HomeMy WebLinkAbout0583 IYANNOUGH ROAD/RTE 28 - Health t' , - ---.
:583 IYANNOUGH ROAD,HYANNIS
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lIILLAGE
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IgSTAALEU'S NAC3E 6 ADDRESS
64414HE-R— OR 0t q ER
DATE P E 0 M I T ISSUED 9 f ��-
DAT E COMPLIANCE ISSUED C�—�` �� S'
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7015 p
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a 4'7) FR7 N I H
-71
t ` 'OWN OF BARNSTABLE
LOCATION 5-8-3 2 y_Announq SEWAGE # J;;J e'Crl-10'4
VILLAGE` NTM�//SS ASSESSOR'S MAP& LOT �D
INSTALLER'S NAME&PHONE NO. �• �GLCrn/ i s/e2
SEPTIC TANK CAPACITY //00 691
IM LEACHING FACILITY: (type) (size) 6 XB
NO.OF BEDROOMS A- /
BUILDER OR OWNER
PERMTTDATE: 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
� cu-a.�
Furnished by
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1-0
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No....j3.j-'/M3 .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------------------------------ ---------"OF...... ....... ..........................
Appliration for,Disposal luorkS Tonstrurtion Vrrmit
i Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
1,Y14
.............J_ .13.........7....................U................. ...........................................................................................
Loc j�Add .r Lot No.
............................. ............................ .........
ner -A Address s
d*
............ ....... ......OT---e............. .................................................................................................
Installer Address
Type of- Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...........................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No, of persons_______.__._____.___..___.__ Showers ( ) — Cafeteria
P., Other fixtures ........................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank Liquid*capacity_---------gallons Length________________ Width._..__._.__._.__ Diameter-------------_ Depth______________-_
Disposal Trench—No..................... Width_._.___.__._.___._._ Total Length_.____._.________.__ Total leaching area....................sq.:ft.
Seepage Pit No_____________________ Diameter__._.__..___._______ Depth below inlet____.__._......_.._. Total leaching area..................sq. f t.
Z YOther Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
4
Test Pit No. I................minutes per inch Depth of Test Pit______.______._____. Depth to ground water........................
0i4 Test Pit No. 2................minutes per inch Depth of Test Pit_._.._..__________._ Depth to ground water______.___.:_________...
C4 *---------------------o......................................................................................................................................
0 Description of Soil.......................................................................................................................................................................
........................................................................................................................................................................................................
U P4
.................... ------------------------------------------------------------:•........................ � -_ -------- -___, ..... .........XV,
—Answer when applicable.___(®®! _... ... AX7.
U Nature of Repairs or AlterationsV-------- ---
................47_4�....//..n..Lp.......Y:....r<.Q.W....... ..........................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL Ili U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ssued by the board of Lf4lth,
J_
Signed . ...... .......................... ................................
Date
Application Approved By......... .................................
--------------------D a-t-e--------------
Application Disapproved for the following reasons:..............................................................................................................
. ..................................................................................................................... ..................................................................................
Date
PeimitNo........................................................ Issued_.......................................................
Date
No.... :.... / .. v ♦r i EB..... ..................«.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ..... ....................OF..................................-............................--.........................
ApplirFation for Disposal Works Tonstrartiun Vrrmit
Application is hereby made for a Permit to Construct, ( ) or Repair ( ) an Individual Sewage Disposal
System at: rg
_ s
................_...------ ------ --... ..---- - -- :....
gyp'.�Q.�, L��+ l,LLno;c�tn�gAdd'qfress or Lot No.
..........rT.�f.`_'_.L ......... i. T._A.S:. :J.l`_�............................. .......................................................--...._.....__............----^......-•---
ner Address
----........` .....__ �r� � '.... ----------------------- ------------------------------------------ ..----------------._..._...........--------
Installer 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........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................a •---•---•---------------------------------------•--•---.......__...---------.................------..........................................................
0 Description of Soil.......................................................................................................................................................................
x
U •-•---------••-----•-•------•-•------•----•-----------------•--•---------•---------..._..........••-----••-----••---•-•-------•-----•......-----••-•...................................................
-•--------••---------•-----•••-----••---------•----.. .---•----••--••--••-•-•--••-•--•....... b"""
U Nature of Repairs or Alterations—Answer when applicablee�a - r .4._ f__.___._ j_. ._ ..._.
................ "!y. :P....--- -•---:"-, ,......Y.1-.�aV6'4..............................................................................................
Agreement:
If
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ,isssued by the board of
Signed....... .V f.... iA& ........................... w.
D to
Application Approved BY v- _ sue, :t ., �' � -�� 4f� a�
-----•-------------------------- ----•-......•-
Date
Application Disapproved for the following reasons---------------------------------------------- ------------------------•--•----------------------••-•--•---
-•--------------------•-------•--------•-----•-•-----•----••......-••---•-------•---..•----•-•--------•--•-----------------•--••----•-••--•-•--•---------------••------- ...............................
Date
Permit.No......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F.....................................................................................
(9ertifirFatr of TontpliFanrr
THIS' CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------------------`-------,-�- ..................................... ---------
Installer
has been installed in accordance with the provisions of TITLP: n 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. 1_-X�U................ dated.........................._.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SA ISFACTORY.
DATE--•---.....-•............:............... „�. ------------------- Inspector----------..k1A.k.,/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No._....:....��... ..._. FEE... .................
Disposal Works Tonutrnrtion rrntit
Permission is ereby granted.............. . ... _ c:---.-----------------------..._....-----------------..........-•-------.....................
to Construct ) or Repair ( ) an Individual Sewage Disposal System
atNo.•--•-••••-•----g•3....... ---- -------�.! 't- '---------------•-••-------•
Street
as shown on the application for Disposal Works Construction Permit No...................•. Dated..........................................
-�-' -------
DATE _
/"�x%Board of Health
--------------------•--� Aa....................................
125S HOBBS & WARREN. INC., PUBLISHERS
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 593 i�{ annov5h �dl. ikjc�nn;5
owner' s name vi 0-9 n e_ POLCJ CA o c: ape op�IC lCtnS
Date of Inspection M y
PART A
CHECKLIST
Check if the following have been done:
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
available with N/A.
t� The facility or dwelling was inspected for signs of sewage back-up.
r/ The site was inspected for signs of breakout. .
1/ 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
If residential
0 number of bedrooms
0 number of current residents
No garbage grinder, yes or no
AD laundry connected to system, yes or no
(o seasonal use, yes or no
If nonresidential, calculated flow:
I2�tQ, 1 51-o c-e. ._ 5 b G ,P: lb,
Water meter readings, if available:
Din. [moo .� Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
W010e- 6 M
tJb System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
✓ S,gptic 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:
iVU Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:l/
(locate on site plan)
depth below grade: I `
material of construction: t"*'- concrete metal FRP other(explain)
dimensions: 8 ' [o X y ' IU"
H " sludge depth
distance -from top of sludge to bottom of outlet tee or baffle
2 " scum thickness
t.,� distance from top of scum to top of outlet tee or baffle
I,A„ 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 fQr repairs, -etc.,) �}
lees pR - �. O"J-" �eJC1 W-A 0"Tli
DISTRIBUTION BOX: N D.-unAe_r CL5pha14
(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:
(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. )
r
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : 'Pi4-
(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 ( i t_, C)DO G Ia L.
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. )
(rood work.;-Na cjodlc�� �lOn
CESSPOOLS (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 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. )
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
Rt 132
AlB
0 septic tank-inlet
A B a pit
75' tank 15'
79' pit 31'
DEPTH TO GROUNDWATER
3y,
*Q , $ F+ depth to groundwater F,
method of determination or approximation:
1.10I A l 3n -L on e D Mn, r I I�i4 5
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?
NO Static liquid level in the distribution box above outlet invert.
On(Aer Q.5pha-14 Pa-k-- J0 lof.
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow? E s
�I Required pumping 4 times or more in the last year? ,
number of times pumpeda
r ;
}. r.. r ... ... .. ...w .x...:..ie — . .........a.n..
N 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? ,
N within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
. water supply?
N— 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?
'1J 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 analysi
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
e
13
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector
Q r�o� (`1 c�ea 11►5��
Company Name (20 rsJroL-�, ov,
Company Address ij Pon 6�-ceeA
psi-�r,;�11e; �`c� oars
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. The 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
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.
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 Signature a i14L
Date Jain-e- 13.1 Pq
Original to system owner
Copies to: I own a �r�S�c�b�e �c���( o-'r Neut�-l1
Buyer (if applicable)
Approving authority