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Home My WebLink About0084 BASSETT LANE - Health `84 Bassett:Lane Hyannis �\ o 0 0 0 7 OWN OF BARNSTABI i L'OCATION SEWAGE# I VILLAGE ASSESSOR'S MAP&PARCEL309 a35 INSTALLER'S AME&'PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BE OOMS - OWNER PERMIT DATE: COMPLIAN E DATE: V'ACA�et pS a 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 Wetland and Leaching Facility(If any wetlands exist-within 300 feet of leaching facility) Feet j FURNISHED BY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: $y 0,Cu—,4"C,4— Oaner. Dae al lmpect ""S�C-�Q� G SKETCH OF SEWAGE DISPOSAL SYSTEM ' include Ales Ao m leass tutu perosucem Aelvences landmarks or ben hmahs bone all-11,within 100' _ 5 I � t / No. 9 �/� :, ®a ��` Fee 7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS r 01ppYication for ligpogal 6pgtem Cow6truction Permit Application is hereby made for a Permit to Construct( )or Repairµ( 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. 14 Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures 1 Design Flow gallons per day. Calculated daily flow 3325� gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Altfrations(Answer when applicable) :Zmn,Stro 5 077 C✓T� �>L� 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 d not to place the system in operation until a Certifi- cate of Compliance has b o of Signed Date Application Approved by Application Disapproved for the following reasons Permit No. 9 G r �'/ Date Issued r-?a 46 is�•..-•:,'._.. ..:....,.ti;�SK..- :.....�....�.:;��t.Jro'.s AP'd+.►4..7,• '.�,.'�e`.-f•=g2cr[' , , ,�y,+'du."..<._ :y,,... �...r' . Y ... ., �.vJ..�.a "^. :.• w fii:-tS'--:i-�:; e 1 No. �/� £ l� �i'� Y Fee 4 9 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS '. 01pplication for Migpogai *pgtem Congtructton 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. l Installer's Name,Address,and �T,e✓ anndd Tel.Now Designer's Name,Address and Tel.No. t � r v K-�J �D e- CS O (� 14 wK 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, 77:11345> gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alt44rations(Answer when applicable) w 6t l 5 1J77 C✓r� �`��y 'TlvO TYZk G GEC 5 O 1e - Date last inspected: Agreement: i 4 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 d not to place the system in operation until a Certifi- Cate of Compliance has beea-issee o of _ 1 tLe Signed Date t a Application Appioyed by Application Disapproved for the following reasons ~ v i•` Permit No. / 6 -/0 Date Issued -�a 4� Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of compliance - - THIS IS TO IFY, Ih e Sewage Disposal System installed( )or repaired/ceplaced(L� J c��o by cT I, b e ' S for �/V A C,Lc,, as L_G V_Q4-::g n..—t has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. y dated 74m Use of this system is conditioned on compliance with the provisions set forth below: J i No. (, l y Fee L/O THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogal *pgtemm Congtruction Permit �Permission is hereby granted to �d ,-r_, f o b to construct( )repair(---)-an On-site Sewage System located at F',i 1TA-S4,c-T Lti" 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. s' Date: a — �� Approved by 9 CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONS'FRUC'I'I,ON PEItMIT(WITHOUI'DESIGNED PLANS) I, Q hereby certify that the application for disposal works ' construction permit signed by me dated�'j at'�c (j, concerning the ,�. property located at_ �`� �- ASS meets all of the .following criteria: 4. There are no wetlands within 300 feet of the proposed septic system d There are no privatevelis within 150 feet of the proposed septic system W 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: LICENSED SEPTIC SY TEM 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). !, A' ' ... Q� �� C` �-. I ASSMMW PARCH -- Z JI ,. Commonwealth of Massachusetts 9,6� � Executive Office of Environmental Affairs John Grad D.E.P. Title V Septic Inspector Department of P.O. Box 2119 ' E.-'-Environmental Protection Teaticket, MA 02536 W111lam F.weld (508) 56476813 3aemor Trudy Coxe "- r 8ecretuy,EOEA David B. Struhs - Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM w 41 PART A CERTIFICATION L N ,7 f® Property Address: < �' , 61EI�S Address of Owner: S 1996 Date of Inspection: �j` ea\Os t o (If different) Name of Inspector: Company Name, Address and Telephone Number: IN,~' 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 N ds_F_urtherEvaluation By the Local Approving Authority rails Inspector's Signature: 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 anu cope: pent to tier butei, ii applicable and the appro,ir,g authority. INSPECTION SUMMARY: Check A, B, C, o AJ SYSTEM 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. Bi SYSTEM CONDITIONALLY PASSES: 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 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. (revised 8/25/95) I One Winter Street a Boston,Massachusetts 02108 9 FAX(617)5*1049 o Telophoee(617)Z112-" s. +Printed on Rwydd PAW I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: O `l ?)CzS,e,.Atk Owner: Sio C,\ Date of Inspedio : 51,B 1 BJ 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 wily pass inspection if(with approval of.the Board of Health): . broken pipe(s) are replaced ' obstruction is removed 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 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. 1) 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 ENVIRON-NiENT: nP >\sieni nd> a setim tdnM anu luii d6borption syiitni and i5 wiihir. iuv ree, "C' a iufa:c '.vatc. G: It;uu:a'r' t3 a surface water supply. _ The s\s!Pn- ha, 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 Dj SYSTEM f AILS: 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. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or ,cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' c ' 1 CERTIFICATION (continued) Property Address: �� S,�,e�-� ISWr'u._ Owner: 'f) 1(i cl\ Date of InspectionbI g' 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. 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 col iform.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 6/15/95) 3 I OOF SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: UU 1 Date of Inspedibn�rJ b Check if the following have been done: —L,P�'mping information was requested of the owner, occupant, and Board of Health. 4_. on of the system components have been pumped for at least two weeks and the system has been receiving normal flow riles during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. t built plans have been obtained and examined. Note if they are not available with N/A. _LjJw facility or dwelling was inspected for signs of sewage back-up. _� system does not receive non-sanitary or industrial waste flow l—We site was inspected for signs of breakout. _�<1I 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. �he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. }fie fzc;l;!%. o,,. ' i.'., �.�,,n?,t� if diffciani frnrn owne,l were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 18/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property ress: L Owner: WCACu Date of Inspe �S0 rh/ �tr� FLOW CONDITIONS RESIDENTIAL:„ Design flow: all ns Number of bedrooms: Number of current residents:_ Garbage grinder (yes or no):2aQ Laundry connected to system(yes or no):010 Seasonal use (yes or no):_ Water meter readings, if available: Last date of occupancy: 1� eQ( QC COMMERCIAUINDUSTRIAL: t1Whr 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 informati n: ,Ij nd �D Q System pumped as pan of inspection: (yes or no)_ If yes, volume pumped gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Li--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: .-.��Jv-.-• - - Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (Continued) Property Address: �y"1 c sseA l.A tom. Owner:5 ki( \ Date of InspectiJl g)ci(. SEPTIC TANK:\F1% (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 thickiie». Distance from top of scum to top of outlet*tee or baffle:' Distance from bottom ni Fril-n 1n bottom of outlet tee or.bahle: ` 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.i (revised 8/.5/95) 6 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Ins 4� sppect'9drY SI�Sl ct(, TIGHT OR HOLDING TANK(A\�A (locate on site plan) Depth below grade: Material of construction: concrete-metal - FRP __other(explain) Dimensions: Capacity: gallons Design flow.: rtallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BO (locate on site plant Depth of liquid level above outlet invert: Comments: (note if levei and distriuutiun.i,eyuai, e,id,:nce of solid., Ca;,) El, e\idence of leakage into or out of box, etc.) PUMP CHAMBER:�`(�- , (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 r. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1� SYSTEM INFORMATION (continiaied) Property, ddress:. Owner: Date of Inspectto 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, number: leaching chambers, number:_ leaching galleries, 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,etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert:_!xc c�OT ; Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of ground..xc-. t1C 1 inflow (cesspool must be pumped as part of inspection) Com ents: (note condition of soil signs of.hydraulic failure, level of Rqndin , condition o vegetation, etc. C C PRIVY: ('*'Apt (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, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: y�0. Owner: < ��(( Date of Inspectb?t�S1 1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Nouse- Gac�ye DEPTH TO GROUNDWATER Depth to groundwater: feet. ` 1c c method of determination or approximation: W vJ M cLos. (revised 8/15/95) 9