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HomeMy WebLinkAbout0083 OLD CRAIGVILLE ROAD - Health 83 OLD CRAIGVILLE RD., HYANNIS A= f I f I E i F i � o. Page 1 of 1 Wadlington, Ellen From: Wadlington, Ellen Sent: Monday, January 29, 2007 2:34 PM To: McKean, Thomas Subject: 83 Old Craigville Road Mrs. Rondinelli called re the above address. She wanted to relay that the material has been cleaned up and can be inspected. She stated she is following up on the extension granted by the BoH on January 10, 2007. If you have any questions, please give her a call at 781-769-5329. 1/29/2007 a' Town of Barnstable Board of Health P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. 1 January 10, 2007 Mr. and Mrs. Frank Rondinelli 14 Cherrywood Drive Norwood, MA 02062 ARE; Extens>on ofTune toRem'ove Branchesfrom $3 O1c1Craig �&IIeRoad;Hyannis Dear Mr. and Mrs. Rondinelli: You are granted an extension of time, until February 15, 2007, to remove the piles of tree branches from your property located at 83 Craigville Road, Hyannis. This extension is granted because you stated you plan to burn the branches and brush during the 2007 burning season. However, one cannot obtain a permit from the Fire Department to burn until after January 15th. 2007. An additional 30 days was granted to provide you reasonable time to ensure all of the branches are burned or removed from the property. Sincer y yours, r` W yne iller, M.D. Chairm n Board of Health Town of Barnstable RondinelliBranchesRemova107 Dec 04 06 12: 25p Ken Grant 781 -619-6771 p. 1 December 4, 2006 14 Cherrywood Dr. Norwood, MA 02062 Barnstable Board of Health , 200 Main St Hyannis, MA RE: notice#BAR-W5978 83 Old Craigville.Rd. Hyannis, MA Attention: Dr. Miller As instructed,we are forwarding this letter of permission to you for two reasons. First, we would appreciate your granted permission to extend our actions regarding warning notice#BAR-W5978 until next month, January 2007, during burning season. The original reply/request was received and documented by your office on November 14, 2006. Secondly, due to our permanent residence being in Norwood,MA (approximately 70+ miles away) and our employment obligations, we will not be able to attend this Thursday's meeting. In our absence we would like to grant permission to our neighbors(of the 83 Old Craigville address), Tom and Cathy Moriarty, to attend in our absence and represent our perspective. Should there be any questions, do not hesitate to contact us directly (781) 769-5329. Thank you for your anticipated understanding in this sensitive matter. Regards, g , Frank and Rose Rondinelli Gi. 1 { ,% November 14, 2006 Town of Barnstable G; Board of Health 200 Main Street Hyannis,MA 02601 Attention Doctor Miller RE:Notice#BAR-W 5978 To Doctor Miller: i I am writing to you regarding a warning notice we received about location/property: 83 Old Craigville Road, CenterV`M/Hyannis(Notice#BAR-W 5978) We are asking for a variance,or extension,to address the brush in back of the property. We received this notice on November 13,2006. The warning is dated by the office on September 7, 2006. According to the post mark on the outside of the envelope (which I retained)the letter was not mailed out to us from this office until November 9,2006. As you can see,that's two months after the inspection. As it stands, I have only two days to act on this notice,and address your concerns. I am asking to postpone any consequences/fines until the burning season begins in January. We had planned, as usual,to take out a permit, again,this year to burn away all the brush. We have always maintained a clean and well-landscaped yard. Your anticipated understanding in this time sensitive matter is greatly appreciated. Respectfully, Rose and Frank Rondinelli Home Owners I7oo/— 9 a � � w t r-. TOWN OF BARNSTABLE' BAR-W 5978 Ordinance or Regulation WARNING NOTICE me of Offender/Manager_Fn4-�\ � .dress of Offender 4 MV/MB Reg.# .11age/State/Zip A ®).- Oro' siness Name -` d am/V 2061 .siness Address '§i1gnatQV of Enforcing Officer .11age/State/Zip All Lrl fill cation of Offense A Aa Enforcing Dept/Divi ion I f e n s e. .cts Sl� PJRb .is will serkre onJQ as a warning. At this tifine no legal action has been taken. is the. goal of Town agencies to achieve voluntary compliance of Town dinances, Rules and Regulations. Education efforts and warning notices are tempts to gain voluntary compliance. Subsequent violations will result in propriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. 1� ----- NO.-'aq -,5--- 1 Fee BOARD OF HEALTH TOWN OF BARNSTABLE 0pp[icationArlVei[ Con5truct ion Permit App ation is er by adeQr permit to Cons r ct (�, ( ), or Repair ( )an individual Well at: ----------------------- - ----- ----- --- --- ,�j�,,/ Location /Address �— Assessors Map and Parcel Owner ppcan,� Address ---- ------- - -------- ---- � �'�----------------- Installer — Driller Address Type of Building Dwelling - Other - Type of Building-------------- No. of Persons---------------------------------- Type of Well--- � -------------—- Capacity-- ------------— r-------- Purpose of Well---- �� — -- 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 unt' a Certifi at of o 71Ahas been issued by the Board of Health. -- - - ---�-�—o - Si ed Application Approved - ---- -— - -- date Application Disapproved for the following reasons:------------—------------- -- - -------- -- ------------ — - ---- -------------------------- - ------ --------- date � Permit No. -��— -- -- Issued--- ��t -®--- -- ----- ---- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of IComp MCC THIS IS TO CUTI�I That hg Individ 1 Well Constructed (vj, Altered ( ), or Repaired ( ) by---------- �L 0 ----- -------------------------------------- - -—- -- ---------- Installer at---------- __�'_� 22-01-- ------------------------------------ --- ---- - 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 No. --------------Dated------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- --- ------- - -- Inspector-- - --------------------------------- - No.- -�= - l Fee------ ----- BOARD OF HEALTH TOWN OF BARNSTABLE - application forlVell Co0tructionpermit Application is her by made for a permit to Cons r ct (�, Altt ( ), or Repair ( )an individual Well at: oG� L •�� IZ& Al d _ ----------------------- --- - ---- Location —Address - Assessors Map and Parcel Owner Address --------- ----- ----- ----- --------------------------------- - - - Installer - Driller Address - -- Type of Building Dwelling ---------- Other Type of Building--------------- No. of Persons------------------------------ Type of Well--- 5� - —---- Capacity-_� y� Purpose of Well---- 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 Cornplian -has been issued by the Board of Health. Sigc ate Application Approved y - ---- -— ---- date Application Disapproved for the following reasons:— ----------------------- -------------- --- ----------------------------- - ---------- - - date o Permit No.— -_�`'�-�-�—'• ©—$- — Issued-----C, r -= — -- ---- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That thg Individ jal Well Constructed (vI, Altered ( ), or Repaired ( ) by Installer athas been installed in accordance with th provisions of the Town of Barnstable Board of Health Private.Well Protection Regulation as described in the application for Well Construction Permit No. ---------------.Dated----- ----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---------------- —_ — - — -- Inspector-- - - = - ——------ - BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Con5tructionVermit �a �G 5 No. ----------- t �- /� �f fee_—_-----___ Permission is hereby granted to Construct ( (Alter ( ), or Re air ( ) an Individual W 11 at: 3^ ---- -- ---- -- ------------------------------------- NO. --------_ street as shown on the application for a Well Construction Permit C7P �j ( ' __ Dated - tP�-`v-� ----------------- - No. - -- - .J ----- - "----------------------------- /� - -- Board of Health DATE /0 - LOY COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A// DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617)292-6500 TRUDY Stcr ARGEO PAUL CELLUCCI TF S D 8 DAVI . ' F. Govemcr Cor SUBSURFACE SEWAGE OMPOSAL iSYSTEIAII NSPECTIOM FORM / PART A -Property(9/*a641-1. c�✓,Ile, 9d �1 �NAif /J��Q/`ERT'FMATION / / v� 1 tidni.at o n.:oam.. v lacf ,►�i�r"S �fJ�o N►e 11__"4/�1 Qate of le spacdon: '�Q/��J�I C l Nam.of Inspector.(H.tea Prirttl , ' /a/'� iol e,/l i I ant•DEP ove¢S w�eetor to SOLOon tb,340 of Title b 1310 CMR 15.0001 Company Mama: r//V �—' �C �7 Mang Address: Telephone Mtambar:( r aWo CERTIFICATION STAB I certify the, I have personally inspected the sswege disposal System at this address and that the information retorted 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: v Passe: Conditionally Passes Needs Further Ev luatlon By the local Approving Authority •� _ Fail % inspector's signature: C/& i The System Inspector shall ubmit a copy of this inspection report to the Approving Authority (Board of Noalth or DEPtwWn thirty(30)days c 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 own shall submit the report to the appropriate regional office of the Department otEnvkonntsnW Protection. The original should be sent to-" system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 `�Pnnied on Recydrd P&pu I SUBSURFACE SEWAGE DIIPOSAL IYSTfa7Y1 YISPEC110l1 PORM PART A �A �� �� ��� li f r CfillTiF#CATfON 1 y�.. 1 1 Property'ddreea' Pm►q e d �j p�wvt fS` owrmrr: i/1 /GI�'v✓� Q` pats of Irhep.o.en: 9 '00"o iNSPECTWX SUM Y: Chick A. 8. C. Of D: 4. ffiY PASSES: I have not found any Information which Indicates that any of the failure aero dons dowWbed in 210 CMR 16.303 exist. Any ftikue witerls not evaluated are Indicated below. , COMMENTS: S. SYSTUA CONDITIMALLY PASSES: One or more system components as described In the•Conditional Pass'seaflon need to be replaced or ropalred. The evatefn,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 44--ote yes, no, or not determined(Y.N,or NDI. Describe bell@ of determination In N Instancell. H "not detanthinad",explain why not• _ The septic tank is metal,unless the owner or operator has provided the systant Inspoctor with o espy of a CattHleato of Compliance IfMached)Indicating that the tank was Installed within twenty(201 roars prior to the date of the k+npeation;or the septic ter*.whether of not metal,Is ansltad,structurally unsound,shows substantial IrAtration or sxliltrotion.or tank failure is Imminent, The system will pass Inspection if the existing septic tank Is replaced with a complying&optic tank to 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 obstnrotad pipets) or due to a broken, settled or uneven distribution box. The system will pass Inspection If(with approval of the Board of Health). broken pipets)are replaced'. obstruction Is removed distribution boa is levelled or replaced • The system required pumpfno I mi.than fourVmoe•yeer•dus to broken w eirmcted plpolst. The vystern will Ism inspection If Iwfth approval of tM Board of Health): broken pipe(s)wo replaced obstruction is removed revised 9%2/96 Period1 e v. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 00 ,/ _� �� � CERTIFICATION Ico+rtinued) Property Address: �76&1 �` J �� a l Owner: k1LA �-ova Date of Inspection: 0 C. rFURTHER EVALU TI 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 tt public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 I1Hb)THAT THE S! IS NOT FUNCTIONING IN A MANNER WHICH-WILL JMCITECTTHE PUBLIC HEALTH AND SAFETY AND THE ENWRONMENL- Cesspool or privy is within 50 feet of 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 ANY)DETERMINES THAT THE SYST FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supp tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS 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 tf well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or le: than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3orn i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Iro+ma+ed) V l% )U ( 01P1 �� oacol Property Address: / Owner: /(� / -pv / Date of Inspection: //11 JJ } D. SYSTEM FAILS: 9 0o Q You must indicate either"Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 irriofacility-er-v"tem component-dos,tto an overloaded oreMgged SASor:cesapool. =�----- -. 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 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). Number 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. V� Any portion of a cesspool or privy is-within a Zone I of a public well. Z/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. 7 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" to each of the following: The following criteria apply to large systems in addition to the criteria above: i 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 ia-witlwn 200 feeto(+tributary-toa ourfaoe-drinking-water•wMly 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforgiation. revised 9/2/98 PaRe4orII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST a 3 Ad �� G����i o Q1 Owner: �Q Date of inspection: �V(/eci 1�� -Zhave .0,01Check if the followinbeen done: You must indicate either"Yes" or"No" as to each of the following: Yes V Pumping information was provided by the owner,occupant, or Board of Health. V _ None of the system eompooents.h_`1man isompedWoraRJoest-two%weeks an&tbe system hasbwoaoceiaingewsastal low 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. V _ The facility or dwelling was inspected for signs of sewage back-up. V _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. 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 septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. L1 The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H: J� _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) The facility owner land.occupaats_Jf dlfferaat trot-%moor).aware-prauWad.with iofnrrn zt on on.tbe.p .maair4Lrtaooaof Subsurface Disposal Systems. i - revised 9/2/98 page torll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 0`�y/ Owner: A/",/- /o V- / Date of Inspection: FLOW CONDITIONS RESIDENTIAL- Design flow:—I-0—g.p.d./bedroom. Number'of bedroom (d;_ es' ri):-�- Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder)yes or no):2 Laundry(separate system) (yes or n /v(� If yes,sepaWeinspaction required _ Laundry system inspected (y s or no_� Seasonal use(yes or no):AVf/ Water meter readings,if available(last two year's usage(gpd): /If//// Sump Pump)yes or no): O/ Last date of occupane. (7 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: aad ( Based on 15.203) Basis of design flow 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: System pumped as part of inspection: (yes/or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, data installed4if Anown►•and source704armation: ---� -- — _ Sewage odor detected when striving at the site: (yes or no) revised 9/2/98 Page 6of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: �1191-0'd (Locate on site plan) Depth below grade: Material of construction: "cast iron_40 PVC_other(explain) Distance fr p. to water supply well or suction line Dia meter Comments: (condition of joints, venting, evidence of Ieakoge,etc.) SEPTIC TANK: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is fnetal,list age_ Js.age confirmed by Certificate of Compliance_(Yes/No) 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: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, strueturai-integ►ity, evidence of leakage.etc.) GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: 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: Date of last pumping: Comments: Irecommendation 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.) revised 9/2/98 Psge7or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION f�(oartirtusd) Property Address: Owner: VLA (.�I 0 Dote of 7&LD�IN/GTANK._ 4-oov TIGHT O (Tank must be pumped prior to, or at time of,inspection) (locate on site plan) Depth below grade:_ Materiel of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOXA (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, etc.) j PUMP CHAMBER:/V (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 .r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrtira 1 � Proper ty�A Owner: 20(�S �, Yo�Date of Ir�pe oae+: �SOIL ABSORPTION S SAS) (locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: l leaching pits, number: Ctl- leaching I chambers,number: /� W I � � 0/ 5 4'Pit leaching galleries,number:_ i , leeching trenches,number,length: leeching fields,number,dimensions: A �� �2✓�'�PVI�` ` _ 1✓�S�l�c �e� overflow cesspool,number:_ 01- Comments: ( /o— l) s��j r v1 ✓1 S SQ Alternative system: /' / ✓l Name of Technology: n 5�0 N e G✓1 Lv � (note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) CESSPOOLS:_ (locate on site plan) " G} Number and configuration: Depth-top of liquid to inietin rt: Pv,•r .,�0'1 �o �,v �C� /5 _ �L� -/ /� // Depth of solids layer: * l gv/ e 9/" �S s Depth of scum layer: Dimensions of cesspool: f7�cr 1'7S s a / l�v� GV� Materials of construction: V G Indication of groundwater: Iry 2 �/C��A✓) ��s jj/'C U�, inflow(cesspool must be pumped as pert of inspection) Comments: (note,condition of soil, signs of hydraulic failure,level of pending,condition of-vegetation, etc.) - PRIVY:& (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) revised 9/2/98 Page 9ofit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '3 V/ / / e�y///� SYSTEM INFORMATION(confinu44 Property Address: V 1 �o Owner: ,� G, Date of Inspection: �191A Goo SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) d { S i t i 7,t- 3-3 7" 53 revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION(continued) Property Address. �ty ©�C ��✓rile �� �� c;,0P1 f 4Y 0, � OWIDsoMr: � l�l�®ems of NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked 4 Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 37 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property. observation hole. bassmeot sump etc.) Determined from local conditions Checked with local Board of health I Checked FEMA Maps Checked pumping records hacked local excavators. installers 7/ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) II 0 lee-,c � /G>-r� � �e lv lam(/ C' 421 3o 20� ^ d revised 9/2/98 . Parr It of I 7 r No........... 6.4f__. Fiziz ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �. _...........O .A .................................................. Appliration -for 13ispootti Works Toastrnrtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( )�ividual -Sewage Disposal System at ation-Address .•- or Lot No. ______ _________________________________ ___-•----------_---- --___.___------------------------------•------- Owner Address Instal ler 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 ( ) Q' Other fixtures W Design Flow--------------------------------------------gallons per person per day. Total daily flow----------------------------------------.._.gallons. USeptic Tank—Liquid capacity........-...gallons Length................ Width................ Diameter................ Depth......._.....-. xDisposal 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 ( ) aPercolation Test Results Performed bY--------- ------ --------------------------------------------------------- Date----- --------------------------------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit..................... Depth to ground water......................_. 44 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water...-....._-------------- �+ ----------------------------•-------.....-...-•.-----•--•-•---•--•-•--•-------------------------------................................................... ODescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x ------------------------------ ----------.....---.-.-........._...-_.-_....-..--•------••---- ---------- -- -- / V Natu e of Repairs or Alterat one—Answer when livable.. -.. . .. ._./ 1...P-D 4 __... d -"" . --- ----------------------- - A Bement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be t sued byjx4oard of yal.t igned-. - ----- - ---- --� -._ h -`-+`�� ----------- - ----- Date Application Approved B ........ 7G Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------------- --•..__.....-•---•-----•--•------•------------------------•------------...----•-•••-----••--•-•--•---•••---•--•----------•------•-----•-------•--•-•----•-------------------------•--...••--------•----- Date PermitNo------------------------- --= •--•••------•-----_. Issued........................................................ Date No........... ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .................................................... Appliratinu -fear Miipoiittl Works (omitrurtiuu Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( Wran Individual Sewage Disposal System at 4 ---•--•--••----• -•- -•-••--•-- ---•- -•-•••-• ----- 0 ---•--. ----- (f.ocat,on Address �'� or Lot No. Owner Address a ......-- ---- ---------------•-•-----• *---------------------- ---------------------------------...........-•-•••-••-•-•••---•----•....----.......--•--•--•••--- 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 ( ) Q' Other fixtures Q :--------------------------------------------------------------------------------------- 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-.._-__---_.---._.-----. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------•-•---- -------------------------•-•---•--•-•-•-••-• ..........................................................................------------- ODescription of Soil--------------------------------------•----•-•-•-••--•----•----••-----•----••---------------•--------•----...-•--• ............................. -----•------ x V -----------•-•-----•--------•---------------------------------------------•-----•-------••-----.._._..........---....---•---------•----.....................--•-•-•-----..........._...._-------------- UW ---------------------- ...................-.................................................................... •----------- ---....-.-----•------------------------- Nature of Repairs or Alterations—Answer when applicable Y p° s --.._..... `__.. Ai reement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be.-r1"t`ssued by th oard of health t, Date Application Approved BY............. ....... �i(.!f - - --- f�/---------------- �Date Application Disapproved for the f ollowing reasons----------------•-------•------------------------------------•---•-----------.-----.-------•----------•---------- ---.------•--.--•-•----------------------------------------------•--------•---------•----------------.--- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ............0F........ .... . ..an "' .'...'` "I .................. Trrtifiratr of f ompliaurr T S T ERTIF4Y, hat the Invi 1 Sew ge Disposal System constructed ( ) or Repaired by.. ; �di ---- -------- -------------------------------------- at.- � ��=/------ 1. ( /� ��lle f -- v+� TT yy r has been installed in accordance with the provisions of . rti e-/ I of The State Sa �v de as described in the P . application for Disposal Works Construction Permit Now �� dated.�✓'/�-�l.•-... _.!_i..7 +--. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. - DATE-------------------------------------------------------------------------------- Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEA.LT_H� � j,1- �r, .............OF......... � ' ! No.----ice-- - ......... . FEE. ........... Permission is hereby granted ---- ✓ fr =............................................................. Y g ✓ to Constru•t ( ) or Repair (")an I dividual S a i posal�Syste.mn.at No. E,t 2' = /1 . ./ 1 / ..-- ...... . ..... .v Streit '� as shown on the application for Disposal Works Construction it No.:__... _ aced_--.--�..__��f.y.7l DATE. . ___ C/!---__ / ............. Hoard o Health .:.J' _._ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS S