HomeMy WebLinkAbout0369 STRAIGHTWAY - Health 369 STRAIGHTWAY, HYANNIS
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TOWN OF BARNSTABLE
LOCATION ,� 13� � _�l__ SE AGE #
VILLAGE tiI _ ASSESSOR'S.-MAP & L/OT
INSTALLER'S NAME&PHONE NO. �.
SEPTIC TANK CAPACITY Ale e)
LEACHING FACILITY: (type) L✓ ��.�.�- (size)eLD
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:/6`G'�7 v
Separation:Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Ching Facility Feet
Private Water Supply Well and Leaching FaciliYetk1ands
any wells exist
on site or within 200 feet of leaching facility Feet
Edge of Wetland and Leaching Facility(If any exist
within 300 feet of leaching facility) Feet
Furnished by
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___ _�
�� 2(,S?- AX .� $50 .00
No Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes /
" PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS �
01ppYtcation for Migpogar *pgtem Congtruction i3ermit
Application for a Permit to Construct( )Repair fix)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
raig wa -
Location Address or Lot No. MA y Owner's Name,Address and Tel.No.
Hyannis Beatrice Williams 47 LaBelle Dr
Assessor's Map/Parcel C h is o ppe e MA 010 2 0-47 0 6
In lle 'sI�m q�idress,and Tel.No. Designer's Name,Address and Tel.No.
K0 JnSon Septic Service
PO Box 1089 Centerville MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ng
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Re rs r Iterations(Answer when applicable) Title 5 Leaching consisting of
newp�-lox, and. 2 HD precast leaching chanbers .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thi�. e
.
Signed �G>1 'i Date . -
Application Approved by Date�JC2
Application Disapproved for tkJfollYving reasons
Permit No. - Date Issued
4S C
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TOWN OF BARNSTABLE
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LOCATION s Cr ,� YC A hIT k,1,4 SEWAGE # 3
VILLAGE I _ ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. L NS G A-- 2,5�- 2 2
SEPTIC TANK CAPACITY Ad 6--e) r r
LEACHING FACILITY: (type) = L✓oLD �� (size),-�
NO.OF BEDROOMS -3
BUILDER OR OWNER ,
PERMTTDATE: / 14-1. Z--2� COMPLIANCE DATE:/6—/,7-
Separation Distance Between the:
Maximum Adjusted Groundwater Table to.the Bottom of ching Facility Feet
Private Water Supply Well and Leaching Facility any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any vletlands exist
within 300 feet of leaching facility) Feet
Furnished by
6,
No. Fee $50-00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplication for ;Di-4pozal *pztem Con!gtruction Permit
Application for a Permit to Construct Repair( X)Upgrade Abandon Complete System 0 Individual Components
Location Address or Lot No. _36, t Owner's Name,Address and Tel.No.
9 S�ra K way 413-592
Hyannis MA Beatrice Williams 47 LaBelle Dr
Assessor's Map/Parcel Chicoppee MA 01020-47o6
Installer's N Address, Tel.No. Designer's Name,Address and Tel.No.]re&1d '? S
W E 0 ITS septic Service
PO Box 1089 Centerville MA 02632� 2
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder n?
Other Type of Building No. of Persons Showers Cafeteria(
Other Fixtures ;1
Design Flow gallons per day. Calculated dailyjldw_* gallons.
Plan Date Number of sheets Revisi-on Date
Title
Size of Septic Tank -----Type of S.A.S.
Description of Soil sand
Nature oA#Vai Title 5 Leaching consisting of
,p Broyterations(Answer when applicable)
and 2 HD precast leaching chanbers .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B d ealth.
Signed— Date,/
Application Approved by Date /e2
Application Disapproved for t6e/follging reasons
A,o
Permit No. y Date Issued
--------------------------------------- -
THE-COMMONWEALTH OF MASSACHUSETTS
Williams 7513ARNMIMU, MASSACHUSETTS /0—/-3
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired�' )Upgraded
Abandoned( )by
at 369 Straightway Hyannis has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer W E Robinson Septic Service Designer
The issuance of this permit shall not be construed as a guarantee that the systgern will function as designed.
Date Inspector-
- ---------------- ------------------
No. n/e/�i3 Fee$50-00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Williams
1=i!5po.e;a1 6potem Con.5truction Permit
Permission is hereby gran ed to Construct� )Repair(X)Upgrade Abandon
System located at 399 Straightway
HyaHn--ls MA
Installer W E Robinson septic service
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: Approved by
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)
ASSESSORS MAP N0:
PARCEL NO: ..2 `; f
L`7-2C/
I, William E. Robinson, Sr ,hereby certify that the application for disposal works
construction permit signed by me dated s6—,13--"1 concerning the
property located at 369 Straightway,Hyannis, meets all of the
following criteria:
* There are no wetlands 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 now and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not 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) j.
B)Observed Groundwater Table Evaluation(according to Health Division well map) ®
SIGNED: �� �.�� DATE Q �S
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
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COMMONWEALTH OF MASSACHUSETTS t)_t 9
F EXECUTIVE OFFICE OF ENVIRONMENTAL IRS 10
DEPARTMENT OF ENVIRONMENTAL TEC1Wq
3� ,•t
ONE WINTER STREET. BOSTON, MA 02108 61'7-29 -_ 00 �/0I O
.y / 2 5 19
98
5 (/ 70"
WILLIAM F.WELD o IDY CORE
Governor
A '`, Secretary
ARGEO PAUL CELLUCCI E Z AVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 369 Straightway, Hyannis Address of Owner: Beatrice Williams
Date of Inspection: 10/1 3/98 (If different) 47 LaBelle Dr
Name of Inspector: Wm E Robinson Sr Chicopee MA 01020-4706
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Servi cp
Mailing Address: PO Box 10890 C -ntpr >i 1 1 p., MA 02632
Telephone Number, 5 0 8 ` 7 7 r,—R 7 7 6
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 Signature: 4�tt , Date: 16'd 3—9
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 of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check , C, or D:
AI .SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYS EM CONDITIONALLY PASSES:
ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
ompletion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate y s, no,or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the.tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the Worid Wide Web: http:/twww.magnet.state.ma.us/dep
e'J Printed on RecyGed Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
"�t'�r+ 369 Straightway Hyannis
Addre.rProperty�� ss•
Williams
Owner: 10�13�98
"`Date of•Inspection:
it B],SYSTEM CONDITIONALLY PASSES (continued)
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). Describe observations:
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) FURT ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SY TEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
TH SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
EN IRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
!J 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 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. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 369 Straightway Hyannis
Owner: Williams
Date of Inspection: 10/13/98
D] S1kTEM FAILS:
You mu indicate eir;er "Yes" or "No" as to each of the following:
have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
f r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
th failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 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_.
l
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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 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 SYSTE FAILS:
You must indica either "Yes" or"No" as to each of the following:
The fo lowing criteria apply to large systems in addition to the criteria above:
T ystem serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public ealth and safety and the environment because one or more of the following conditions exist:
Yes No
th 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
th system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
pu lic water supply well)
The owner or opera r of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 C R 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) , Page 3 of 10
• 0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 369 Straightway Hyannis
Owner: Williams
Date of Inspection: 10/13/98
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
L/ _ The facility or dwelling was inspected for signs of sewage back-up.
V _ The system does not receive non-sanitary or industrial waste flow.
v _ The site was inspected for signs of breakout.
v _ 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.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
v _ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 369 Straightway Hyannis-
Owner: Williams
Date of Inspection: 10/13/98
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 250 g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder (yes or no): ®
Laundry connected to system (yes or no):kj�"
Seasonal use (yes or no):
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):
Last date of occupancy:Jf�a-�3"a/
COMMERCIAL/INDUSTRIAL:
Type establishment:
Design ow: gallons/day
Grease t ap present: (yes or no)_
Industria Waste Holding Tank present: (yes or no)_
Non-sani ary waste discharged to the Title 5 system: (yes or no)_
Water m ter readings, if available:
Last dat of occupancy:
OTHER: (D tribe)
Last dat' of occupancy:
GENERAL INFORMATION
PUMPING RECORD nd�urce of information:
System pumped as part of inspection: (yes or no).&O
If yes, volume pumped: 1 allons
Reason for pumping: .A' �l L� S
TYPE OF STEM
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: oo</255�IiCJ �Q^•J j" '
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
a
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 369 Straightway Hyannis
Owner: Williams
Date of Inspection: 10/13/98
8 UILD NG SEWER:
(Locate n site plan)
Depth low grade:
Material f construction: _cast iron _40 PVC_ other (explain)
Distance from private water supply well or suction line
Diamete
Comme ts: -ndition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
a �
Depth below grader
Material of construction: _/concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is 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 baffler % i
Distance from bottom of scum to bottom of utlet tee or baffle:
How dimensions were determined: 8 � -L=� 7'd N- Y�—
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle °depth of liquid level �tn relation t et inve true ural
irate nty, vidence of leak e, etc.) 64 0 �� 1 J J 'b
GR SE TRAP:
(loca on site plan)
Depth below grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimen ions:
Scum t ickness:
Distan a from top of scum to top of outlet tee or baffle:
Dista a from bottom of scum to bottom of outlet tee or baffle: .
Date last pumping:
Comme ts:
(recomm ndation 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 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 369 Straightway Hyannis"
Owner: Williams
Date of Inspection: 10/13/98
TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate iin site plan)
Depth be ow grade:
Material construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimens'ro s
Capacity: gallons
Design fl w: gallons/day
Alarm I el: Alarm in working order_Yes; _ No
Date o previous pumping:
Com ents:
(conditi of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: ,/
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level an distribution is equal, evAence of solids carryover, evidence of le age into or out of box, etc.)
6
PUMP HAMBER:_
(locate o site plan)
Pumps i working order: (Yes or No)
Alarms working order (Yes or No)
Comm ts:
(note ndition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 20
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 369 Straightway Hyannis
Owner: Williams
Date of Inspection: 1.0/13/98 /
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note_condition of soil, signs hydraulic failur )level of d f veetatio}, etc.) �/ J
CESS OOLS: _
(locat on site plan)
Numbe and configuration:
Depth-t p of liquid to inlet invert:
Depth o solids layer:
Depth o scum layer:
Dimensi ns of cesspool:
Materials of construction:
Inclicatior of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comm ts:
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on 'te plan)
Materials o construction: Dimensions:
Depth of s ids-
Comments:
(note cond tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 369 Straightway Hyannis
Owner: Williams
Date of Inspection: 10/13/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 369 Straightway Hyannis
Owner: Williams
Date of Inspection: 10/13/98
J
Depth to Groundwater // Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
1 /Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
5
Use USGS Data
Describe in your own wordshow you established the High Groundwater Elevation. (Must be completed)
(revised 04/25/97) Page 10 of 10
LOCATION SWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME i AD.D ESS
R U I L D E R OR OWNER
DATE PERMIT ISSUED
OAT COMPLIANCE ISSUED
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No! . .............................
THE COMM ONWE-ALiWOF MASSACHUSETTS
BOARD OF HEALTH
OW..rep.................oF......�'r9 lL. ..s.. , t.�L _..----------------------•------•-
Appliratilan for Ditipniial Works Tnnitratrtion thrutit
Application is hereby made for a Permit to Construct (VJ or Repair ( ) an Individual Sewage Disposal
System at:
............. ...... !?7 &I......................... .................................
Lo lion-Ad ss or t No.
�r'e.�r � .. . �? .�' .. !cnr� r....�r.�r -✓.tl --------•.................._.....
caner ...............+off Address
•
Installer Address
dType of Building Size Lot/O.d.25......Sq. feet
Dwelling o. of Bedrooms.................. ..............'.........Expansion Attic (su c) Garbage Grinder (Nod)
Other—Type of Building No. of persons............................ Showers — Cafeteria
W Other fixtures .......................................................... ----- --------------- ------------------•------ --------.--------------------------
-
W Design Flow............ZZ/0...................gallons per 44W;4? day. Total daily flow..........:3.3.0_...................gallons.
WSeptic Tank—Liquid capacity.&P.O..gallons LengthB:.�_ Width v..�q.°... Diameter................ Depth.. "
x Disposal Trench—No. ........ .......... Width.. ........... Total Length.................... Total leaching area............_---_ sq. ft.
Seepage Pit No....../.......... Diameter../jo----:... Depth below inlet...6........... Total leaching arear _sq. ft.
z Other Distribution box Dosing tank ( )
aPercolation Test Results Performed by. .6.aA_D_-A:.. ...... Date.- PAZil . -_3,,.29
a. Test Pit No. 1...,9!L --:.minutes per inch Depth of Test Pit../?- ....._._. Depth to ground water. j.vAe.f....__. '
GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-----•.....---•-•. ---•-••-••-•-•---•-•-•------••• .....•-- ••----•-----•.-•-•--.........................................................
O Description of Soil.... =1�.._. ---• -...r - S44J.bY-------
W
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 TIME 5 of the State Sanitary Code—T e undersigned further agrees not to place the system in
operation until a Certificate of,Compliance has been iss y th rd of 1 th.
1
S' ned......... Z
Date
Application rApproved BY 1«Jl� •---•---•------- --••
4/ Date
Application Disapproved for the following reasons:................................................................................................................ '
U
-- •---------------------------------J----•-•-----•--•-- .....-----(--�•--Date-----•--._... `
Permit No. • - Issued j� ---•-•------.
` Date
N �9 I.... 4 Fxs.... ... Lr
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALTH
..........::.....OF......&A.R.A)--S X.U 4.C..............._._.................
App iration for Disposal Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct (44 or Repair ( ) an Individual Sewage Disposal
System at:
• .I�/- N'o.L
- ............
e
Address
Address
Type of Building Size Lot/ .2_ ......Sq. feet
U Dwelling—No. of Bedrooms...............-............._. .Expansion Attic (JU 4 Garbage Grinder (Vo)
~ Other—Type T e of Building ............................ No. of ersons.............._......__...._ Showers —p`�., yp g p ( ) Cafeteria ( )
P4 Other fixtures -•---•-••-•-......-••-----•....••. -•-- •• • .....•• • • •.
4 .-•-- - ------------- .
W Design Flow............/1G1..................•..gallons per.F-Aa n p ay. Total daily flow...... '-.l ...........gallons.
W Septic Tank—Liquid capacity a.00 "..gallons Lengths 4.. ... Width` '�f?! Diameter_____ _________ lleth__�.+�'_
._ p r 'f
. ....
x Disposal Trench—No.................... Width._.................... Total Length...................... Total leaching area......... _._.sq. ft.
Seepage Pit No......1........... Diameter./D......... Depth below inlet..6..'.�.......... Total leaching area �K.sq. ft.
Z Other Distribution box Dosing tank ( )
a Percolation Test Results Performed by. Czar _A 4.? _ A_: PA f....... Date.APRA.....
Test Pit No. I..e.Z--_.minutes per inch Depth of Test Pit../.;.`......... Depth to ground water.A,i,v_Ao r....__.
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ...........•••••••--••••••••-••-•••-•••-----••••-••---•..............•--•-------------••----•-----......----•.._.......--••-----------•--•-- - ------
O Description of Soil t /2 ...... '. / ----- 4Lr4&:S e
v ................ ............ /4 '........ W/V_>---------------------------------------------------------------------------------------------
W
UNature 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 T IT j.E 5 of the State Sanitary Code— The undersigned fur r agrees not to place the system in
operation until a Certificate of Compliance has bee dd by the and f h th.
gned......... :.
-Vi --._..._..-••---••--•- •--•-•••••.--••z ...
Date
Application Approved By.... •. ... .. .............. ---•--�` �e -•' '
Date
Application Disapproved for the following reasons:-------•------------------------•--------- •---•---•----•----•-------------•--•-----------•------------......
.......................................................-------------•----.........................-••--••-•-•------•---•--•-••--•-•••--•---•----•-•--•--•.......••---•--••-••--•••------•-••--..------
Date
7Y
Issued_..1..a .--- -_Permit l�°b.............................• •------ •----•- -D� --------•----,
THE COMMONWEALTH OF MASSACHUSETTS
t
BOARD OF HEALTH
>.. .. ...........OF...: �,, /2.A).�� %�1�.....1 .....................
f�pr#ifirtt#� ia$ �ri�t�rli�a�trr �� ,,
THIS IS TO CERTI they vi( ual wage Dis osal System constructed r Repaired ( )
C�
by y -E.�� I ...... "i 1........
u
Installer +
at-•••-.!!�--0 f .......42.1................. , l2 ...............
............
has been installed in accordance with the provisions of T r f�:The State Sanitary C de as described in the
L
application for Disposal Works Construction Permit No.- ��................. dated-__. "+2rT_"'7�._.._...
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE Nm
SYSTEM WILL F TION SATISFACTORY.
a
DATE................. ._.. .. ,Inspector...............
�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
N '� ....... lC . �?. ............OF.......� ? 1.: ; Wit!. ......................... FEE....._.....- ..
... �...
1 nrk� � n,��r Uan lerutti
Permission is hereby granted. ��'Y. ..._ :........ _C�.t✓..._...
to Construct or Repair ( ) an Individual Sewage Disposal System It
at No......L_0.-7......... /...------..S:2.�.a! ,' f'`!�•N� ........................................
Street
j„ 'as shown,on the application for Disposal Works Construction Pe No Dated.._ /dC/,,.•---
UM
r +� 7 VB.�a/do�f Health
DATE...... /`or.
* ,wi
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS _ ✓•-�
.dt`SjF
'TEST" OL-E.
7. LOT l•f ,
A-PRIL 31. f97$
PAUL_ MURRAY—. INSPECTOR
2 s'` so' E I E.b. O
P.ROp65 E-o 1 3 1 LOAM
ae
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