HomeMy WebLinkAbout0021 JANICE LANE - Health 21 Janice.Lane, Hyannis
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
implication for 13ispo9al *pftr ✓��IYstCUttion 3pPrmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( omplete System ❑Individual Components
Location Address or Lot No. a1/ aAN<G L.IV If 1V1,S Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 3611,32 7 a( -T41J/(Z6 OF- t4uu )lt'(
Installer's Name,Address,and Tel.4b. ',6 g--q z 7_g-8 7 q Designer's Name,Address,and Tel.No.
CA PE LU c D E eVT6;PQ.15�5 C.C.G. N A
t 5'3 6&WA — r _
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(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 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 Certificate of
Compliance has been issued by this Board of Heallh-n,
Signe Date
Application Approved by 74. J Date —
Application Disapproved by Date
for the following reasons
Permit No.?(j Date Issued
—�
----------------
rqb� &_1 P�
No. 04 Q l `I I Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered;ncomputer:
' a Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Misposaf *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(V ®complete System ❑Individual Components
Location Address or Lot No. ;t I ,TAiV'/ 'G Ln/ tf%t0jd1UlS Owner's Name,Address,and Tel.No.
13ARDO(AA (3a9&k
Assessor's Map/Parcel 367 77 t, _;U -7•41JICE LAOS t4YAtJXX
Installer's Name,Address,and Tel.146. 'Sbg_q-17_gg Zr7 Designer's Name,Address,and Tel.No.
' CA Pc-W tDe �T Qt5 5 c,c.c. NA
Type of Building:
i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
r
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: 1,
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in t_
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of '
Compliance has been'issued by this Board of Health.
Signed, Date
- 1
Application Approved by Date
Application Disapproved by U Date
for the following`reasons
Permit No. ) ON - I :�7 Date Issued T - r/ f
TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
CoAAec �
�y.�p� �.VX_ Certificate of Compliance ,
�T IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandone )by n It-, E?�!�7 Zd�Q I< t' (,LC,
a cA/ -r,4010—r— //RAJ- HY"I has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.2 0 /
LJ- I dated 7- /V
Installer CAPRA)Ipz�' LG Designer tU
#bedrooms r ► Approved desig flow ti A 1 gpd
�
The issuance of this permit shall not be construed as a guarantee that the system will/functio/n)as designed.IL
✓ /�f ,j (`�
Date
Inspector
1;
No. 1((_ Z Fee
/ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal *pstrm Construction permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon
System located at TAm(cic_ 4-.4eUg HY w ut s;
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must he completed within three years of the date of this permit. R
Date 6 // Approved by V V' l
AsBilt Page 1 of 1
w . -
'TOWN OF BARNSTABLE
LOCATION_ � �cnr.t sP. Uv--Q SEWAGE d - 6�' _
VILLAGE ASSESSOR'S MAP & LOT:F0 7 -.-- ;r
INSTALLER'S NAME & PHONE NO. �CQZA+ L"N
SEPTIC TANK CAPACITY `QbV 65,1 O 04-X
LEACHING FACILITY:(type) Y�.�.Q,�t�Js..t/S (size)lZe �'n v,&
NO.OF BEDROOMS(`PRIVATE WELL OR UBL WATEQJ6
BUILDER OR OWNER c)nN 0
DATE PERMIT ISSUED:
/6 1y,S_
DATE COMPLIANCE ISSUED;
VARIANCE GRANTED: Yes No
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Postage $ S
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Certified Fee / / 1
0 Retum Receipt Fee tf j Postmark
l€ l Here:
(Endorsement Required) ` f Jar
Restricted Delivery;Fee Ik�
t7 (Edorsemen ni Required)
O Total Postage&Fees
rNaa WALTER& BARBARA BAKER, III
r21','JANICE LN
R� ,
HYANNIS, MA 02601
Complete items 1,2,and 3 Also.complete A. Signature
item 4 if Restricted
.Delivery is desired. \, /�
® Print Your name and address on the reverse X \ �y✓'S ❑Agent-
so that we can return the card`to you. 0 Addressee
e Attach this card to the back of the mailplece, B. ecelved by(Printed a C. Date of Delivery
or on the front if space permits.
1_Article Addressed to: D. Is delivery address different from I em 1? ❑Yes
If YES,enter delivery address below. ❑No
WALTER_,&-BARBARA BAKER,-IIf
2 JANICE,LN
H ANNIS,:MA 02601
3. SSegoce Type
G Certiffed Mall ®F.xoress Mall
ti 0 Registered Iff Return Recel r Me dise
❑Insured Mall ❑C.O.D.
f, n
4: Restricted Delivery?(Extra Fee)
' 2. Article Number, Yes,
(transfer hum serv/ce tabs - — ---
9 7012 1010 0000 2848 1438
PS Form 3$1 f,February 20Q4 — Domestic Return Receipt
„ a 1,02595-02-M-1540
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Town of Barnstable Barnstable
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Regulatory Services Department "'�'��'�
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39- ,� Public Health Division
'Olfp MAl a -
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7012-1010-0000-2848 -1438
March 28, 2013
WALTER&BARBARA BAKER, III
21 JANICE LN IMPORTANT NOTICE
HYANNIS, MA 02601 Map & Parcel: 307- 276
The Department of Public Works informed us that public sewer lines are now
available in your neighborhood. According to our records, your property has a septic
system. This letter directs you to connect your dwelling, at 21 Janice Lane, Hyannis,
MA, to public sewer on or before 9/30/2015.
The old septic system must be either removed or filled in due to future safety
concerns. This may be done by the same contractor who connects you to the sewer.
Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main
Street,Hyannis.
Failure to comply with this Board of Health Order may result in a complaint
against you, in a court of law.
For additional information pertaining to the sewer connection, please see the
reverse side of this page.
PER ORDER OF BOARD OF HEALTH
Y)'YV�
s A. McKean, R.S., C.H.O.
Agent of the Board of Health
Cc: Barbara Childs, WPC/Roger Parsons, Town Engineering, DPW
Enc.
QASEWER connect\L.etters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc
-Public Health Division - March 28;2013
ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS:
SAVINGS AVAILABLE/GRINDER PUMP:
A reminder to those of you who need a grinder pump for your connection:
Department of Public Works (DPW) sent you a letter in December 2012 stating the town,
for a limited time of two years, only from the receipt of the DPW letter, would provide
you with the pump at no charge. (This can save you thousands of dollars.) Please note:
You must pay the installation cost through your own contractor. Please make your
contractor aware of this, if interested. Also be aware: this is a shorter deadline than
the Public Health Division's deadline on the reverse side of this page.
SAVINGS AVAILABLE/PERMIT FEE:
The Town offers a waiver of the residential sewer.connection fee of $420.00 for those
properties that connect within two years of the receipt of the DPW December 2012 letter.
LOANS:
For loan(s) available, please see the enclosed brochure, or see the town website:
http://www.town.barnstable.ma.us/cdbg (under the "CDBG Programs", see "Sewer
Connection Loan Program). For loan specific questions, you may contact Kathleen
Girouard, Growth Management, at 508-862-4702.
CONTRACTORS:
Information on Licensed Sewer Installers is available on our web site at
www.town.barnstable.lna.us/PublicWorksTech/sewerinstallers. Contractors, approved to
perform sewer connection work in the Town of Barnstable must obtain and file a Sewer
Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way,
Hyannis—contractors,please call Dave Anderson at(508) 790-6244.
- FOR ANY QUESTIONS [ASSISTANCE:
Len Gobeil at the Town Manager's Office is available to provide you with direction you
may need in reference to the Stewart Creek Sewer Connections. You may contact him at
508-862-4701.
QASEWER connecALetters Stewart Creek Sewer ConnectsWAUNG LetA Sewer 2Pgs Merged 3-28-13 Y0015.doc
e
' FS
Commonwealth of Massachusetts
Executive Office of Enviromlental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 'John i
D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD 4- 813
Governor
ARGEO PAUL CELLUCCI ti i
Lt.Governor c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F �-
PART A '�f
fl
CERTIFICATION NOV 2
ro O 4 1997 4
Property Address: 21 Janice Lane Hyannis Address of Owner: FCTyp VSTAStE
Date of Inspection: 11/21/97 (If different)
Name of Inspector: John Graci Donald Silva �
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number: Lr 9
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 This Inspection Is based on criteria donned In Title V
_ Conditional y P855C5 code 310 CMR 16.303.My findings are of how the system Is
performing at the time of the Inspection.My inspection does
_ NeedfF aluation By the Local Approving Authority not imply any warranty or guarantee of the longevity ofthe
Fells septic system and any of Its components useful life.
Inspector's Signature: Date: 11121197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
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 determined(Y, N, or ND). Describe basis of determination in all instances. If."not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is 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 WNW)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
Fv)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 21 Janice Lane Hyannis
Owner: Donald Silva
Date of Inspection:11121197
_ Sewaqe backup or.breakout or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
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.
2) 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
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate elther"Yes"or"No"as to each of the following:
_ 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.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revleed 04rl7197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 21 Janice Lane Hyannis
Owner: Donald Silva
Date of Inspection:11121197
D] SYSTEM FAILS(continued)
Yes No
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).
Numbers 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 1 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
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 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:
Yes No
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 OWD97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 21 Janice Lane Hyannis
Owner: Donald Silva
Date of Inspection:11/21197
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_t_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x 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.
x The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)(15.302(3)(b)]
(revleed 0427187)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 21 Janice Lane Hyannis
Owner: Donald Silva
Date of Inspection:11121197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 9•P•d.lbedroom for S.A.S.
Number of bedrooms:4
Number of current residents: 5
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): Noila
Water meter readings,if avable:(last two(2)year usage(gpd):
n1a
Sump Pump(yes or no): No
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:9 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped in September 1997
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: Na
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)_( if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source Information:
1996
Sewage odors detected when arriving at the site: (yes or no) No
(rev1sed0427197)'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 21 Janice Lane Hyannis
Owner: Donald Silva
Date of Inspection:11121197
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 1'
Material of construction:x concreate_metal_FRP_Polyethylene_other(explain)
If tank is metal, list age nla . Is.age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: t.6'6"H6'7"W4'10"
Sludge depth:1"
Distance from top of sludge to bottom of outlet tee or baffle: 26",.
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:0
How dimensions were determined: Na
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.)
Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: Na
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: Na
Scum thickness:Na
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: Ns
Date of last pumping;l
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.)
Na
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1'6"
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line?own
Diameter: 4"_
irveirnments: (conditions of joints,venting,evidence of leakage, etc.) .
(revised 04127)97►
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 21 Janice Lane Hyannis
Owner: Donald Silva
Date of Inspection:11121197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: Ne
Capacity: rJa gallons
Design flow: rda gallons/day
Alarm level: n1a Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
ma I
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)to
Alarms in working order(yes or no)_yea
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(revised 04127197)
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 21 Janice Lane Hyannis
Owner: Donald Silva
Date of Inspection:11121197
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type:
leaching pits,number: Na
leaching chambers,number:3•flowdlfn,sera
leaching galleries, number: nla
leaching trenches, number,length: nla
leaching fields, number, dimensions:rda
overflow cesspool,number:Na
Alternate system: Na Name of Technology:_Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The flow diffusers were structurally sound and functioning properly.They had 3"of water In them.
3
CESSPOOLS:_
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: Na
Depth of solids layer: Na
Depth of scum layer: Na
Dimensions of cesspool: rda
Materials of construction: Na
Indication of groundwater: Na
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Na
PRIVY:_ `
(locate on site plan)
Materials of construction: Na Dimensions: Na
Depth of solids: Na
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
PdvyComments
(revised 04127)97)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
21 Janice Lane Hyannis
Donald Silva
11121197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
AA 1�
6A 3 Y'
Pay ! of 10
(revleed 04)27197)
I • V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
21 Janice Lane Hyannis
Donald Silva
11121197
Depth of groundwater 10
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and charts
_ I
)rye 10 of 10
(revised 0427197)
yam+ . TOWN OF BARNSTABLE
LOCATION ` t c ( .Q SEWAGE #
VILLAGE �� ASSESSOR'S MAP & LOT30 - z 74<
INSTALLER'S NAME 6t PHONE NO.
SEPTIC TANK,,CAPACITY `Q)0V
L)V+ 00-e:Gmag
LEACHING FACILITY:(type)S �6"� oZ'Jzrs (size)1�' p b �rd`Cr
NO. OF BEDROOMS-PRIVATE WELL OR UBLI WATE&Lb
BUILDER OR OWNER ,,�[�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No. 9.1r� _f / Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS
0pprication for Mi!6pool *pgtem Congtruction Permit
Application is hereby made for a Permit to Construct( )or Repair( Y�an On-site Sewage Disposal System at:
Location Address or Lot No. is Name,Address and Tel.No.
_ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
,G I
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 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Re airs or Alterations(Answer when applicable) A J V �C'�
'V
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 iss d by this Board
Signed Date
Application Approved by r %
Application Disapproved for the following reasons
1
Permit No. 9 3 "' � l Date Issued , !
1 —
! No. �q/ Feet
THE COMMONWEALTH OF MASSACHUSETTS -
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIPPftcation for -Mt!5Poga1 *p!6tem,CQngtructton hermit
F, Application is hereby made for a Permit to Construct( )or Repair( V�an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
a 1 � Clo'c"A6 a, 3w\;e_`
Installer's Name,Address,and Tel.No. "" Designer's Nacrre,Address and Tel.No. v
Qd
ScdA` IN S
• .i 1,
Type of Building: ik
Dwelling No.of Bedrooms UI Garbage Grinder( r,
Other Type of Building No. of Persons �� Showers( ) Cafeteria( ) `
Other Fixtures
Design Flow 41 v 0 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Re irs or
Alterations,(Anwer when applicable) A JJ LI Raj D`
� cPl � ®�' —
,_..cy .
Date last inspected: _.
Agreement: i r' TL
.*n-_. J
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'f
cate of Compliance has been issi6d by this Boaz
Signed A d i. F° Date _
Application Approved by
� - a
Application Disapproved for the following reasons
Permit No.. 7 , '' f� lJ Date Issued; 4?
——————————————————————————————————————THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVIISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance -
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(�)on
by �5CO m 71_w_U for
as t I-J` has been constructed in acc rdance�,
with the provisions of Title 5 and the for Disposal System Const o.tion Permit N . dated ,�' ~ / ��
Use of this system is conditioned on compliance with the provisions set forth below: �^
ale
No. � Fee ' O f
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
&.5po.5al *pgtem Construction permit
Permission is hereby grant 0-to S Co
to construct( )repair( )an On-site Sewage System located at Q cx t L ck& _
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.
Date: "^ r Approved b
TOWN OF BARNSTABLE
q
LOCATION a 1 .) apt, -- G I SEWAGE #
VILLAGE 14 X $ ASSESSOR'S MAP & LOT
INSTALLER'S NAME 6& PHONE NO. 04��/G
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 3 F/o w S ,! %(IWK- (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER L I✓�- wt L- Sd l
DATE PERMIT ISSUED: �f s 3,) , f
DATE COMPLIANCE ISSUED: -�
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
I
Appliration for Bilipnsal Warkii Ti n itrn.rtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( L.,�'an Individual Sewage Disposal
System at:
L_.1 ............. 1' t ..5...............................................
..-.--- - - Location-Address -..--or -----....Lot No.
�f�' .......................................................
-------••--.-...-.'.-...--.---
l ....,r ...I-,(�I�44 ..------a..".LSd�'l/.----------•---• -•--......-- .e. _
....--•----- ---•-•-•C.dJ� ..........•-- ----------------�------•---------------
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms......... ._...Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers Cafeteria
a' Other fixtures -----------------_....................................................................................................................................
W Design Flow.......... ......................gallons per person per day. Total 5,,y. flow____. c�. _.....................gallons.
W Septic Tank— .�Liquid capacity___.__.__.__ga]lons Length_ r._.. Width...
Diameter________________ Depth................
x Disposal Trench—No .P _ O._- 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................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........................
Pa' ------------------------------------------
•........
•-------
-.................................................................................................
0 Description of Soil...............................................................................-------------------------------------•-•-•---------------------•••--•--•..............---
x
(� ------------------------------------------------------
•----------------------------------------------------------------------------------------------------------------
-------•-------------------------
----•----------------------------------------------------------------------------------•------------------------------------.._....---------------------------•-----------------------------•••......••.
U Natur of Repairs or Alteratio s Answer when applicable.....P000_......&_5� �.. A_lt1....................
------ut`.feC/ ;. CS-----wA; .,...�bOE------Q-� e t? }—Z37--5 (S 1Z --.`_ . C-�i!(� ---•------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has be issued by,the boQrd of health.
Signed .........�...----..... _G� ............................... i
Date
Application Approved By ...............
CJ
e
Application Disapproved for the following reasons- ---------------------------------------- -------------------- ---------------------------------------------------------------
----------------------------------- ------------------------------------------------------ --------------------------------------....................................................-------- ...............................
q 'Dare
Permit No. /�..-...- ..�f.. Issued
Dale
No....
THE COMMONWEALTH OF MASSACHUSETTS �~
BOARD OF HEALTH -'
TOWN OF BARNSTABLE
Applutttiun for Disposal Works Tonotrurtiun 1rrmit
Application is hereby made for a Permit to_Construct (, ) or Repair ( 4,)'� Individual Sewage Disposal `
System at: .,,:A,
............... F-7 .....1 14 ------------- --• _ !,tQ_n�/ti/ ...................
- •-------...-e- -....:......-
Location-Address •--•• -•or Lot No.
- t�l-- _�•A am la �
....-----• _ :-=- t5_,,.4 ---------------------------------------------------
-
Owner Address /
a �'"�� 1 ,,/J1 L,j /c/ Sim' E!%. � �--�l� ••e .-•---�`•...... •••••• /(^
- ----------------- --•-----..-
I Installer Address r
Type of Building Size Lot............................Sq! feet
a Dwelling—'.\No. of Bedrooms___.....-.�.............................Expansion Attic Garbage Grinder,( )
aOther—Type of Building ............................ No. of persons......................... Showers ( ) — Cafeteria,!( )
Otherfixtures .............................=.........................................................................................-•-------•--------------•--•-
W Design Flow...........5Z� --------------------gallons per person per day. Total daily flow.....�_"'?Z-)---------------- --.gallons.
WSeptic Tank—Liquid capacity.._.___.....gallons Length...i. .._._ Width.... ._._. Diameter............:... Depth.._._......._..
x Disposal Trench—No.3..PI lam!: 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 ( )
aPercolation Test Results Performed by.......................................................................... Date............................-----•------
,� Test Pit No. I................minutes per inch Depth of Test Pit.....................Depth to ground water.......................
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ----------------------------------------------------------------
".................-----.... ...•...........................................................
0 Description of Soil..............................=--------------••--•---------•--....------------•---------------------------.............-----------••-------------------•---------------
U ...............-.........................................................................................................................................................................................
----------------•-------------------------------•----- ---•-•-•--------•--•-----------•--•---•----------------------•••-•-•----....------------•--------•--•-------•------•--.....----..........._.
U Nature of Repairs or Alterations—Answer when applicable...._. —--_
► u � i Y � rl� a.................
........... Z r `5. _ --- . .
Agreement:
C
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance.with
the provisions of TITLE 5 of the State Environmental Code—The undersign,ed.further agrees not to place the.
`system,in operation until a Certificate of Compliance has been issued by the board of.health
Signee
Applicaticin Approved B \ °r --!.�C
x Applicatlon Disapproved'for the.f0 lowang rearonr.
------ ......... ----- _-
.;
. ....................
Dart
Permit No.
--------- ------------/ .=....�. .,.j----- Issued ----
rive
THE COMMONWEALTH OF'MASSACHUSETTS
r'
BOARD OF HEALTH
TOWN OF BARNSTABLE
CnPxtttirate of C ampliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) orlRepaired
by ...cA..I.F... _.t .V1. i C�. .................-- ----------------
Insraller
at -------------------------.......... ..1-.. �® l� `C '1 .. f. - - � �' -
has been installed in accordance with the provisions of
TITLE 5 of The/State Environmental Code as described in
the application for Disposal Works Construction Permit No. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... .`.✓..�... ... Inspector ................................
v.....
;...----J-----------------------------------------
} THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
TOWN OF BARNSTABLE
No:.:..�� FEE...
Disposal Works Tunstrnrtiun rrmit
Permission is hereby granted kQ( t....:n«. Ftl 't. ...--••----••--------------•---.-----------------------
�.
to Construct ( ) or Repair _An Individual Sewage Disposal System
at No............................ .•of.....; ;�........ - • � ....................4rr Street 11 C ti..
as shown on the application for Disposal Works Construction Permit No. �l_�/ 7t Dated..........................................
•----.....-•---•-------------�;.. C�:=............----•---...-•-•-•---...........--•-•---
ec�� Board of Health
DATE------------------•-�'".L. ...L�..V--•-•••..; 4.��,j� a �+
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS