Loading...
HomeMy WebLinkAbout0049 WHITE OAK TRAIL - Health 49 WHITE OAK TRAIL, CENTERVILLE A = 191 043 UPC 12534 No.2_153LOR � HASTINGS, MN No. 19L 1 0/ pA�SpS/E�S�jSOr/W,1111fY N� g< / `{ Fee G f� YARCELVO= / r v 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Mi!6pogar *pgtem 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. ThIc Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. s/2ea 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) ad 4:�-4,0WE 7'® ?�7''/e 4/' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health Signe Date .J(� %6— Application Approved by Application Disapproved for the following reasons Permit No. / _ Date Issued �d ,t. 9-C_ 492 I l � / 30 No. `3 V' �� °. Fee HE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS A 01pp ication for Xh6pooaY *pgtem Con!5tratton 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. T, �i9 Ar 1je.4 , / � /11 el/2 S •-7 c Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.. 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) &�,'iE24' -;iAc 7-0 7-/ T 1/,P l/ /`$'O as-r © Z?o X S i.y..� '/titer ry 2S 3 ' STa .ate L Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore desc� tr•.bed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Healt _ Signe Date Application Approved by Application Disapproved for the following reasons Permit No. / Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that thq On-site Sewage Disposal System installedA )or rePaired/replaced)on by /I G� 7— for E A' /,T14,/2 4 Y as y 6d 10 J rr ©0/? 'TEA I` �� ,, 9 d ha lien constructed 'n acc rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. J dated .z>a . Use of this system is conditioned on compliance with the provisions set forth below: �o No. 92 s� ti Fee 3� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS =igpoal *proem Construction Permit Permission is hereby granted to /J��f,e to construct( )repair( an Op-site Sewage System located at �N Tl� �i ry //?�► i � r ..,76/Z / Ac% and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: Approved by r �4� CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) —.3"A&l f hereby certify that the application for disposal works ' construction permit signed by me dated 3d( 5 , concerning the, property located at meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are norprivate 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. SIGKB / DATE: O --34Z LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. CONI-fO ALTH OF MASSACHUSETTS E ECL?TI« OFFICE OF EN IRONv ,.IENTAL AFFAIRS �= DEPARTAdENT OF ENVIRONMENTAL PROTECTION .-.- �� ONE'WINTER STREET, BOSTON NIA 02106 (Fli) 292 ab01:) TRUDY CORE Secretary STRUHS ARGEO PAUL CELLUCCI ` C . sioner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r 9 '^�t3'2 �q CERTIFICATION �w LOT Property Address: V6 I (y� ��it� Nartae of Owner —` Z 9y(` � q �, ddress of Owner: Date of inspection. 1 I�- f Il./, / � � ``/� �` ,l9 'rs Nance of Inspector: (Please Print)/� Clr 3,Da�G iT�C? _ 99. 1 em a DEP opprovedl/sy`�stem Inspector pursuant to Section IS.340 of rrde 5{310 CENR f 5.0009 !! compsiny Name: A&�� - -- L!a err a. +CA i N Mailling Address: d c.1 3 3 _ G 83'SL� "-- 4-c`7 Talaphotta Number: �� ,�-44 91 Z WTIFICATION 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-sits sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By Loc Approving Authority .�. Fails Inspector'2 signmre: Date: - The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)w(thin 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. NOTES AND COMMENTS revised 9/2/99 Pagel of11 IDPrmied or Recycled Paper f' 1 SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART A e ' a '�^ CERTIFICATION Jeontinue�d) %roperty Address: "1 I W 1/1 t {-c- 00 — Jwner: Date of inspection: / (VI G INSPECTION SUMMARY: Check A, 8, C, or ®: A. SYSTEM PASSES: A, I have not found any information which indicates that any of the failure conditions described In 310 CMR 16,303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: — ---- ----^--- B. SYSTEM CONDITIONALLY PASSES: One or more system components as described In the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty 120) years prior to the date of the inspection; or the septic tank, whether or not metal,is 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more then four times a year due to broken or obstructed pipelsl. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of inspection: I C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 3101 CMR 16. 3(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AN HE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 31 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER S LIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND S ETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system ISAS)a the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and t SAS is within a Zone 1 of a public water supply welt. The system has a septic tank and soil absorption system and a SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system an the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for lifo►m bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the Ores ce of ammonia nitrogen and nitrate nitrogen is equal to or less then 5 ppm. Method used to determine distance (approximation not valid), 3) OTHER revised 9/2/98 Psge3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART CERTIFICATION l(continued) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: you must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in/31The basis for this determination is identified below. The Board of Health should be contacted to determine wry to correct the failure. Yes No Backup of sewage into facility,or system component due to an overloaded o t:logged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface aters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or availabl volume is less than 1?2 day flow. Required pumping more than 4 times in the last year NOT d e to clogged or obstructed pipe(s). Number of times pumped,. Any portion of the Soil Absorption System, cesspool o privy is below the high groundwater elevation. Any portion of a cesspool or privy.is within 100 fe of a surface water supply or tributary to a surface water supply. _ Any portion of a.cesspool or privy is within a Z e I of a public well. _ Any portion of a cesspool or privy is within 0 feet of a private water supply well. _ Any portion of a cesspool of privy is les han 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If t well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic co ounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each o the following: The following criteria apply to large Sys ms in addition to the criteria above: The system serves a facility with a sign flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environ nt because one or move of the following conditions exist: Yes No the system is wit ' 400 feet of a surface drinking water supply the system is thin 200 feet of a tributary to a surface drinking water supply _ the system located in a nitrogen sensitive area finterim Wellhead Protection Area-IWPA)or a mapped Zone It of a public water su ly well) The owner or operator of ny such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the Focal regional office of the Departme tot further information. revi ed. 9I2I98 Page 4ofII r s . SUBSURFACE SEWA GE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address- Owner: Date of inspection: Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: s No Pumping information was provided by the owner, occupant, or Board of Health. �( _ None of the system components have been pumped for at least two weeks and the system has been receiving"ermal flow *1 rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. XAs built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. Ali system components, excluding the Soil Absorption System, have been located on the site, 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. t The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. !! Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) _ The facility owner (and occupants,if different from owner) were provided with information on the proper mzlnt4waaza-0f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION $roperty Address: Owner: Date of Inspection: '1 C, �qC, FLOW CONDITIONS RESIDENTIAL: Design flow: g•p•d./bedroom. Number of bedrooms(design): Number of bedrooms (actuaf):(� Total DESIGN flow Number of current resi ants: a Garbage grinder(yes or no):Ask Laundry(separate system) (yes Of nol:�: if vas, separate inspection required Laundry system inspected► no) Seasonal use(yes or no): Water meter readings,if available (last tw ar's usage tgpd). Sump Pump oyes or no):4t� Last date of occupancy: z-,�„e 'v S COMMERCIALANDUSTRIA L: Type of establishment: Design flow: od ( Based on t 5.208) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no),_ Non-sanitary waste discharged to the Title 5 system: Eyes or no)! Water meter readings,if available:_ Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of i forMeon� �}S System pumped as part of inspection: (yes or no)_.&� If yes,volume pumped: gallons Reason for pumping: Tlfp�Of SYSTEM Septic tankldistributiort box/soil absorption system Single cesspool Overflow cesspool Privy yes, attach previous inspection records,if any) Shared system(yes or no) (if I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank ,--Copy of DEP Approval Other cc c P 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 9/2/98 Page 6(of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address-M' txAJt OG.. Owner: III Date of Inapectlon: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:li,cest iron_&,40 PVC_ other{explain) Distance from,grivate water supply well or suction line Diameter (A 4— Comments: (condition f jobs, venting, a idence of leakag ,etc.} SEPTIC TANK: (locate on site P n) Depth below grade:121,4 metal_Fiberglass _Polyethylene_other explain) Material of construction:Xconcrete It tank is metal, list age_ Is age confirmed by Certificate of Compliance (yes/No) Dimensions: Sludge depth:. ,a►r 2�( ffler Distance from top of sludge to bottom of outlet tee or ba Scum thickness:,_ Distance from top of scum to top of outlet tee or baffle;_ I L Distance from bottom of scum to bottom of outlet tee r baffler_ Flow dimensions were determined: :omments: (rocommendation for pi , condi ion o 'nl and out t tees or baffles, th o�liquid level in relapm outlet inv rt, tructuralimta nty, evi nce o ieakege,etc.) et ch' 1� GREASE TRAP: (locate on site plan) Depth below grade:,. Materiel of construction: —concrete metal Fiberglass _Polyethylene_other(explain) Dimensions: 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: Date of last pumping: Comments: Ion of inlet and outlet teas or baffles. depth of liquid level in relation to outlet invert, structural integrity, (recommendation for pumping,condit evidence of leakage,etc.) _ revised 9/2/98 Pane 7 of i t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirwed) Aroperty Address: Owner: Dsrte of Inspection:��2A TIGHT OR HOLDING TANK:�(Tank must be pumped prior to, or at tirrie of, inspection) (locate on site plan) Depth below grade:__ ,concrete metal _Fiberglass_Polyethylene potheriexplain Material of construction: Dimensions:_ Capacity:.gallons Design flow: gallonstday Alarm present Alarm level:____!_Alarm in working order:Yes No, Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan! C _ Depth of liquid level above outlet invertl-t u Comments: (no a if level and distribution is ual, a 'donee o4 soli s c rover, evi once of I age into or out of bo . etc��� 7 1� A pLIMP CHAMBER:•a— - iiocate on site plan) Pumps in working order: (Yes or No) Alarms In working order(yes or No)_— Comments: {note condition of pump chamber,condition of pumps and appurtenances, etc. Page 8of 11 revised 9/2/98 IN SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continuedi bopertY Address: ownw.. Date of Inspection:,y c� SOIL ABSORPTION SYSTEM(SiASI: (locate on site plan,if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:, leaching chambers, number:-5,,N'C-t� 5 VC4-5' leaching galleries, number:_____ leaching trenches,number, length: _ leaching fields, number, dimensions: overflow cesspool, number: Alternative system: — Name of Technology: Comments: (note co dot on of soil, signs of hydraulic failure, level of po ing, damp soil, a nditian c4 vegetation, etc f CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert:__ Depth of solids layer: )epth 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 (locate on site plan) Dimensions: Materials of construction; Depth of solids; Comments: (note condition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Papc9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART C SYSTEM INFORMATION (continued) 'roperty Add►ess:M ,�� �(� )wrw: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) O n� P r Pal;r 10 of f 1 revised 9/2/98 TOWN OF BARNSTABLE 1:Gi:A'.ON 'AC` U3\r\t VC. CIDAL S.- SEWAGE # V,I:,),:GE CKA3�-t"` ASSESSOR'S MAP& LOT oqz INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IS 0- 2 LEACHING FACELrrY: (type) ���\ 1 iL�\c��(l,C (size) ioX 3 NO.OF BEDROOMS BUILDER OR OWNER FP.QATE: t \, �/p COMPLIANCE DATE: Z 9 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet} Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wcdand aad Leaching Facility(If any wetlands exist within 300 feet of leaching facility) A Feet Furnished by �� L\C\ 6 1F pa, A,3- 9V TOWN OF BARNSTABLE LOCATION <1i i�' /�}y� �2 A i SEWAGE # S L 17 VELLA E G� �✓i L 2 y1 1 `e ASSESSOR'S MAP&LOT/ INST �ALLER'S NAME&PHONE NO. ,4k G/y / `3 SEPTIC TANK CAPACITY 5 ©D G14/4 LEACHING FACILITY: (type) TP 2--s (size) '-/0 ?C a NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 81- V LS MPLIANCE DATE: '^' --3 0— Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � I �b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ropedy Address: '49 (jktT--e- ,, 0jk*--'— Owner: Date of Inspection: MRCS Report name Soil Type Typical depth to groundwater USGS Date wabsite visited Observation Wells checked Groundwater depth: Shallow — _ Moderate _Deep__ SITE EXAM Slope NCB Surface water P C) Check Cellar a.( Shallow wells` tF} Estimated Depth to Groundwater',"`Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc,) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Y Used USGS Date Describe how you established the High Groundwater Elevation. (Must be completed) o ®� U�S UOS UQN)r, � ra�c It of u .revised 9/2/98