HomeMy WebLinkAbout0048 OVERLEA ROAD - Health . 48 overiea ,Road
Hyannis
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LO T ION S EW A G E PERMIT 'NO.
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VILLAGE
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INSTA LLER'S NAMIE & ADDRESS
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6 U I L D E R 0 OWN Ell
DA T E P ER T ISSU E' D y `�
DAT E COMPLIANCE ISSUED
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20
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Fps.
THE COMMONWEALTH OF MASSACHUSETTS
/BOARD OF HEALTH
..ICE,.W_I ..............OF.......
.�/�!/�S_�-�:.� .._.._..._.-..
Appliration for Dhipoii al ,ark cinstruitinn rruti#
Application is hereby made for a Permit to Construc ( or Repair ( ) an Individual Sewage Disposal
System at:
................_._.. .... . C._�, 1......__._/ �?�wo... ..:. ..............................�..G?..T... -
Location-Add or Lot No.
/Z IV r
W .... L�'Se tr ...... _ .�'---- . --.....�-.i►✓................ ...............-•---.................. .--•---.
Owner ��^ .Z� � S d Addres
Installer dA dress
Type of Building ` , Size Lot----------_/_ _Sq. feet
V Dwelling—No. of Bedrooms________________?__._____._ .__._Expansion Attic ( ) Garbage Grinder W9
►-+
Other—Type e of Building ersons____________________________ Showers
tz, YP g -------------------------=__ No. of P ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------------------------------------------------- I.............................................................
Design Flow..................................... per person per day. Total daily flow....................... CO.......gallons.
WSeptic Tank—Liquid capacity_l.�_gallons Length_l_P___'_(.e.'.'___ Width__5 1_Fi.n Diameter________________ Depth.____.1.__.
x Disposal Trench—No_ ____________________ Width_................... Total Length.................... Total leaching area.. __�1:.__;._._sq. ft.
Seepage Pit No._'�___'L-------- Diameter......IO___._.__ Depth below inlet____5.....______ Total leaching area. „___�_.._.sq. fx
Z Other Distribution box QK) Dosing tank
'-' Percolation Test Results Performed by-.gip___ f'LC c.y�C R:- NQ y.-/!?K� Date_._�__�_� _I
a 0--------.
Test Pit No. 1_._t'_ -___minutes per inch Depth of Test,-Pit.... �______. Depth to ground water.._ ®_..__...-
44 Test Pit No. 2__ 4._2..__minutes per inch Depth of Test I ...... Depth to ground water....NP___.._...
a ./0 1 0 y�= !'!!pyvt a vas o!_�,o _:.2 y"----�s -"
0 Description of Soil------------ .......Aet!o......j—ev 2-,-2--------- NC[1IJ/L�T.Ei = -------------------
T P
v ------------------------------------------•
----------------------------------------- �"� .;.5A11JD i 17 '�-._/41 .......�(!f1/TG S.q t/�O__....._/UU 1N.9>F'f2...
T/ COU.(>T.E EIj
U Nature of Repairs or Alterations—Answer when applicable..........................................................._...................................
------------------------------------------------•---------------------------------------------•_•--••---••------•-••----••-•-----•------••-------------...-•-----------------•----------------...._..__.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State San itar o e T e ned further agrees not to place the system in
operation until a Certificate of Compliance has en'issu by e bo,r health.
Signed.---•:,. .----...• -------- t:--- ---... ....... ................................
Date
Application Approved BY 1'e.� = -------------------•--....................... --------------
Date
Application Disapproved for the following reasons____________________________________
----------------------------------------------------- ......----___,
-'............................-.............................................................................................--------•---------•----•----------------------•----------------------•--...
Date
T-`- �- Permit Na__11_.'s�y
- ----------------•---------------.. Issued.......................................................
_ Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- /CIA/.............OF......
ApplirFatiuu for Dispao al Workii Tonlitrurtion Prrutit
' .Application is hereby made for a Permit to Construct (X) or Repair ( } an Individual Sewage Disposal
System at:
- ............._.... ---k!. :s _,<, ..........!;ZO _-_ --•----•-•-••--•-••••.............••.La..............................
Location•Add or Lot No.
�:. t. . _ ..__�. .��.............................................--....-..............................................
W Owner Address
,-a ••••.........••.........•••------- -
....................................................
� .•, Installer Address "�'-
UType of Building tt ,{{ Size Lot------_.__ _ _Sq.-feet
Dwelling—No. of Bedrooms________________` ______________________Expansion Attic ( ) Garbage Grinder W9
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures
d
W Design Flow......................._........... _gallons per person per day. Total daily flow_._._._..___.____.__::_ : .......gallons.
WSeptic Tank—Liquid capacity. _gallons Length_h�__Sn. ._ Width... Diameter_______________' Depth.....
r x Disposal Trench No_ ____________________ Width___t.............. Total Length.................... Total leaching area........................r� sq. ft.
Seepage Pit No ___. - __--__ Diameter------/1-________ Depth below inlet.....5�".__......... Total leaching area._'4.%_f..sq. ft.
Z Other Distribution box (,X) Dosing tank ( )
Percolation Test Results Performed by. *Q... _ Date... 21
_'_ :
••--•-•....-
Test Pit No. L_______________minutes per inch Depth of Test Pit_.:�:.�_!��'._e,_____ Depth to ground water:._ ..._._______.
f3. Test Pit No. 2_..e.4 .._minutes per inch Depth of Test Pit `_ ? r`_____ Depth to ground water---- p_.....
__
O Description of Soil.............I-W. 49 }q iilu Ia/�3r�'. ' .' EC�c�ii.t ', '.f� ?
VA .... --?.. . 4 ,�(ram" .kv �✓p. G idJJ ',�"�' z.Sa{J:t `�../Ge,,.. 4 ... �'� P
•W ------"�----------4� s-10 `I�..>__-�a-`'uA.�._../" ..........iV g/ :r4r*.5"`.?f"0_-----:�'t.�(�'----o' 41"":161Z----1F1UCaD�.X1)7",e'eAZ,
x
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•-----------------------------------------------------------------------------------------------•---------------------------------------------------------------------------•-•-.....__......_.....................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITiZ 5 of the State Sanitar o e T e, ned further agrees not to place the system in
operation until a Certificate of Compliance has b en issu by bo o health.
Signed......... ...... �- ................................
•`f. --/ •�.3
Date
ApplicationApproved By-•••-------.. =---------•--------------------------••--------------...........•---•--- .................
Date
Application Disapproved for the"following reasons-----------------------------------------------------------------------------------------------------------------
Permit No.... ._.....`�° Date
cr
Issued..........................................................
Date '
THE COMMONWEALTH OF MASSACHUSETTS- # r'
BOARD OF HEALTH
��:1 ......... OF...3 / 9t �r f- ..
TrrtifirFatr of ToutpliFattrrY'
THIS IS TO CERTIFY, That the Individual Sewage.Disposal System constrgcted,t ( or Repaired ( )
by.................��-_ :_Ifi._ !c `.__--• �e > -- .... 1 . ............................................
at.-•-••----•- /_d l w ...................................
---• --- -•--• ... _ ----
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary 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....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS .
l _ BOARD OF HEALTH
...-.....OF._.....�� 1 �/I /c. .
a� ;..........
No.. ...� FEE........................
1 ` Disposalurku utr � tutrrutit
� ermission is hereby granted------ '_---- -----•-
to Construct ( ,or Re ( ) an Individual.sewage Disposal System
at No. ______-_ _`
Street
as shown on the application for Disposal Works Construction Permit No.. ___......1._ Dated..... ..........................
--------- ------
Board of Health
DATE•Y�- ......--5
`, FORM 1?55 HOBBS & WARREN. INC.. PUBLISHERS
?EI;U M Y 13 PM 3- 31
7 105—
DATE
PROPERTY ADDRESS 48 Ovea.eea Road
Kyann.izpoat
' Na.6,3 02672
On the above date, th®;.teptic system at the address above was
Inspected.
This system consists of the following:.
- 1 o 1-1500 gaiion zept.ic tank.,
2.• 1- Dizt.zigut.ion* Box.
3., 2-1000 ga eon ieach.ing 72it¢.'
Based on Inspection, I certify the following conditions:
4., 7h.iz .iz a 7.it ee Pave Septic zy.6teh ('18 Code)
5.- The .6e121_.ic •.6yztem- i, .in -paojea woizk.ing oadea at the
�ae�ent time:
6., Both ie¢ch.ing p.it,6 weae day at, time o, .in, e o
SIGNATURE -
a., .
Name::Robert A. Paolini
Company: Joseph P. Macomber & Son Inc .
Address: P. O. Box 66
Centerville. Mass 02632
Phone: 508-775-3338 or 508-775-6412
-JOSEPH P. MACOMBER & SONt, INC*
Tanks-Cesspoolsd,eachflelds
•Pumpod .&.•.Instilled
Town Sewer-Conne4tions
P.O. Box 66 Centerville, MA.02f 32-0066
775=3330 . 7 .5.6412
COMMONWEALTH OF MASSACHUSETTS
£XECLTpIVE OFFIGE•OF EN-Vile 'WSM�AL AFFAIRS
. ` DEPARTMENT-OF jIMItOMMENTAL PROT'�C`1 ON
y
A.k ,.;' TITLE 5
OFFICIAL INSPECTION FORM—.NQT;FOR.'VOLUNT"YMEWS
S.MS.MACE SEWAGE DISPOSAL SYSTEM FORM
PART-A
CERTIFIC8TIQN
Property Address:4 8 0 v ��
yannch/202; na
Owner's.Name:Ri cha2cl DL a oo 2�_
Owner's Address: 18 ountau ( Ou0 �� rve
Cummauu r d l7a ?h 3Z J
41 1210 i
Date of Inspection:
Pogeat R l ao.eini
lease rint),, W
Nance of Inspector: (p P
Company Name: co
Mailing-Addt'ess: I
e , ad.a.•OZ63z Telephone NumbCERTTFICA'TION STATEMENT .I have ersonally inspected the sewage disposal system at this address thaw� d on my .
I certify thatp inspection.The inspection was p
below is true;accurate and complete as df the time of the insp ms.I am a DEP
training and experience in-the proper function and maintenance of on Bite sewage disposal U s
approved system inspector pursuant to�Section.1�5:340.otTttle 5(310 CMTt liSc000). The system:
X rX passes'.
-Conditionally Passes
Needs Further Evaluatiortby the Local Approvin&Autbority
F s ate
D
Inspector's Sigua�nre: : '
inspection reportto the.ApproWnp Authorlty(Boird of Health or
The system inspector shall submit a copy of this insp or has a design flow of 10,000
DEP)within 30 days of completing this inspection.If the$ystepi is a.shaied sy
gpd or gfeater,the inspector and the system'owner.stiall`submct a report to the appro riate o sVPMvM9
licab It,and f
DEP.The orig'uial should be sent to tha system ovrnm and copios sort to the buye r,{f app
authority.
Dotes and Comments
****Th ls'rep ort only describes conditions at the time of inspectidri-and under the
conditons same of a different
..^ lt
tone.This Inspection does not address how the system will perform inu the
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION.FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:4 8 O v e a 2 a /2 o a d
Ily nnizRoAt Na
Owner: /2.ichazd lDipaoia -
Date of Inspection: 4122105
Inspection Summary: Check. A;B C;D or E/ALWAYS�couiplete all of Section;D
A. System Passes:' q E S
NO l have not found any information.which indicates that any of the failure criteria described-in 310 CMR
15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
Sep- .ie zuz"tem .ins .in. Pit oRe2. woA kin'9 oncle2 at the /22ezant time'.,
B - . .
S stem Conditionall .Passes:
Y Y
NO One or more system.components.as described in.the"Conditional Pass'section need to be replaced.or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer,yes,no or not determined(Y,N,ND)in the ' for the following statements.If"not determined"please
explain.
NO The septic tank is metal.and.over 20 years old*.or the septic tank(whether metal.or not),is:structurally "
unsound,exhibits substantial..infiltration or exfiltration or tank failure:is:imminent:System will pass inspection.if the
existing tank is replaced with a complying septic tank;as approved by.the;Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain.
NO. Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box, System will pass inspection if(with
approval of Board of Health):
broken.pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced "
ND explain:
- NO The system required pumping more than 4 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 u
obstruction is removed
ND explain:
2
Page 3 of I I "
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART A
CERTIFICATION'(continued)
Property Address:48 Uve22ga Road
Ryann.i,6Ro2.t lea
Owner:.kichaltd D ipao ea
Date of Inspection: 4122105
C. Further Evaluation-is Required by,the Board of Health: -
NO Conditions,exist which require further.,evaluation.by.the Board.ofHealth in order to determine ifthe system
is failing to protect public health,.safety or the environment.
1. System will pass unless Board of Health determines--.-in accordance with 310.CMR 15.303(1)(b)that the
system is not functioning in.a manner which will.protect public health,safety and the,.envir-onment:
n o Cesspool or privy is within 50 feet of a surface water
n o 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 land Public Water Supplier,if any)dotermines:that the
system is functioning in a manner that protects the.pilblic health,safety and environment:,
NO The system has aseptic tahk and soil absorption system{SAS).:and the SAS is within 100 feet.of a
surface water supply or-tributary to asurface water supply.
no The system has a.septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
rz o The system has a septic tank and,SAS`and the SAS is within.50 feet of a private water.supply well.
rto The system has a septic tank and SAS and the-SAS is less than 100 feet..but 50 feet or more frorh a
private water supply well". Method used to determine distance- v L3U'a.2
"This system passes if the well water analysis,performed at a DEP certified laboratory,, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other
failure criteria are triggered.'A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIALINSPEETION FORM-NOT TOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION:FORM
PART A
CERTIFICATION(continued)
Property Address•48 Ove.¢.�ea 12oad • r
�11 arzhiz o �u � 2Na
owner:R-i'cha2d Di doia
Date of Inspection: 4/Z /OT.
D. System Failure Criteria applicable to all systems:.
You must indicate."yes"or`ono".to each ofthe:following,for all;inspections:
Yes • No
_ X. . Backup-of sewage•Into-fattity-:or system-component due-!to overloaded,or clogged SAS..ar.cesspool
_ X " Discharge:or ponding of effluent to thm surface of the:;ground or..surface maters due to.an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above.outlet invert due:to an overloaded or clogged SAS or
—' cesspool
X Liquid depth in-cesspool is less than 6"below invert or available volume is less than'Wday flow
T_ .Required pumping more,than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
-of times pumped
X Any portion of.the SAS;cesspool or privy is below high ground water elevation.
_ X A iy.portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface
T water supply.
Any portion:ofa cesspool-or privy is within,a:Zone!l.ofapublic.well..
_ X " Any portion of a cesspool or privy is within.50 feet of a private water supply well.
X Any portion of a-cesspool or-privy is less than 100 feet but greater.than 5,0 feet from a.private water.
' supply well with no acceptable water quality analysis. [This system..passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic.compounds
indicates:that the well is.free from pollutiow.from:that.facflity and.the presence of ammonia ,
nitrogen and nitrate nitrogen is equal to or less than.5 ppm,provided that no other failure criteria
are•triggered.A copy of the analysis must be attached,.to this forge.]NO,- (Yes/No)The system fails.I have determined that one ormore-ofahe:Oove.failure.•criteria exist as.
described in 310 CMR 15.303,therefore the.system-fails.The system owner.should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
-To be considered a large system the:system rnustserve.a facility,with a.design flow of 10100.0 gpd to 15i000.
gpd•
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)
yes no
.
the.system is within 400 feet of a surface drinking water supply
_ X the systp.m.is within 200.feet of a tributary to a surface drinking water supply
X 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
f If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"Yes"in Section D above the large system has failed.The owner-or operator of any large system considered a
significant threat under Section E or.failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional.office of the Department.
4
t -
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SLtSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM
PART B
CHECKLIST
Property,Address:48 Ove/lie a. Roar
Hu arzni�izo2t �10.
Ownerl2•icha2cl D7 iLEo Qa
Date of Inspection: 4122 22 it 05
Check if the following have been dyne You must indicate"yes or to,,as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health `
X Were any of the system components pumped out in the previous two weeks?
X .Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of thlansptction?
X Were as built plans of the system'obtained and examined?(If they were not available note as N/A)
X. Was the facility.or.dwelling inspected for signs of sewage backup?
X — Was the site'inspected.for signs of break out:?
X Were all system components,�Acluding the SAS,located on site?.
X Were the septic tank manholes.uncovered;:opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and:depth of scum? .
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper`
maintenance of subsurface sewage disposal systems?
The size and location,of the Soil Absorption System(SAS)on the sitelas been deterir}ined based on:
Yes no
X Existing information:For example,a plan at the Board of.Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation-of distance .
is unacceptable)[310 CMR 15.302(3)(b)J
Page 6 of 11
OFFICIAL w..sPECTI .FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISP-.0SAL:SYST19M>IWECT1`ON FORM �
PART.0
SYSTEM_MORMATION
PropertyAddress:48 0ye/L:eea Road
K ann.i1s o./zt Na
owner:/2.icha2 lD.il�ao ea
Date of Inspection: 4/2 2/0 5
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design: :-4 ... :Number of.bedrooms..(actual): 4. 4 X 10 4 4 0Gi D
DESIGN flow based on"310 CNOt lS.203(for example:110 gpd s#ofbedrooms):
Number of current residents: .1
Does.residence have a garbage grinder(yes or no): r,o
Is laundry on a separate sewage.system(yes or no):. n o (if yes separate inspection required] ,
Laundry system inspected(yes or no): is o
Seasonal use? (yes or no):rt o 0 3=3 3 3, 0 0 0 ga i e o ns qi!D=*912., 3 8 .
Water meter readings, if available(last 2 years usage(gpd)): 0 4=12 6, 0 0 0 ga.e$o n 13 G%!D=3.4 5 2 0
Sump pum (yes or no): n o
Last date o occupancy: on rz o w n _
COMMERCIAIUSTRIAL `
Type of establ}snt: N R
Design now.(l 'a on 310 CMR 15.203 xpd
):.
Basis.of dt�si yflow(seats/persons/sgft,etc.):,
Grease trappresent(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/use: .
OTHER(describe):. ,
GENERAL INFQATION
Pumping Records
Source of information: Not ava.i&.&Pe
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X 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) '
_Innovative/Alternative.technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank. Attach a.copy of the DEP.approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
.cnhta-Ued 1983 /
Were sewage odors detected when arriving at.the site(yes or no):Xf
6 _
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INS ASSESSMENTS
FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:48 Ove2Qea I2oa.d
fl./ann.L.s/2o2t Na'
Owner: Richazd Q-i/ ao ea
Date of Inspection: 4/22/0,5
BUELDING SEWER(locate on site plan) `
Depth below grade:4 P 3" `
Materials of constructio cast ast iron _40 PVC X,other(explain):L-i yh� we j gh.t I VC .
Distance from private water supply well or suction line:.10 f/e et
Comments(on condition"joints,venting,evidence of leakage,etc.):
ocnts a eat tz ht. No . •s�ic .s o� Qeakaye. System �� vented
tnzough houze vent.
SEPTIC TANK:y e-Alocate on site plan)1500 ya'.e eo n-.s
Depth below grade:6•�
Material.of construction:-_ concrete metal,_fiberglass_polyethylene
_other(explain) _
If tank is metal list age:— Is age confirmeS by a Certificate of Compliance(yes,or no): (attach a copy
py of
Dimensions: 10' 6 n L X 5 ' 8 a 1Z X 5 ' 8 n y
Sludge depth: t a a c e
Distance from top of sludge to bottom of outlet tee or baffle: t2 a c"a'
Scum thickness: t 2 a c e
Distance from top of scum to top of outlet tee or baffle: t 2 a c e
Distance from bottom of scum to bottom of outlet tee or baffie z a c le
How were dimensions determined; m e as ti e d
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural
as related to outlet invert,evidence of leakage,etc:): integrity,liquid levels
lank •shoujd le, 12um12ed eve2y 2 yea2�s. Inlet out�e tees ate in Qa A \
Tan �z auc u2a y noun eve a ate no2m. R ee.
GREASE TRAP; NU(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: v
Distance from bottom of scum to bottom of outlet tee or bafll
Date of last pumping;
Continents(on pumping recommendations,inlet and outlet tee or biffte condition,structural as related to outlet invert,evidence of leakage,etc.): integrity,liquid levels
rat.
Ti*la S Tnennn4inn Fnrm Ail sionnn 7
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
P,R&URFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
-Property Address:48 Oveztiea Road
H4jrinn-J'Annnf /yin
,Owner;l2iaha2d Dipao.ea
Date of Ibspection: 412210-5
TIGHT or hIOLDING TANK: N0 (tank must be pumped at time of inspect ion)(locate on site plan)
Depth below.grade:
Material of construction: concrete metal fiberglass----polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: t gallons/day ..
Alarm present(yes or no): -
Alarm level; Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc,):
T.iah.t oa ho ed-ina .tank. ate -no•t Pee,in t ,
DISTRIBUTION BOXq f S (if present must be opened)(locate on site plan)
Depth of liquid levelabove outlet invertp
Comments(note if box is level and distribution to outlets equal,.any evidence of solids carryover,any evidence of
leakage into or out of box, etc.)
Box' -ins .levee., It has '3 iatelta.&3., No' .s.ign�s o;e .so.Qid caa2y ove2.
No Xeakage to on ou
PUMP CHAMBER: NO (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.):
Pump cham9ea .is not /z�,ent
8
Page 9 of l l ;
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: 4 8 0 v a o rz cl
annzz o2.t . l7a
Owner!Ucha2d D 2' a a
Date of Inspection: 4122105 ,
SOIL ABSORPTION SYSTEM(SAS):, .(locate on site plan,excavation not-required)
If SAS not located explain why:
Located zee page 70
Type
X leaching pits,number: 2 -
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,,dimensions:
overflow cesspool,number:'
innovative/alternative system Type/name of technology:
•t' of vegetation,
• Comments(note condition of soil; signs of hydraulic failure,level of ponding,damp soil,condition
etc.):
Loam t o medium. iaacl., No z.i n '
egea a ion iz no2ma e.' .
CESSPOOLS: NO (cesspool must be pumped as part of inspection)(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(yes or no):
Comments(note condition of soili-signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Ce,35 kQQJZ CiRP a0i D noAonj,
PRIVY: NO (locate on site plan)
Materials of construction:
Dimensions:
Depth-of solids: J
Comments(note condition of soil,signs of hydraulic"failure,aevel ofponding,condition of vegetation,etc.):
9
Page 10 of 11 �. ^
OFk CI, - QP �OV ASSESSMENTS
. FC, RSFRV Y.
: . lgP-QS��•SYSTEM-.INSPEC.TION:FORM
SP$S1A:CE SEAC�E I�
PART C-
SYSTEM INFO (nontinured)'
Property, Address:
--------------
Owner:
Date of Inspection:
S TCH OF SEWAGE•DISPOSA,L SYSTEM
Provi sketch of the sewage disposal system including ties tout least two perinanerit reference landmarks or
benchmar .L,ocate all wells within 100 feet.Locate where public�water supply enters.the building.
-t'
w.
10
I ,
Page 11 of 11 _
- Y ASSESSMENTS
_ VOLUN
TARY_ FOR
VO
. FORM NO
T' OFFICIAL'INSPECTION FO
--� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 UUea.eea Road ,
K u aan.i�
Owner: R_ichaad Na/zoia
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells.
Estimated depth to ground water 50 feet .
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed:
y e z Observed site(abutting property/observatign hole within 150 feet of SAS) y
u e Checked with local Board.of Health-explain:��s P u i P-1 c a a d
n o Checked with local excavators,installers-(attach documentation) ,
.e�®ccessed USGS database-;explain /�r town.,g a a n!5 cz t�i e. ma.,u h
�—.. You must describe how you established the high ground water elevation:
l•1,,ed Ca Re' Cod Commizion Oatea Ta�2e 995tou2.s And 1 u9Qcc lJatea Su�/2�y
G/eQi head ao.teezion aaeas ma Se t
�a e2 sehouaee� o ices cane cod comm.izion., -
� n •
Leaching .
Pit' 12 '. Beet
Groundwater3 8'Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method 2.4
' Therefore,the vertical separation.distance between the bottom
of the leaching pit and,the adjusted groundwater table is
feet. 3:5,,6
11
• .. Tsrsis•e••mrmr3isr•r••}
:r•RflnTlrRi'fC�'iT�iRT1fR'RTIt►ITRRSRTTRTft'li1'TS791fJ!nRaTILT97RTR7YTO1'�i7LlRlofRn
TOWN ,OF BARIVS7R 3L£ I30ARD OF HEALTH
SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM - PART D• CERTIFICATION
. - raKr.tue+e•tn,trml�Ta*++'e•�1A' nm1 vnraT••rr•�/—r•�
•""�:�t;T-r,�:.» � � - -TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRES$ 48 O'veaiea Road Hyannizpo2t
ASSESSORS MAP, BLORK AND- PARCEL # 287-152 -
OWNER'S NAME Richalt d .Dipao.e.a
' PART D -,CERTIFICATION
NAME OF INSPECTOR Ro&e._�_' Pa.o11ni '
COMPANY NAME ;ozeph P_ f?acom&e^',Son Inc
COMPANY 'ADD.RESS , Box 66 Cen•teavit.ee as.s• 02632
Street Tort, or City. State UP
COMPANY TELEPHONE ( 508 ) 77.5 - 3338.7 FAX ( 508•.b90 - 1578
R701 Ct17 Rl.IR'Si R, ,
CERTIFICATION STATEMENT
I "certify that I have personally .inspected .the sewage disposal system at
this address and that the information reported .is true ,. a.cetirate-, and
omplete as of the time o,ftinsp.ection. The inspeetio:n was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site _sewage disposal systems -
Check one: '
XXXX Systeiri PAS S`ED • ,
The inspection which I..hav ' Conducted' has ,not found any information .
which indicates that, the system ,.fai.ls to adequately protect .public
`h.ealth 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.
System FAILED*
The ifnspectian which II*,have can L ted has found that the system fails to
R protect the jiublic health and the environment in accordance with Title
51 310 CMR., 15 . 303, and , as specifically noted on PART C - FAILURE
CRITERIA .o'f . this in ` ectio :.form.
r
Inspector Signature Date
Onecopy of this certifi.cat-ion must •b.e provided :to the .OWNER, the. BUYER
here appli.aable ) and the BOARD OF HEALTH.
* If the inspection FAILED., the owner .or operator shall upgr:ade' the system.
within o•ne year of the date of the inspection, unless. allowed or requ.i;red '
otherwise as provided in 110 CMR 16 , 3051
partd.doc
Make application to local Fire Department.
Fire Department retains original application and issues duplicate as Permit.
��jh�xrmz�zta�t�axe r�ea�rsicea—�c aair�a��iiXe ��ez��zl,�,an .
APPLICATION and PERMIT
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisio
of M.G.L. Chapter 148, Section 38A, 527 CMA 9700, application is hereby made by: ns
•
Tank Owner N e(please print) Richard Di ola
X
Address 40" Vetlay Road Hyannis rt, MA
swat C,
Sure VP
Company Name Enviro—Safe Prig Co.or Individual
Addr ss P•O•-BOX 810, E.Sandwich, MA
Address
Sig ature (if applying for permit)
Signature(if applying for permit)
IFGI Certified Otherff-TIN O IFCI Certified O LSP#
Other
--T
Tank Location '.48 &erla Road _ cry 11 17 D
seer adaess. HYi � MA ! I l 02
Tank Capacity(gallons) '11000
Substanc
e
. .�. Last Stored #2 011
Tank Dimensions(diameter x length)
Remarks:
7MCMO
Firmtransporting waste - Enviro=Safe State Lic.# 329 MA
Hazardous waste manifest# E.P.A.# MAD9 8 5 2 6 9 3 2 3
Approved tank disposal yard Turner Salvage Tank yard# 002 I
Type of inert gas Tank yard address 235 Commercial Street Lynn, MA
City or Town _ Aif//j//� FDID# D 2 99594
ermi
Pt#
Date of issue Date of expiration
Dig safe approval number. 19993109318 Dig Safe Toll Free
Signature/Title of Officer granting permit T�t
w
After removal(s)send Form FP-290R signed by Lo I re a to UST Re ulato X
Room 1310,Boston, MA 02108-1618. / 9 rY 'ompliance Unit, One Ashburton lace,
L-Al
292(revised 9/96) �'
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS- �pF"'Le4 ror
ASSESS ORS MAP NO. PARCEL NO..
ADDRESS: — VILLAGE �IIIV f"y Qr �l
NAME',-
CONTACT PERSON y ' — PHONE NUMBER
LOCATION OF TANKS; . CAPACITY: TYPE-OF• FUEL. AGE: TYPE: LEAK
OR CHEMICAL: Z DETECTION
� fc'�l sYSTEM
DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5. _
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.
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