspection: (yes or no)_A,-d If yes,volume pumped: gallons Reason for pumping: TYPE O YSTEM 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: A, Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addresw 35 W�\% 6 otA k 4t204( cNw�c-2vt`�l� Owner. LiS,,� yrtko Date of Inspection: 51�gl�r6 SEPTIC TANK:_ (locate on site plan) ,t Depth below grade:_L_l / Material of construction:_Vw crete_metal_FRP—other(explain) ,! 66 Dimensions: /U Sludge depth: O Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: b Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: B 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.) -_ 1'1-S 1`.4/4 P/ 5' Q L G E TRAP:_ (locate n site plan) Depth be w grade: Material construction:_concrete_metal_FRP—other(explain) Dimensio Scum from top of scum to top of outlet tee or baffle: from bottom of scum to bottom of outlet tee or baffle: Commen ( dation for pumping,condition of inlet and outlet tees.or baffles,depth of liquid level in relation to outlet invert,structural integrity, eviden of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 V A, 2� 4fI /< %r19 Owner. 1�"91 m'wv Date of Inspeotion:.S a 9^ e G TIGHT OR HOLDING TANK_/ (kxx atte on, ' plan) Depth below Material of n:_concrete_metal_FRP_other(explain) Dime Capacity: one Design flow: ons/day Alarm level: Comments: (condition of' tee,condition of alarm and float switches,etc.) 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,etc.) PUTiworking BER:_ (loplan) Pu order:(yes or no) Co(no of pump chamber,condition of pumps and appurtenances,etc.) LU (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION(oontinued) Property Address: 3 S' (,tJ/1 i � O.vK Td'/52 Owner. �-/S fI Date of Imp sotion:S`� 9 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:_ leaching chambers,number:_ leaching galleries,number: leaching trenches, number,length: `h 4[ 'Z' �, a leaching fields,number,dimensions: overflow cesspool,number: , Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) CESSPOOLS:_ (loca site plan) Number configuration: Depth-top liquid to inlet invert• Depth of so layer. Depth of layer: Dimensions f cesspool: Materials of construction: Indication o groundwater: (cesspool must be pumped as part of inspection) Comments: ( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: (locate on site Ian) Materials of co ction• Dimensions, Depth of solidr Comments:(note ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) g ' I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' V AG I 5,v s °l �I r� Jl�;C( DEPTH TO GROUNDWATER Depth to groundwater:_�� feet 8 I method of determination or approximation: �j r (Orevised 11/03/95) 9