HomeMy WebLinkAbout0116 PONTIAC STREET - Health 116 PONTIAC STREET, HYANNIS
A = 269 195
i
_f f TOWN OF BARNSTABLE
LOCATION �'J VQ V\+I GC 'rA- SEWAGE # `7 7-3 �d
VII,LAG ASSESSOR'S MAP & LOT Z`
INSTALLER'S NAME&PHONE NO. P� C� nt' �� ,- 77 6—y6L
SEPTIC TANK CAPACITY I SGa Qac1C o u
LEACHING FACILITY: (type) P r }k�fo (size) ���x as x 01
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: / 2 /Q'" 9 ?� COMPLIANCE DATE:
Separation Distance Between the:
j Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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L�111acn/� � tvo��
a a�
TOWN OF BARNSTABLE
' �. ill JVF '.. _ •1 -
LOCATION' 0 I'o V y' 1 iGC I��ne. ;% SEW\✓✓AGE'#
VILLAGE �-�VQ✓l�ll.S . r ` ' ASSESSOR'S MAP & LOT
a 1
INSTALLER'S NAME&PHONE NO. ! ",fin!I d C n oc Ec ll c 177-9`
SEPTIC TANK CAPACITY: I S�0 a�IC o t t
LEACHING FACILITY: (type)4. ' Co-mc i 10 4X+0 (size)
NO.OF,BEDROOMS -�
BUILDER OR OWNER Afa-"Y L X o PIS V 3'
2 O- DATE: 2 `>
Pr MPLIANCE
PE / CO
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any.wells exist
on site-or within 200 feet of leaching facility) Feet .`
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
r
Furnished y K ,
w) ,
3 .
o �
O p
M
• 4 0 '
D
66
.,
No. ta. . 7 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
/'
01pplication for Mt-4pos Y *pgtem Con5tructiun permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ^omplete System 11 Individual Components
Location Address or Lot No. � —�yti t(�C_S(fie Owner's_Name,Address and Tel.No.
's
Assessor's Map/Parcel Q" �� L� 1 CA.v
Installer's Name,Address,and Tel.No. J Designer's Name,Address and Tel.No.
W% S_r P\
o,o I
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures C I
Design Flow �3 30 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank _ n Type of S.A.S. t Ci .K- c)L
Description of Soil Q SKh'�/
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 ironmental Code and not to place the system in operation until a Certifi-
cate of Compliance ha�.l�e sue y o
Signed Date
Application Approved by Date / Z/d��
Application Disapproved for the following reasons
Permit No. Date Issued
No. / �, r {� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
ZippYication for Mi_4po2;ar *pztem Conf�truction 3perrnit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ^omplete System ❑Individual ComponeV
Location Address or Lot No. ice;i(�L.S!-e-'T Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. J Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms .3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures Design Flow -_3 3U gallons per day. Calculated daily flow 731'n gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �i I'Q C. Type of S.A.S. - •JA
n ✓
Description of Soil �j S,,q v�
f
Nature of Repairs or Alterations(Answer when applicable)
r i 7 ( i ►�S C.�.� C(r S(C. p k-.S t��
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_kwironmental Code and not to place the system in operation until a Certifi-
cate of Compliance hasrbeen-iss'a -y i - om ealth. '
Signed, Date
Application Approved by _ Date / 2—/o'
Application Disapproved for the following reasons
Permit No. Date Issued Z�B
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( .
Abandoned( )by �e I)-GA(� S;�C�(--
at o Do^ W e- !:,a (/----e'i 4-`�titer-y+,ia has been constructed in accordance
with the provisions-of Title 5 and theforDisposal System Construction Permit No. -7, 3 dated
Installer rx . . .-�' Designer
The issuance of this pemut shall not be construed as a guarantee that the syste wi functi��a=9signel.
Date Z If - r' Inspector �-
.. -ale-
No. ---?8� ------------- ------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
�i��oga'r �pgtern �ongt�Lion �errrYit
Permission is hereby granted to Construct )Repair( )Up rade( )Abandon( )
System located at ( --C_
and as described in the above Application for Disposal System�Construction Permit. The applicant recognizes his/her duty to
11
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of.,this e
Date: �C" Y.--�""1 i Approved by
�✓ � I \
loor
,,�
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only:
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
1, �, ✓ Ahereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at ilk ( l'�(Il - , jG meets all of the
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)'Top of Ground Elevation(according to the Engineering Division G.I.S.map) acJ1—!
B)Observed Groundwater Table Elevation(according to Health Division well map)�U
\C�'c( F-V-t-
SIGNED : DATE: -/O "lt/
LICENSED SE IC SYSTEM I STALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder.cut
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Commonwealth of Massachusetts
Executive of Environmental Aff airs
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DEP
Department of
Environmental Protection S
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION d
Property Address:
Address of Owner.
(if different) t �
Date of Inspection: Pt � _
wt a2bc- 1
Name of Inspector: M iAael tD e�ecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o Box 2384 - M ashpee Ma 02649. Tel : (508)4771420
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
---- Conditionally Passes
---- Needs further evaluation by the local Approving Authority
---- Fails
Inspector ' s S ignatur . ( Date:
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (30) days of 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 owner shall submit the report to the appropriate regional office or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if applicable
and the approving authority.
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 t, g k
Owners : 43�X. Nt e—
Date of Inspection :
INSPECTION SUMMARY:
Check A, B, C, or D
A) SYSTEM PASSES:
-k I have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are
indicated below
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 determinate (Y,N, or ND). Describe basis of determination in all
instances. If "not determinated",explain why not.
---- The septic tank is metal, 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.
---- Sewage backup or breakout or high static water level observed in the distribution
box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven
distribution box. The system will pass inspection if (with approval of the Board of
Health).
----- broken pipe(s) are replaced
----- obstruction is removed
---- distribution box is levelled 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address : \ L, �IN C_
Owner
Date of Inspection : c�``6,-b
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health , safety and the environ-
ment.
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 of water
---• Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING 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 water supply or tributary to a surface water supply.
---- The system has a septic tank and soil absorption system and is within a Zone I
of a public water supply 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 is less than 100
feet but 50 feet or more from a private water supply well, unless a well water analy-
sis 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 notrogen is equal to or less than 5 ppm.
D)SYSTEM FAILS:
-- I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM 15.303. The basis for this determination is identiied below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
--- Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
I
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: l\10 '43ti k j ��—
Owner:
Date of Inspection :
D) SYSTEM FAILS (continued)
-- 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 over-
loaded 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 NO T 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 cesspool or privy is within 100 feet of a surface water supply
ortributary to a surface water supply.
---Any portion of a cesspool or privy is within a Zone I 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 ana-
lysis. 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.
i
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: I\k, -PIC
Owner:
Date of Inspection
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above :
The design flow of system is 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 :
--- 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 I I of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compli-
ance 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: r � R)NT%pc_T
Owner: 5T�et�I-r�
Date of Inspection:
Check if the following have been done :
-x 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 system has been receiving normal flow rates during the 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 NIA.
--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.
--x 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 sep-
tic tank was inspected for conditions of baffles or tees,material of construc-
tion, 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 deter-
mined based on existing information or approximated by non-intrusive methods
-x The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: i e Poi, , ,pc_ -Sr
Owner: <>M
Date of Inspection:
RESIDENTIAL:
Design flow : c—k,O gallons
Number of bedrooms :p2
Number of current residents: L)
Garbage grinder (yes or no) : t,J
Laundry connected to system (yes or no):
Seasonal use(yes or no) :J,�
Water meter readings, if available:
ti r.z,
.Last date of occupancy :
COMMERCIALANDUSTRIAL :
Type of establishment:
Design flow : gallons/day
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:
I
GENERAL INFORMATION
PUMPING R E 0 R D S and source of information
...n?4 ...NC + �Q�.,
System pumped as part of inspection (yes or no) :.........
if yes, volume pomped : .................... gallons
Reasonfor pumping :............................................................................................................
V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 t i,
Owner: S-r -
Date of inspection: o1I �I
TYPE OF SYSTEM
--- Septic tank/distribution box/soil absorption system
--- Single cesspool
.. Overflow cesspool
--- Privy
XO hee Shard(explainj system�es or��?:to`(if�
es,�attach�evio�u\ \s in�spe_ction records, if any)
APP OXIMATE AGE of all components,date installed(if known) and source of information
. . x....c�.C....:L... .................................................. .......... . ....................
................................................................................................................................................
................................
Sewage odors detected when arriving at the site : (yes or no).....!'!?Q
SEPTIC TANK :
(locate on site plan)
rr
Depth below grade: ......
Material of construction: .. . concrete ......... metal ........ FRP ........ other (explain)
........................... .....................................................................................................................
Dimensions: SX .X;iS.
Sludge depth :..Q..'...... ,
Distance from top of sludge to bottom of outlet tee or baffle:.......3X.1..............
Scum thickness :......I..'........... ,
Distance from top of scum to top of outlet tee or baffle: ..........!.(.
.......................
Distance from bottom of scum to bottom of outlet tee or baffle :.......I.S..`............
Comments :
(recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid
. eluc in relation n to outlet invert,s inte 'ty,evidence of leakage,etc. .....
l�G. oQ
l �. ,............................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1\tc, Qtt'�\f- tg
Owner:
Date of inspection: C�k\.,V,
GREASE TRAP
(locate on site plan)
Depth below grade: ...............
Material of construction: ........concrete.........metal........FRP........other(explain)....
..........................................................................................................................................
Dimensions:...............................
Scum thickness:........................
Distance from top of scum to top of outlet tee or baffle:......... .........................
Distance from bottom scum to bottom of outlet tee or baffle:...............................
Comments:
(Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................
................................................................................................................................................
................................................................................................................................................
TIGHT OR HOLDING TANKS:.....
(locate on site plan)
Depth below grade:...............
Material of construction:........concrete........metal.........FR P..........other (explain)..........
. ................................................................................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallons/day
Alarm level:.............................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:t�b li6 1 g-7
Owner:
Date of inspection:
DISTRIBUTION BOX:...�XJ
(locate on sike plan)
Depth of liquid level above outlet invert:...................
Comment:
(note if level and distribution equal evidence of solids carryover, evidence of leakage into
orout of box, etc.)..................................................................................................................
................................................................................................................................................
..................................................................................................................................I.............
PUMP CHAMBER:.... .
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)....................
................................................................................................................................................
................................................................................................................................................
SOIL ABSORPTION SYSTEM (SAS):...- .s......
(locate on site plan, 0 possible; excavation not required, but may be approximated by non-
intrusive methods)
if not determined to be present, explain:
.........................................................................................................................................I......
...............................................................................................................
Type:
leaching pits, number: 11. .>c b e�—
leaching chambers,number:........
leaching galleries, number:...........
leaching trenches,number ,length:.....................
leaching fields, number,dimensions:...................
overflow cesspool, number:..........
Comments:
(noteWnc&,,' of,. il , Sig of ydra�uli�cf ilure, levpof ponding, o itio of veget n,
.moo
V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: l �41�tee_s`-1
Owner:
Date of inspection:
CESSPOOLS:....! -�.
(locate on site plan)
Number and configuration: ...................................
Depth-top of liquid to inlet invert: ...........................
Depth of solids layer: ...............................................
Depth of scum layer: ...............................................
Dimensions of cesspool: ......................
Materials of construction: .....................
Indicator of ground water: ....................
inflow (cesspool must be pumped as part of inspection)
.................................................................................................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
................................................................................................................................................
................................................................................................................................................
PRIVY : ....
(locate on the site)
Material of construction: ........ ..........................
Dimensions: ......................
Depth of solids: ................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.).
................................................................................................................................................
................................................................................................................................................
I
k
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of inspection: t
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'
2-1
f DEPTH TO GROUNDWATER:
Depth to groundwater: 30...feet
Method of deter ation or approximative:
u. ..................................................................................... .....
......................................... ................................. ..........................................................
................................................................................................................................................