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Home My WebLink About0050 WHITE OAK TRAIL - Health 50 WHITE OAK TRAIL, CENTERVILLE A= 191 047 //// �REcrnFo�o UPC 12543 No53LOR RAS?INOS,MN No. ` .3 l Fee 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Xuooai *potent 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. 1 Q i (� Owner's Name,A dress and Tel.No. Assessor's Map/ParcelP4Fz-V\1 dress `^y 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 Soils ka � Nature of Repairs or Alteratio s(Answer when applicable) 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 a not to place the system in operation until a Certifi- cate of Compliance has been is this Bo Signed Date a5 j! Application Approved by ' Date Application Disapproved for the fo owing reasons Permit No. 7 lv 3 if Date Issued No. WO` 3 y L_ Fee y THE COMMONWEALTH OF MASSACHUSETTS V. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z[ppYtcatton for Mtopogal *pztem Con.5truction 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,gdre�d Tel.No. 14 Assessor's Map/Parcel 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) /5M St-Tr 10-6 CY —TV'o 919t1C T 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 an not to place the system in operation until a Certifi- cate of Compliance has been issue this Bo "dam S gn Date ed Application Approved by ' Date -3 - Application Disapproved for the fo owing reasons Permit No. 9;/0 - 3 t!+-/ Date Issued —--————————————------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certtf tcate of Compliance S TO CE.�,that the On-site Sewage Disposal System installed( �j or repaired/replaced( )on by �.�.' Installer , ,, .-- at ^ 6 W -A r` 0WV_--X--t r.-A C ,._ < ,er-t�'v�+� Chas been constructed in accordance with the provisions of Title 5 and the for Disposal System Constructio r,21mut No. ated 7 Date / Inspector f THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. ——————————————————————————————————————— No. `? ,. 1 t/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpo.5al *pztem Conotruction permit Permission is hereby granted to G oA-r I R�_� to construct( )repair( 4 an On-site Sewage System located at No.# �J ��'�� . CJ+4- '�4�• Street and as described in the above Application for Disposal System Construction Permit. 91,_2 t No. Date 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 three years of the date below. Date: - Approved by Board of Health 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 -7- aS (0 , concerning the property located at 60 tjl�r\-e-c ft�-: CL1% 4e-e`;Xz' meets all of the following criteria: 1 • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the posed ro septic system p • 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. i i SIGNE DATE: . :�S LICENSED SEPTIC(/YSTEM 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]. TOWN OF BARNSTABLE �L LOCATION, ` �� 6,j� 'P�// SEWAGE # VILLAGE Cem6e211//f_ ASSESSOR'S MAP & LOT 91- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACEL=: (type) /te,4C/7 (size) 6oX q, . NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: `" "0�5 COMPLIANCE DATE: - 7010 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 le g f ility Feet Furnished,by ��t'� a 3_1 g 3 Q 1 .11' C I _ Ca &AR ReAA �- r ,r f �V/ TROY WILLIAMS SEPTIC INSPECTIONS �Wv49�� Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass ver Road South De ,MA 02660 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WilliaGommmr F.Weld o Trudy Cox* Arpso Paul Csllucci S—Vt" LL Go emor David B.Struhs CamJwbnar SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION Property Address- 5 A 0 h-)LG U w/- (e . Address of Owner. JaLn o u( EIA.4� NLv I L . Date of Inspection: 5 12 X t/f G (If different) Name of Impectot►rro yy Company Name,Address afid Telephone Number. SL f__ C' 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: _ Passes Conditionally Passes _ eeds Further Evaluation By the Local Approving Authority Fails Inspector's Signature I n J -Yra Date.- `�j' G✓ c .' 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. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: Al 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] SYSTEM CONDITIONALLY PASSES: N/4 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) The septic tank is metal, cracked- structurally unsound, shows substantial infiltration or exfiltration, or tank faihtre is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tarsi as approved by the Board of Health SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5G w 4 4--,- Owner. Date of Inspection: fZ /9,4 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 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 CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /✓t14 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 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) OTHER (revised 11/03/95) 2 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 (t) 6.,j-L Owner. A/ c u, �� e Date of Inspection: c5 �.2tr/9� 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. YBackup of sewage into teeility or system component due to an overloaded or clogged SAS or cesspool. NDischarge 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 t 6"below invert or available volume is less than 112 day Row. (,lJc�.�l-L✓ leu-1 �.i-dt �0 � G S- c . - 1-0'�- i o,v-c Y f- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped AZ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. -LI Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Al 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. -A-1 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 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 U 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 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECEUST Property Address: So Owner. /JGu 1 Date of Inspection: yG 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. N�4 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 system does not receive non-sanitary or industrial waste flow ✓//The site was inspected for signs of breakout. 1/All 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. _JZThe 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 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: 56 Owner. Date of Inspection: RESIDENTL&L ( FLOW CONDITIONS Design flow: 330 vallnna Number of bedrooms: 3 Number of current residents: Garbage grinder(yes or no):'6,y '.sundry connected to system(yes or no):yC 5 Seasonal use(yes or no): lzVo q Water meter readings, if available: Last date of occupancy: COMMERCIAL/INDUSTRiAI• ,(/�iy Type of establishment: Design flow:______.pUona/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yea 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: - I � I ti o�+. L,, a w ti Sy�m Pumped as part of inspection: (_yea or no) . If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool ZOverflow 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) A/o (revised 11/o3/95) 5 TOWN OF BARNSTABLE LOCATION 5) SEWAGE# V;LLAGE Cc F ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: 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 (rri t��. �. 3z s� L � yZ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address 56 Owner. Date of Inspection: SEPTIC TANKNIj (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: 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, evidence of leakage, etc.) GREASE TRAP-_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—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: 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 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: -5 U Owner. At f-01 I( c Date of Inspection:S /a s'/f e TIGHT OR HOLDING TANK Y/� (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity:- ¢allons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX /Y//9 (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.) PUMP CHAMBER:_,�k//� (locate on site plan) Pumpe in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: Se) LJ 4' Q� Owner. h 1 e�j '/1 Date of Inspection: / 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: Ong pit:, number:_ leaching chambers, number:_ leaching galleries, number. leaching trenches, number,length: leaching fields, number,dimensions: overflow cesspool, number: Oc-.L Comments: (note condition of soil, s' of hydraulic failure, level of ponding, condition of ve tatio etc.) 6 t , �., r.1,�uiJ 1, c_ `1✓��- r1' �,.ti, v� i n Sr�t �� e� i CESSPOOLS:_✓ (locate on site plan) Number and configuration: Ukc. 0%,j Depth-top of liquid to inlet invert:_ / a 5o y � Depth of solids layer- Depth of scum layer: Dimensions of cesspool: k Materials of construction:__ Indication of groundwater: N6/V� inflow(cesspool must be umped as of inspection) Lj �Jt ✓c- �w ,A S I C., Comments: (note condition of soil, signs of hydraulic failure, level of n po ding, condition of vegetation, etc.)) �,1L✓t y+o V.lo✓�.H -f"D -1- w of 6 cows vt y PRIVY: �//-/ (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/955 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S Owner. Neu t Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: Indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �' 3a ' 63 bc3t✓��dc,J GGS}��C• DEPTH TO GROUNDWATER Depth to groundwater: feet adjusted high groundwater level method of determination or approximation: US /� G.��.+ .,,, J-c �,h s S o�✓ �. �,: s/, yra�kl --A L C{ 9