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HomeMy WebLinkAbout0090 ISLAND AVENUE - Health 90 ISLAND AVENUE,HYANNISPORT A 207 080 1 e � i o TOWN OF BARNSTABLE LOCATION CPO�5�� SEWAGE # 15 VF_LAGE t-t�(41 ` S0014:-K ASSESSOR'S &LOT INSTALLER'S NAME&PHONE NO. �` SEPTIC TANK CAPACITYS� LEACHING FACILITY: (type) L--Q—(size) 7 �` NO.OF BEDROOMS BUILDER OR OWNER G> PERMITDATE: 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 p Furnished by E. V o `, )pp No.------- -- -- - r Fee---- -- -----oWV 4 BOARD OF HEALTH TOWN OF BARNSTABLE Application, For Well Construction Permit Application is h pre ade for a permit to Construct (<Alter ( ), Repair ( )an in 'vidual Well at: - ,e 50 Location — Address Assessors Map and Parcel Ow y Address /` �' l t/ l i/` 6_ -------------------------------------- Installer — Driller Address Type of Building Dwelling A -lo•c1t-�3— — - Other - Type of Building------------------------------ No. of Persons---------------------------__—____________ �---------------- - — Type of Well--�--- - --- �- - ------------------ Capacity---------------------------------------- ----- Purpose of Well 1�rB � d ,�✓ r - --- -- - Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed — � -------- ate ------ Application Approved By ---------- - - - clafe IApplication Disapproved for the following rea :----------------------------------------------_-______-______—____--________ I - — -- -— TO- - -- — ------- ----- - date ------Permit No. - - — —-- -- - Issued--- -- 1�/ I /- -- ------------------- - -- --- d to - -- -- --------------------------------------- -- ---------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate (Of Compliance THIS IS TO CERTIFY, That the Individual We Constructed VI-),'Altered ( ), or Repaired ( ) by = '- r,7111s1t 1� `'l — ''=�J— -- ----------—--------—-----------------—------------ p ��// �' / Installer at- L T ��-, �1�'` J�--��✓'��� / -------------------------------------- -- -- - has been installed in accordance with the provis>ons of the Town of Barnstable Board of Healt Private Well Protection Regulation as described in the application for Well Construction Permit NAM© ated------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------—- —----------------------------- -- Inspector-------------------------------------------—----------------------------- Jl jNo.------- -- ----- -- Fee--------------0 wt------ BOARD OF HEALTH TOWN OF BARNSTABLE I zipplicationArVell Con!9tructionPermit ! t Application is hereby /made for a permit to Construct Alter ( ), or Repair ( )an in 'vidual Well at: I � r-1/ ,26r7 �;FL l/", (/� // — r Location — Address Assessors Map and Parcel ff / � i Owner Address Q19 �/z,, r� �r �i, n; (ri _ lit/ �� S r�� - - -Address -- j - Installer — Driller - --------'�------�--�---------- j Type of Building Dwelling !i= /�,�V.i i>? / ------------- !' 1 Other - Type of Building --- No. of Persons------------_------------ Typeof Well A� - i/C----v ----------------------- Capacity-------------------------------- ------ ----- Purpose of Well---i!L f, -'--t'E �--------- ----— Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Sign-d ate Application Approved By IS`-r '/C� —51 __ � � �--� � _ ------ date iApplication Disapproved for the following rea :-----------------_____-------------------_--------__---------_—__________________ ------------------------ — ----- - --- -- - ----------- ------ ----------------- ------ ----- ---------------- --- --------- 64, date f Permit No. - - -� - — --------------- Issued --- -- ! 1_ -- -------------------- i / d1te i. If------------------------------------------------------------------------------------------------------- I 4 j BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed 'Altered ( ), or Repaired ( ) do by Q 9 r Installer f� �/�/ram / tp r f�'� �� Ls� I has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit Nowzft Dated------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. i �j DATE-------------------- - ------------------------ --- - -- Inspector------------------------------------------------ E ----------------------------------------------------- ----------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE lVell Cootruct ion Permit i No. -- ---------- ti Fee--- -------- - ! Permission is hereby granted_!,,,�_( [le ---- `"r'_____-*'_"____'__ / ------------_--------- to Construct ( , Alter ( ), or a air ( ) a IndiviP,a Well i" No. - - =� �V� �— f sty e' I /-1 �, -1 ------------- ------------------------ as shown on the application o Well Construction Permit 4 _ �/_� }____ l /�_._�______- No. 0 --1� ------------------ - - Dated--- -d a- ���-----------.- Board/of Health d DATE--�1---- t i ti Ad6re3s of prvporty 90 -POAA�-p Omer Is name (Ar.G� ,r ���IyN SAsa- aato of Inspoction �b��l�BGis' Ghcck if the f Cuint havo goon don-: Pumping i.nfor-waLAor. �,4c if Health. --' ,_Y... Axone of the op:3tcn coiupgn,"nt.; h .,o j;:. n. and the syc_,en harp boon roucivinq rormu period. Large volumes of wator hove naL ��<. ,. .' .•< _ ,a_ oyntem rocei►41y ov )art or V4U As built plans have 'loon obtained t,nel c H1 1 available with W/A. The facility or. Otio' ling jLs in. wte�1 The site eras inspectod f ois� of b6 cckout:, All nyotem componorS:13, c..ccluaincj S:*'1W SAL , - • site. . The septic tank vanholoo wor:a WICDVL:-C , , the septic tank aaa inspoctocl for uondi tS on a.. 'y material of construction, dfi�.unuioni�, depth oi 1i sludge, depth of scum. The size and location of the SAS oil on existing information or approxiiaatod bl The facility ownor land occupant , 1L dif -.0 1'. provided with information oil CIO prdpG� • 4 i BUBSURFaCE SEUAGN DI€POSAL SXt3zEN X!IS312MA ON PART 0 BY8TEM INPO=TZON FLOW CONDITIONS If residential number of bedrooms S ,!'� number of current residents garbago grinder, yes or no laundry connected to oystom, yes or no cedsOM'I use, yes or no If nonresidential , calculated flow: Wzter meter readings, if available: /414_ Last date of occupancy ---�r P Y GENERAL INFOPUUTICN Pumping records and source of i fo ation: System pumped as part of inspection, yes or no if yes, volm a pumped. Reason for pumping: Typeof system Septic tank/distribution box/soil absorption sy:,'Cem Single cesspool . Overflow cesspool Privy . Shared system (yea or no) (if yes, attach prevLoL�C .___.._ records, if any) Other (explain) Approximate aga of all components. Date install.cd, if information: r r : Sewage odors detected when arriving at the sits, 1 }r . OUBSURFACE 02NAGE DIDPOSAL OYSM %A&PLIC�:Xod VART B ' � SYSTEM INFOR+"�TIO�i oo�atiauo6 SEPTIC TANK:, (locate on site plan) depth below grade:material of of construction: V concretes metal __._ -FRr� dimensions: .� ��j�� d2t2 ('►a� f�� , ' ' . sludge depth { distance from top of sludge to bottom of outlet ton c - � -t scum thickness `' distance from top of scum to top of outlet toe or beffl- distance from bottom of scum to bottom of outlet too cr 1:alflc Comments: (recommendation for pumping, condition of inlet c-.n ovl:'.c.'- t' depth of liquid level in relation to outlet invert, ntru:.ti'r..'-. evidence of leakage, recommendations for repairs, eta. ) DISTRIBUTION BOX:_Y._._ (locate on site plan) depth of liquid level abovo outlof in,-:;rt Comments: (note if level and distribution is aqual, ov!don.:(:- u:' {c . evidence of leakage into or out of box, recommendation ,Tu_ PUMP CHA.4BER:_-,\—II (locate on site plan) pumps in working order, yen or no Comments: (note condition of plump chamber, condition of pumps anI ri - E recommendations for maintenance or ropairs,otc, ) , BIIBSORFACE 3EAAGO DISPOSAL OYSTEy1 2r":1Pr':CTjON V,3, PART B SYSTEM rNTORNATION aontinucC SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not approximated by non-intrusive methods) It not determined to be proaant laj` n: Type. leaching pits and number leaching chambors 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, lev_;L r � condition of vegetation, recommendations for maintor.cnr:- �r CESSPODIS (locate on site plan) : number and configuration depth-top of liquid to inlet invert 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) Comments: (note condition of coil, signs of hydraulic failurr., condition of vegetation, recommend tions for c PRIVY: (locate on site plan) materials of construction dimensions depth of solids - _-- Comments: (note condition of soil, signs of hydraulic failure, lovn? condition of vegetation, recommendationo for maintenance 01 [1UBSUR2=2 08VAG2 DIGPOaAL ©STOTEN ZVbV2C"2'J JW VUIL. PART S QYSTEM XUPORJ-IATX014 conti2Lod SKETCH OF SEWAGE L?SPOSAL SYSTEM: include tins to at laast two permanent roferoncas lard.zar►: , .�r ,�..• i locut@ all wallo within 200' -75 1 S� DEPTH TO GROUNDWATER d.pth to groundwater method 'of determination or approximations VS 7FL�Ov�� SUBSURFACE BRUAGE DISPOSAL 0Yt3r, BM PART C VAILURE CRXTERIA Indicate yes, no, or not determined (Y, N, or lm) determination in all instances. If "not determinod", .. Backup_ of sewage into facility? �l4._ Discharge or ponding of effluent to the curf.orss lit t.::- �. surface haters. .>; Static liquid level in the distribution boA Lbovu .: .L Liquid depth in cesspool <6" below invert or avoilahle r,, jy _ - j s� flow? Required pumping 4 times or more in the last year71 number of times pumped . Septic tank is metal? cracked? structurally urraoun<—, sty• _ infiltration? substantial exfiltration? tank failure ( Is any portion of the SAS, cesspool or privy; 1 below the high groundwater olovation? within 50 feet of a surface water7 within 100 feet of a surface water oupply or tr .butp:. water supply? within a Zone I of o public well? IL within 50 feet of a bordering vogetatod wLtlp-nd or ji ,, (cesspools and privies only, = the SAS}? within 50 feet of a private water supply -ticl).71 less than 100 feet but greater than 50 feet fror a p,-i%$ I _ t. . . _ supply well with no acceptable water quality analysis ? 1 .-. ; has been analyzed to be acceptable, attach copl of. ocll . i: .for eoliform bacteria, volatile organic compae.rids, a*.man, ,y101$ •n and nitrate nitrogen. UVSSUn ACE OB AGE DIM= DYSTEM PART D CERTIM4TION Name of Inspector Gozpany Name Y G ()"_-," ` Company Address j5Lpcgpe%j&v- }.(-fn.wras oabry, sort ication fitAtnmpnt I certify that I have personally inspoctod the oeozc_, di po-1 . r this address and that the information reported io truc, 0:.cua j complete as of the time of inspection. The inspection !11aa any recommendations regarding upgrade, maintcnanca a:�d iopaLr a consistent with my training and oxporionco in the piopt:r fund' _ wanitenance of on-site oewage disposal sys;toms. CheA one: I have not found any information which indicatu3 'tl,akt to adequately protect public health or tho onvironmerit 310 CMR 15. 303. Any failure criteria not avO LiaLtd c;a the ?rAILVRE CRITERIA section of this form. I have determined that the system fails to preterit pug!1C the environment as defined in 310 CMR 15. 303. he ha s i t�; ` ► determination is provided in tho PAILURE CR,M.UXP ser.;tir', � form. Insp2ctor's signature Date original to ays>tem owner Copies to: 139 Buyer (if applicablo) Approving authority i 1 t. 1. LO-CAT-40M SEWAGE PERMIT NO. VIt:;LAG/ i INSTALLER/''S MANE & ADDRESS L--. 8UILDEa OR OWpER r. GATE PEIIMIT ISSUED DATE COMPLIANCE ISSUED �� le �� -� r .��, � - � � o ,� . . . , No._ THE COMMONWEALTH OF MASSACHUSETTS SOAR OF I-IEALT OF....... ............... Appliration for Uhipaaaal Worka Tomilrnrtiun ramit } Application is hereby made for a Permit to Construct ( )' or Repair ( ) an Individual Sewage Disposal ......... ...-........-...................................................................... -•--......_._.._........---•-•---•--.......•-•---•-•---•----•--•-•--••......_.._.................. ovation-Address or Lot No. • --:::.......:::............................... caner � __________________________Address �W .:...... •--�.. ...... - Instal:er�• Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder (PL4 ) , Other—T e of Building No. of persons._.....____'.............. Showers —. Cafeteria Q' Other fixtures ---------------------------•.•.. - W Design Flow.............................:..............gallons per person per day. Total daily flow.............................................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth........ _... ._.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. w. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area................ ft. Z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by--••••...•••--•---•-•-••••••••••••--•••-••••••-••••.............••-•-•--_. Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..................... (s Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-________•.:__---._.____ -- .— r Description of Soil = '�----------•-•••••.••... •-••-•..............•---••...•-••••••-•••--••••-•--•---•---•-••••••--••-•-•••-••-•-......••----.•••-••••--•-•••••-••••- x W ---------------------------------------------------------------------------------------•-----------•------------------------------------ -- ----------- ----•••- U Nature of Repairs or Alterations—Answer when applicable...____ _ . e � Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T`:'12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board of health. Signed••• - /... to Application Approved By...... ...... _ ���� ............. Date , Application Disapproved for the following reasons:--------•-------------------------•-----------•----•--...-----------------------------......................... ....................•--•-----•---•-•--------•----------------...----...---:...._..._.._......-•••--••••----- Date PermitNo........................f................................. Issued....................................................... Date No... ..... .... FEs... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD_-OF HEALTH ' _:_� .........---OF. _.. .................... Applira#inn for Uiipntiaal Workii Tom3trnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal stem at: t = s .�r....s-..l .... .. -- --•........................•-- --••-••-•---••----••-•---•••-•------....... --------••------------•---...........-•--- ocation-Address or Lot No. > � .. _. :-- ---------------------------------•--•---------- .............•-•-•--•••------•-••.......... -•--------------.........---•--............-•-- Owner Address a �...................................::n............................................. ---•--......------....................----.........................--•-•-----..................... - Installe Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ODescription of Soil .. n.�.......---�---j.• - � ------------------------------- -------------- -................................... U ._....-•---------------•••-•-------------------•-•--•--•--------._......... ...............-----••------------------------------•-•-----...---------..........-----------------••---•-......------.. W ................................................. ---•........................................................................................... ---------• ...... U Nature of Repairs or Alterations—Answer when applicable._.__., ...........................' = .. ....... ..:....-_______ f -- --- ------- -•------------------------------•--•----•-••---...----------------------------------------•-----_...----........•--•-------------•-•- -------------------------------..-------•-------------•--. Agreement: The undersigned agrees to install the aforedescribed Individual.Sewage Disposal System in accordance with the provisions of TiTI-E 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 b 'the board of health. > F Signed.- :. .�---------- ---------- /_ D'at »..... . Application Approved BY =� .:"'''' i! , :_._..... r/ /,-- --_-------- ✓�` Date Application Disapproved for the following reasons---=--------------- ------------------------------------------•-----------------•-----------------••..........._ -------------------------•-•---------•---•--•--••••----.............;.....---•--...-----•--------------••-•------------------•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H . ................OF. ?"' ...... . ...... ............................. Trrtifiratr of TompliFanrr TI�VRS 1 TOERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired " . ..�4.f .- 4 jj��`j` ....... Installer It.......... has been i 1led in accordance with the provisions of TIT L; r f The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__ ''_� >..__...... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........................................•-------••-- l �.��: �. Inspector................---.... Zi -�r-'..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTU z..... ....OF... """' ,.. No......._ FEE...: Difillrrs nTlie�,s Tnni#rnrtinn amit Permission is hereby pgrant j:�-�"......................... * P y to Constrl3ct ( R '"1S an IndwlduaSwa e.D S stem at No... .. Street as shown on the application for Disposal �v__o`rks Construction Permit No..................... ated.._./ .__. � J.......... -.. -----.•............ ...•...... B r DATE------------------' ---• -- ................................. oard of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 3 ' PA 38' f I Q 0,0� �91 DRI Vey �Y NO # 1 � � J 11 Fo �•�� A �-- 28 I � 9. l IR0 21/8/ / GUY WIRE � — 32 A-7 HYDRANT #3 Sol OFFER Pam° 8" CONCRETE WALL / s uS WATER- 3 4. / / I •� 4000 METER PIT �\ .36 9 G i .30 Q� / G TBM a CB 39 70' :2- 2 to 0 r � O v L 0 T A / LAND COURT PLAN No. 15457 A 4 � � J 5 1 i L v / C3 i {i t i • G k