HomeMy WebLinkAbout0039 GREENWOOD AVENUE - Health 39 Greenwood Avenue
Hyannis P .
A = 289 092
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TOWN OF BARNSTABLE rL
LOCATION ` � � �y ��e� `� SEWAGE #
VILLAGEyi .f' ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY.
LEACHING FACILITY: (type) %`Go (size),X
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility i Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) i Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �'�
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Migoar *potem Conwuction Permit
Application for a Permit to Construct)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ?J— Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
i(sv.y/�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�"/�w ��i'80l?/�` 9?���/�',7 �idd�17 �j• I�,�•�®✓ sL�.J�
Type of Building:
Dwelling No.of Bedrooms - Lot Size sq.ft. 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
w
Size of Septic Tank /'3"®� ;,9i?4C0^' Type of S.A.S. � ����"r� �() '� _Inar;e0;W-
Description of Soil
Nature of Repairs or Alterations(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 and not to place the system in operation until a Certifi-
cate of Compliance has been issued his Board of ea th.
Signed ® Date 9 ��
Application Approved by g _ Date
r
Application Disapproved for the following reasons
6E
Permit No. Date Issued
'Y • �.! .y{.ram.::Fy�N
c' Fee 90
ro.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
, Yes
PUBLIC HEALTH DIVISION,-TOWN OF BARNSTABLES MASSACHUSETTS
01pprication for Miopogar 6petem Construction Permit
Application for a Permit to Construct)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 9� Owner's Name,Address and Tel.No.
�' .39 �FE-it/Grio 00 �d!/C' •Co G.Pi�` , ,�/GC`��
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 - Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flowyo gallons per day. Calculated daily flow gallons.
Plan Date — �� Number of sheets / Revision Date
Title
Size of Septic Tank -'03"00 Type of S.A.S.
Description of Soil
Nature=of Repairs or Alterations(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 and not to place the system in operation until a Certifi-
cate of Compliance has been issued b is Board0ofealth. �j�
Signed 1 l/�/l/J /) �., Date
Application Approved by A �. - Date
Application Disapproved for the following reasons r
Permit No. / v Date Issued r
--------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ' )Repaired( )Upgraded( )
Abandoned( )by Q /''s —*"
at 391 wo 0,0 -4 A ^hasen constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No dated
Installer '%*♦-►► 1 �`doC vim' Designer 46A O'id �4& SoA
The issuance11�10
oft s permit shall not be construed as a guarantee that the syst m ill fu ctionn as dft-k-
<57
t Date � � Inspector
�'�---- -----------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
lwi5pooal *pgtem Construction Permit
Permission is hereby granted to Construct( Repair( )Upgrade( )Abandon( )
System located at
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.
Provided:Construction must b/Ico plItte)d i hi three years of the date of th es emit.
Date:_ �� ! t/ Approved by -
i TOWN OF BARNSTABLE
LOCATION
.r/ f��d .4� SEWAGE
i ASSESSOR'S MAP & LOT
VILLAGE
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �,��
LEACHING FACILITY: (type) %'-�o (size)
i-
NO. OF BEDROOMS
BUILDER OR OWNBUILDER
PERMIT DATE:
9--/�- .Z COMPLIANCE
Separation Distance Between the: , Feet
I
� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist , Feet
on site or within.200 feet of leaching facility) _
Edge of Wetland and Leaching Facility (If any wetlands exist l Feet
within 300 feet of leaching facility)
` Furnished by
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Commonwealth of Massachusetts
Executive of E nvironmental Af f airs
DEP
Department of
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Environmental Protection
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:
Address of Owner:
(if different)
Date of Inspection:
Name of Inspector:
Company Name, Address and Telephone number:
1
CERTIFICATION STATEMENT S°�' - ``�� - i•aZ�
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
---- Needs further evaluation by the local Approving Authority
---- Fails
Inspector ' s Signature: `1 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 or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if applicable
and the approving authority.
SUBSURFACE SE14AGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3,1
Owners :
�, \
D ate of Inspection :
INSPECTION SUMMARY:
Check A, B, C, or D
A) SYSTEM PASSES:
- I have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are
indicated below
B) 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 determinate (Y,N, or ND). Describe basis of determination in all
instances. If "not determinated", 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.
---- 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
Y �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address : 3-i
Owner :
Date of Inspection :
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health , safety and the environ-
ment.
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 of water
---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (.AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING 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 ?one 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
analy-sis 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 notrogen is equal to or less than 5 ppm.
D) SYSTEM FAILS:
--- I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM 15.303. The basis for this determination is identified below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
--- Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ?� �--
P y
Owner:
Date of Inspection : ,���3��;
D) SYSTEM FAILS (continued)
--- Discharge 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 over-
loaded 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 S oil Absorption System, cesspool or privy is below the high
groundwater elevation.
--- .Any portion of cesspool or privy is within 100 feet of a surface water supply
ortributary 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 ana-
lysis. 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.
R i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CE R T I FI CAT 10 N (continued)
Property Address:
Owner: v.LAG
Date of Inspection :
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 I I of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements of 314 C M R 5.00 and 5.00.
Please, consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3-j c�� . i---v
Owner:
Date of Inspection:
Check if the following have been done :
-'�Pumping information was requested of the owner , occupant and Board of
H ealth.
, None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during the period. Large
volumes of water have not been introduced into the system recently or as part
of this inspection.
fX As built plans have been obtained and examined. Note if they are not available
with NIA.
X. 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.
X, 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 sep-
tic tank was inspected for conditions of baffles or tees, material of construc-
tion, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been deter-
mined based on existing information or approximated by non-intrusive methods
4, The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3`y Cli��,,c'_
0 wner: >��
Date of Inspection: V; 4.
RESIDENTIAL:
Design flow : gallons
Number of bedrooms : c 3
Number of current residents:
Garbage grinder (yes or no) : ►�=c>
Laundry connected to system (yes or no):
Seasonal use (yes or no) : c-=c.,
Water meter readings, if available:
Last date of occupancy :
COMMERCIAL/INDUSTRIAL
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 information
.7x�t ..C:.L;:.n:i:_...�?".'W..��E1/w�.�:�►..�..c vn .
System pumped as part of inspection (yes or no) :.....la4;...
if yes, volume pomped . .................... gallons
Reasonfor pumping :............................................................................................................
r;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: A- c_
Owner. �� .,_
Date of inspection: ?•��\�,
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
APPROXIMATE AGE of all components, date installed (if known) and source of information
...... .....IV �. ......:^?1�z�Z,
................................
Sewage odors detected when arriving at the site '. (yes or no).... ....
SEPTIC TANK : ....tiGC-L
(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.)......................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: :!5 t
Owner:
Date of inspection: ---AI
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 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.)........................
................................................................................................................................................
................................................................................................................................................
TIGHT OR HOLDING TANKS:.....1J.
(locate on site plan)
Depth below grade:...............
Material of construction:........concrete........metal.........FRP..........other (explain)..........
............................................................................................................ .... ........ ...... ...........
Dimensions:............................
Capacity......................gallons
Design flow:...............gallons/day
Alarm level:.............................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: '39
Owner:
D ate of inspection: } ,�
DISTRIBUTION BOX:...Nti>
(locate on site plan)
Depth of liquid level above outlet invert:...................
Comment:
(note if level and distribution equal evidence of solids carryover, evidence of leakage into
orout of box, etc.)..................................................................................................................
................................................................................................................................................
................................................................................................................................................
PUMP CHAMBER:...U....
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)....................
................................................................................................................................................
................................................................................................................................................
SOILABSORPTION SYSTEM (SAS):...y :s........
(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,`�
C.)..�►.':�`'.-?1 c:,rn..o.-� ��,.cxv�c�c.�. �,.:...�C..`:a..�.�.."L..ca t S.��..���rY1tYJ��C�
�a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: -3,,
Owner: �:x-mac
Date of inspection: )LA
CESSPO0LS:..Q\.,,,' ..
(locate on site plan)
and configuration:
Number
co gurakion. .............................�...
Depth-top of liquid to inlet invert: ...... ...............
Depth of solids layer: ... .........................................
Depth of scum layer: ...........................................
Dimensions of cesspool: ...(k. .4:.........
Materials of construction: .. s -'r -
Indicator of ground water: .1,,.0...
�. c�>> •�c:� ,�:r.,,,,,.�Y""`' :u- c v� ,\� 1.o.v
inflow (cesspool must be pumped as part of inspection),
fvC....C�v.�..�:c.:..p(?�::��....����:� �.u�.:,r'�:1...tir:Q� ?.i;.—t.?.;��!�—�,..l��w��•�`... c�:w ��-a:...,.. 2 �����:,�p 1
1�r�.:li: .�.,,,;�. ..1•.+1....C(.Q L`'.`.::�1�...1.':�;':��-.4�...�i�!.��,..`rc.�'<:�.:�Gi.l CuG.=�2�\G.iv :.—�c..,� :1�i�i:`
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
AC.)
...... ..(—......CLY1�:
PR IVY : ...�1 G....
(locate on the site)
Material of construction: ...................................
Dimensions: ......................
Depth of solids: ................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.) .
................................................................................................................................................
................................................................................................................................................
I a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
N Property Address : arc
Owner: �Je .,Sz-,_
Date of inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'. i
C o•gig¢P\c,,
cc S5�1cc� 1
DEPTH TO GROUNDWATER:
Depth to groundwater: ...*l.S..feet
Method of determination or approximative:
la`i. .. .S.Y\ 3a: .`i�..` ?a.` ., :ti.::�k,G�:;.rJ...�R� .vt..:,s:���? � ...k .. .�a;..nv.....
. ...�NA—.1.l.7,9yy.T,avQ.....1�.c44�...C�:���� i.............................................................
f
ANTLANTIC ENVIRONMENTAL
P.O.BOX 2384
� i MASHPEE,MA 02649
Attn: Commonwealth of Massachusetts Date: 02/06/96
Town of Barnstable
Board of Health
367 Main Street
Hyannis MA 02601
From : Mr Michael DeDecko
Po Box 2384
Mashpee MA 02649
Dear Board of Health Official;
I certify that I have personnally inspected the sewage disposal system at the following
address : 39 GreenWood Ave, Hyannis Ma.
The information reported is true, accurate and complete as of the time of the inspection.
I have not found any information which indicates that the system fails to adequately
protect the public health or the Environment.
If you have any questions regarding this inspection, please contact me at this number:
(508)477-14-20. Thank you.
Sincerely,
Michael DeDecko
phone 508 477,1420
,assEssoRs MAP ---- -Z - TEST HOLE LOGS
PARCEL
e-� G�
� SOIL EVALUA OR ,,
FLOOD ZONE. ��cQ\ I _GJ _ WITNESS :
CS� � �� � �D �-' C h W t�--� ► 1
� Z DATE: lG Ibuou.—I
REFERENCE: '1 � b'� 1
- . PERCOLATION, RA E: IAA1 1
1 Vt. 2 -
�-. TH- 1 TH-2 UPLAAm off,.�_. -(�Dwy�" Z'k WA
- : ,
LOCATION MAP
LAl
S c 7c�00
ti
Y
!� SEPTIC SYSTEM DES IGN_._ _. .
\ o �- FLOW ESTIMATEr ..
I r r
BED'bOOMS AT IC) GAL/DAY/BEDROOM -�✓� GAL/DAY
C WANK _
/DAY x 2 DAYS GAL
o �y
USE GALLON SEPTIC ANK
II
_ t SOfL . ArTION SYSTEM
1 V S' T 0C i i��L ✓vv" G
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I— O � DE AREA: L
:V)TTOM AREA:_ , 9
- ? I (; SYSTEM SECT I ONrQ
( ►,��
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9 �
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SEPTIC TANKo -_L. 1L !� j
Abo4 'i-
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SITE AND SEWAGE PLAN
LOCATION :
PREPARED FOR : --- ' I�OF.5rF7/6
M
SCALE:
W
DAV I D B . MASON -`a DATE:
DBC ENV ! RONMEN�AL DESIGNS
z EAST SANDWICH . MA
W DATE HEALLIA AGENT
W ( 508 ) 833- 2I77