HomeMy WebLinkAbout0069 GREENBRIER LANE - Health 69 GREENBRIER LANE, W. HYANISPRT
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Attn: The Commonwealth of Massachusetts 09/12/95
Town of Barnstable Board of Health
367 main St.
Hyannis, Ma. 02601
From: Mr Michael DeDecko
Atlantic Enviromental
P.O.Box 2384
Mashpee,Ma 02649
Dear: Board of Health Official,
I certify that I have personally inspected the sewage disposal
system att69 Greenbrier n _Lot#12=W:Hy_annisport;M-4 02"672� for
Ethel;M_ar_garetos and the information reported is true, accurate and
completed as of the time of inspection.) have not found any
information which indicates that the system fails to adequately
protect public health or the enviroment.
If you have any questions regarding this inspection. feel free to
-contact me at (508) 477=1420 Thank You
incerely,
Michael DeDecko
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 6c1 �4�wb4-icQ. L►-�. (�, itw.sep�� , HA, O�-6'lZ
owner's name eT�dtL, Hilp�A�L2.;oS
Date of Inspection C(\jZ kgS
' PART A
CHECKLIST
Check if the following have been done:
X. , 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.
_ As built plans have been obtained and examined. Note if they are not
avail.able with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_)( '-The site was inspected for signs of breakout.
_ All system components, excluding the SAS, 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.
The size and location of the SAS 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 SSDS.•
• 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
Tf residential
number of bedrooms
number of .current residents
_ "n garbage grinder, yes or no
_jhj& laundry connected to system, -yes or no
_%AA2A,. seasonal use, yes or no
If nonresidential , calculated flow:
Water meter readings, if available: 0Dt{'SZb (►�,��,`• ,
� ► Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
ar3 System pumped as part of inspection, .yes or no
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. S.ource of
information:
OL \1A
_ j_ Sewage odors detected when arriving at the site, yes or. no
9
1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK
(locate .on si a plan)
depth below grade: 1�r
material of construction: _concrete metal FRP other(explain)
dimensions: 0 x VLS0 Qo-3 -. G.
iu sludge depth
at," distance from top of sludge to bottom of outlet tee or baffle
t i scum thickness
distance from top of scum to top of outlet tee or baffle
k%: distance from bottom of scum to bottom o.f 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. ) 1
DISTRIBUTION BOX: e�
(locate on site plan)
Cyc 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:
(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. )
- i
I
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE ETSPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
j
�'.,
MR. o2,6'1•-
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
� �SC � yea o� �•^^��--� ,,�v.�� �-1 I�. l��i�� o�c��.,.��
12
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 day
flow?
k 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?
X. 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?
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.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector "9 �l�c � �k.p
Company Name, Nit�-ICiL 4U�v�Q�o,,,Z•�'_V
Company Address62�LAI
Certification Statement
I certify that I have personally inspected the sewage�'disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. Th'e " inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails
i
to adequately protect public health .or the environment as defined, n
\310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
''the FAILURE CRITP:RIA section of this form.
I have determined that the system fails to protect public health and ..
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE -CRITERIA section of this
form.
Inspector' s Signatur
Date
Original to system owner
Copies to:
Buyer (if applicable)
Approving. authority ,
a f I Z - �r Pgh��1��
LOCATION rkk,EWAGE PERMIT N0.
VILLAGE- /0 _ _& Qf__
INSTA LLER'S NAME ADDRESS
B U I L D En R ORn OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ( ._ 2,�_ ,
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE A,`
/..'-O&W.....--.---OF.....;/' ✓X ....................:............
Appliration for Uhipoii al Works Tonstrurtiun ramit
Application is hereby made for a Permit to Construct {,:�l or Repair ( ) an Individual Sewage Disposal
Sys.� a -- ---------- ... .......... -
.-•----.....---- ------.
- or Lot
=•Loca Addres
.1 mil! • . --•- . _ .................................. . ..........................
Owner Addr s
.. --.._........._...-••-•-......,.....� _ ...��1 ---------------------------
sta ler Address
Type of Building Size Lot.J yQ....Sq. feet
., Dwelling—No. of Bedrooms---- ..........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
04 Other fixtures -------------------------------••••.---•--....
W Design Flow..........................................gallons per person per day. Total daily flow._._.........._, . --.............gallons.
WSeptic Tank—Liquid capacit -gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—' No..................... Width•..._j_..___...... Total Length...... _,/----- Total leaching area....................sq. ft.
3 Seepage Pit No......../........ Diameter...../0....--- Depth below inlet..... Total leaching area. ....sq. ft.
Other Distribution box �J' Dosing )
Percolation Test Results Performed by..... t re ..... - Date....... y.._ �.._.... . .
la Test Pit No. 1......_��__.....minutes per inch Depth of St?
Pit ground water_._._...
Test Pit No. 2................minutes per inch Depth of Test Pit_.__JJ__._......__._.. Depth to ground water........................
Description of Soil.......................On?.......... � 5,. ......
V -••-........_. .G..- .-- .-•-•------•....................••••--------.......•---------••..................
W -------------------- ----- ----------------------- � '/� . . ----------------------------------------------------------------------•----.....------------......---------
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescrib-ed Individual Sewage Disposal System in accordance with
the provisions of L I:'L% 5 of the State Sanitary Code— he undersigned ther agrees not to place the system in
operation until a Certificate of Compliance has be s d by�h.e/oard o iealth.Signe ... 40
A0 /� ?e
Date
Application Approved By..... ..
Date
Application Disapproved for the following reasons---------------------------------------------•---•--•--••---•--------------------------------------............•.
•-•................................••------------------------------------•••-•--......_..._..-----•------.....-•-•--..._..--------------------•---.------------- ---.....---•---•----------........--
Date
PermitNo......................................................... Issued..... ...........-�----- ---.-....._-.---
Date
...azk w.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE L
.......14� e ..-----.--.OF..... t 5: �rns . . ...............................
Appliration for Bigposal Works Tomitrurtion runfit
Application is hereby made for a Permit'to Construct (41 or Repair an Individual Sewage Disposal
Sys 51.
_ALL
&4
. ............... . ...................................... ......... ..........................
L aton-Addres7' or Lot
ArV14 -------------------------
nerI Adl s
j: o/w,
... ............ ................................... ...........................
------------- 70staller Address
Type of Building 0 Size Lot.,&qpl�'2_0...Sq. feet
Dwelling—No. of Bedrooms........._5--------------------Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
QI
Other fixtures ......................................................I.................................. ......................
- ---------------------*......Design Flow................ .__.gallons per person per day- Total daily flow..............0.,a n............gallons.
Septic Tank—Liquid capa_c*ii;h��.gallons Length................ .Width.........._._... Diameter...,.........._.Depth-..............
Disposal Trench—No. .................... Width.._ . ...... Total Length......... ..._._ Total leaching area...................Sq. ft.
Seepage Pit No ......../-------- Diameter..../ --------- Depth below Total leaching area��._�' ....sq. f t.
Other Distribution box (�p - Dosing tank
Percolation Test Results Performed b
Test Pit No. 1.....ig.....minutes per inch Depth of T*4st Pit........Z Depth to ground water..__.._.
44 Test Pit No. 2................minutes per inch Depth of Test.Pit.................... Depth to ground water........................
9 ................................ . .. .... 74..../............................................................. ...............
e
0 ................ 0. 4..........................................................................
Description of Soil.......................10"2 /;:��_.::t::
UW 'f!l......... ayA4'5 ...............................................................................
.......................................................2. V�6
......................................................1. ......... .........................
------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable._............................•._.._....__..........•.....:;ml...................................
.................................................................................................................................................................................................
Agreement:
The undersigned agrees'to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TTL, 5 of the State Sanitary Code he undersigned drther agrees not to place the system in
I- r, . JF
operation until a Certificate of Compliance has beee, Re by khooard of2calth.
✓
.................... ....Signe .......
= � Date
Application Approved By..... .........................
Date
Application Disapproved for the following reasons:..............................................................................................................
................................I.......................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........1049?0 V-4........OF ...............................
Tatifiratr of Tamplialtrr
THIS IS TO CERTIFY, T.bat'7he Indiv'dual Sal�rage Disposal System constructed (44<or Repaired._
by-------------------- 1_2 �!. ................... .......
Installer
...........
n?Ar...... ........... ........ ------
;
at_...._............z!...................
has been installed in accordance m5th the provisions f State Sanitar' ode as d"e/scribed in the
7 o "The y4e
application for Disposal Works Construction Permit !��s.............. dated.............................. ...............
10 THE ISSUANCE OF THIS CERTIFICATE SHrAi T BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......../..' ..................................... Inspector...... ............................ .... .......................
THE COMMONWEALTH OF MASSACHUSETTS
• BOARD Of HEA
,4el-117............OF...... . ............ .................................
(N o ...9)' --(916 4 . FEE 2e..............
Disposal- orkii on ulion .panfit
0,
......................................................... ']�.....
Permission i�ereby granted.......,.....
f
to Construct or ReDair an ndivi�Au I Sewagg(Disposal S tem V4
�y
at No.........................to'.W.- .........�4.
. .. .............Z=w
Street
as shown on the application for Disposal Works Construction-Permit No......................Dped..........................................
n di
...................................
Board��Iealth
DATE...t-3
-7.........-----------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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