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HomeMy WebLinkAbout0983 SHOOTFLYING HILL RD - Health 983 SHOOTFLYING HILL, CENTERVILL A= 191 032 //// aEcra fo llll � UPO12SA3 Aloes HASTING81"N r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPftTION FORM Address of property Owner's name Date of Inspection -7 -1-7— S' i PART A CHECKLIST check if the following have been done: Pumping information was requested of the owner, occupant, and Board a- Health. ._ZNone of the system components have been for at 1 pumped east 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. As built plans have been obtained and examined. Note if they are not available with N/A. ,t,�The facility or dwelling was inspected for signs of sewage back-up. of Thesite was inspected for signs of breakout. All system components, excluding the SAS, have been located on the 1 V . The sep is �Anmanholes 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. V/ The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. �he facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. �tj �, �`99 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current resident A10 garbage grinder, yes or ,y- laundry connected to stem, or no t/b seasonal use, yes or If nonresidential , calculated flow: Water meter readings, if available: dap Last date of occupancy GENERAL INFORMATION Pumping records and source 7-2 information: -.2-7- 88 -,i7 v �- y- 92 _ System pumped as part of inspection, yes or if yes, volume pumped 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. Source of information: �1 8 t-7 Sewagq�,odors .detected when arriving at the site, yes o� 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (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, recommendations for repairs, etc. ) DISTRIBUTION BOX: �o (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, recommendation for repairs, etc. ) PUMP CHAMBER: O (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued 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. leaching pits and number leaching chambers and number leaching galleries and 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, recommendations for maintenance or repairs, etc. ) 0� CESSPOOLS (locate on site plan) : number and configuration 3 depth-top of liquid to inlet invert fn '� 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) A10 Comments : (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) PRIVY: ( 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, recommendations for maintenance or repairs, etc. ) r F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes , no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static. liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 da: flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? ies-s. 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 analysi, for coliform bacteria, volatile organic compounds, ammonia nitrogen and. nitrate nitrogen. 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE 71 _SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' DEPTH TO GROUNDWATER Y//o ex depth to groundwater method of determination or approximation: TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION -TYPE OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS ASSESSORS MAP, BLOCK AND PARCEL # Q OWNER' s NAME ed-&& 12 EgS4 a� .......... PART D - CERTIFICATION NAME OF INSPECTOR COMPANY NAME 4 e COMPANY ADDRESS treet Town or City State LIP COMPANY TELEPHONE (5-D 0 ) 779 Cc)-V? FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system a this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on site sewage disposal systems . Check -one, System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED The inspection which I have conducted has found that the system fails t protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this in ction form. Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. If the inspection FAILED, the owner or­o perator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.dc V TOWN OF BARNSTABLE LOCATION 3 Si ,T r % / SEWAGE # $' VILLAGE ASSESSOR'S MAP Cz LOT Lg/ INSTALLER'S NAME & PHONE NO. , SEPTIC'TANK CAPACITY F., z LEACHING FACILITY:(type) ia.-y- (size) e NO.>OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER�ti1. DATE PERMIT ISSUED: DATE: : COLIPLIANCE ISSUED: ; li - g 7 VARIANCE GRANTED: Yes No c� O 0 04 bzT C9 b # -� r 1 ! TOWN OF BARNSTABLE LO .ATION ,3 SEWAGE # ;?7 fd VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) / (size) NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 9•- /f L9 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1. ;5 0 ��.� �� �� b �'h i �; TO WN OF BARNSTABLE LOCATION 3 S T =, ;`''` 7l / SEWAGE # 8'-2^ 9 VILLAGE ASSESSOR'S MAP 6z LOTJ4'f - INSTALLER'S NAME Sz PHONE NO.a, ,f, /" SEPTIC TANK CAPACITY 'pr LEACHING FACILITY:(type) 1 j'T'" (size) M _-- . ; NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 9 7 VARIANCE GRANTED: Yes No J BOARD OF HEALTH Application is hereby made for a-Permit to Construct or Repair an Individual Sewage Disposal System at: A Location-Address or Lot No. � 'wnerA""�� --'--'-----------'- ................. _________ _ z=mx� �«dr"ss Type of Building Size feet --}�o c6 ���� ( ) �r���x Dwelling ^ ~ ^ \ 914 Other—Type of Building '________ No. u6 persons............................ Showers ( ) -- Cafeteria � \ Deaign Septic` --- Liquid -',--y--`--g---- Length.... ~--- ''-----�---- Diameter -~r~^~^~-a^ >, Seepage Pit .... Diameter.......A0 Depth below .... Total leaching area.128-5�. ft. Z Other Distribution box (X) Dosing tank ( ) '- Percolation Test Results Performed .................... Date...... -_- 1.4 1.4 Teo Pit No. l.--�c��-m6nz�o per . Depth of Tee / De�� »n orouod / -/:7:=-_- �� Test Pit No. 2_-.'�- per inch Depth of Test Pit'._tc..... Depth to ground watec.-����_--.. 04 0 U Nature of Repairs or '`tera"""" Answer= when applicable.. ------------'--'—'------'-'-''---'-----'--'--'-'------ NST AL ��0�`*���*�p�-��'���+=��_-_ A��eeo�cot' THE SYSTEM WAS INSTALLF-D IN STRICT ApplicationThe undersigned agrees to install the aforedescribed 1nqL3b�AEkKjW ystem in accordance with the provisions of T ITAUE 5 of the State Sanitary Code— The undersigned ther agrees not to place the system in operation until a Certificate of Compliance has been iss I y t e board f i Ith ate - - Disapproved for the following~, reasons:........................................................................................................---- Date Permit ^ ~ ate THE cOmMomm/EALre OF axAssACeusErTs ` ' TOBOARD OF"HEALTH °���' ' --'---_'-'-_--K���---' � T~° �� °~°=°~~°~ °~° T=.°°°p°°~°°°°e That the Ind,*vidual Se rage Disposal System constru oy.................... ' m� �-°n � _1~�b/ ire "t t ' No.......».. -----j» Fxa..........................» ' THE%COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ............. '.I OF...... ....:��-•sl-.;.,�t F ......................t Annl ration for U snusttl World Tonstrurtion jJprmit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: ................... ..•.:. 1 ::» ::.. ................. » •.,� lt �.�1 ............................. Location-Address or Lot No. ..... —1 .. �....... •fin.t^-�.................................. ....••---......................•........... .......-•-•--•---............................. _•» ..» Owner Address a ....� t v ............ ...•-.. ..................._._.. ----•-•......--•---...... .......-•--•-..........••••-•-•-•••-••--------•••--••............................................. Installer`'y U Address Type of Building Size Lot!�kR..�-9.-•S=.z......Sq. feet V Dwelling—No. of, Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p`l4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a'' Other fixtures ...................................... . . . W Design Flow.........f g:.1 . 'i`._'................gallons per person per day: Total daily flow............���-�-'..��............gallons. WSeptic Tank—Liquid capacity.t��y?..gallons Length......1-2.... Width:..�q:'0'.' Diameter......""'=.... Depth. .'Sz.... x Disposal Trench—No..................... Width.................... Total Length..:..::.............Total leaching area....................sq. ft. 3 Seepage Pit Diameter.......t.?....... Depth below inlet... Total leaching area..!.:5.sq. ft. Z Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed by... =....= �� :.� .:. '•' :_.................... Date..........:Zb2.���a 1 !.::� . ............. 1 Test Pit No. 1....G ...minutes per inch Depth of Test Pit.......`7....... Depth to ground water......-..~............. Li. Test Pit No. 2-----G.r minutes per inch Depth of Test Pit........! �...... Depth to ground water........................ fyi ............................................................................................................................................................ O Description of Soil!}.����. �7?� t= '� rOl_ �1A.t 1 hF� `a.. •�t�1 ....................................` ..... ..•••-- --- x .......• {._...... .. - .....----................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------•-------------------•--------.............-•-•..--••......••-----•-•...........••--•-...............--•••-•--------••----.........--•---.........................----•-••..•••---............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:ITLZ i 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 a board -health. Signed....: sZ ApplicationApproved By.......:. ... : .....:. �� ....•--.........._................... ...........................1./.....Da..t.te............... Application Disapproved for the following reasons:.................................o.............................................................. ................Permit No.. -•----...-----..........-•-----...._..-----------=•--...---....c---•--•-••,---•---- Vct/gIssued...------------ 7....D�._--..--..._ Da �. Yi •-�•-• --..._6..-w.-�.-..��..^-�-+rr.-�.� ....- e-..+-r-^r n+.-•r-�.�•�.-.r.-�r-.•-r w.--�-.u-w..-. .r..w r. +.w.ej .-.s+.e_-a s^.s..r-.-.--.-...-. THE COMMONWEALTH OF MASSACHUSETTS --"BOARD OF _HEALTH . J C7w � ....OF..... ...... ........................ (Irrtifuttte of Tomplittnrr THIS IS TO-CERTIFY, That the Individual Sewage Disposal System constructed ( �) �Raired by................::�t _ .-- at.......................... » �� 'Installer ! s-��=�[ ►c- c),, i (-, e 't.......................... ---------------•- .....r......................"....-----------••....-.-----._...............-••--`•••'•----- has been installed in accordance with the provisions of TITI,/ 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.....•.............................................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -�7L ........................ ... .. OF...................c :,`, =�..................................... No....:.................� `1 FEE... ........... Disposal Iforks Tonstrurtion f rrmit- Permission is hereby granted.................: . )I 1 n\�`r c Q ......_..... ..................... ........................ to at Construct ( )-or Repair ( ) an Individual Sewa et Disposal 'System I,,,, I Z r- � � -�-�11 .vt r� r ✓e,- .--•-•--•---.....--••...............•--•----.............---•........................ - Street �r, (� as shown on the application for Disposal Works Construction Permit No..................... Dated...........q/,9/;9 ............................. :...:... Board ............................................... / d of Health DATE...................•-- _r= ............................... 362-4541 926 main street rt 6A ' yarmouthport mass. 02675 down cope engineering civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys November 2, 1987 site planning sewage system Board of Health designs Town of Barnstable South Street inspections Hyannis, MA 02601 Gentlemen: permits On October 28, 1987 Down Cape Engineering inspected the septic system on Lot #1 Breeds Hill Road, Hyannis. The construction complies with the Massachusetts Environ- mental Code Title V, the Barnstable Health Regulations and conforms to Down Cape Engineering plan #87-317 dated August 8, 1987, prepared for Independence Park, Inc. The location of the septic system varies in relation to a shift in building location. Please see enclosed "as-built" plan. Very truly yours, Arne H. Ojala, P.E. Inspected by: M. F. McDonough amp/31 Encl. AGE b f C LL l 0 5�or� 1".-7 ± 45, � c A (2.oCe Ac. i W ` W a i - IE�SE^�►� ,rT v;c . J 24P E. �O \ ,sr — F-J,L,T/ 10-Zg-57 Jae 87-317 CERTIFIED PLOT PLAN' LOCATION: BREEDS HILL RD . BARN . PREPARED FOR.- SCALE: 1=60 DATE. 9/29/87 REFERENCE: pB 438 PG 1 INDEPENDENCE PARK INC . I HEREBY CERTIFY THAT THE BUILDING SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. BUILDING CONFORMS TO SETBACK REQUIREMENTS OF THE TOWN WHEN CONSTRUCTED. ARNE down cape engineering aALA 026SW L G JLANDSJRVEYORS Z1 -7 i _ ROUTE 6A YARMOU T H MA DATE P.EG. LAND SURVEYOR EE �3 I _r ''GCS^^•.« -_. ..`"__-w-«... .~ ` _. \ \ ``'."\.. 1<� r .�,r L i .f 'mow. '•+. \ ( Cv •1G " i 1 G r�- =tots_ 4 t�"1 ,cA 1 t'jL'FT -fv. 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