HomeMy WebLinkAbout0067 WILLOW AVENUE - Health 67 WILLOW AVE, H
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No. >u -7 4 Y _ Fee 2 5.00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TONVN OF BARNSTABLE., MASSACHUSETTS
Zipplication for ;DiopogAY 6p$tem Cow5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon(x ) ❑Complete System ❑Individual Components
Location Address or Lot No. 67 Wit tow ow Avenue Owner's Name,Address and Tel.No.(5 0 8) 7 71—0 310
H E.2mwood Stekting Reatty Tutu,5t
ann
Assessor'sMap/Parcel y 327/64 67 AIittow Avenue, HyanniA 02601
Installer's Name,Address,and Tel.No. (5 0 8) 3 9 8—9 4 7 4 Designer's Name,Address and Tel.No.
Nmthenn Seatcoati,ng 9 Pay.ing, Inc.
Box 995, Vennispont, MA 02639
Type of Building:
Dwelling No.of Bedrooms 0 Lot Size 17,000 sq.ft. Garbage Grinder( )
Other Type of Building Comme-tc.i..at No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 100 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
Nature of Repairs or Alterations(Answer when applicable) Tying exi,5ti,na tine .into Town
Sewer.
Sewer Connection Penm-tt #4318
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 Board of Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. U 0 — 7 Y Date Issued
�.(�0 _7 yy 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— S
at W, I to w A has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. o l 7`( dated U
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
No. >u) Fee 25.00
THE�eOMMONWEALTH OF MASSACHUSETTS Entered in computer:
F+� Yes
PUBLIC HEALTH DNISION NON
N OF BARNSTABLE., MASSACHUSETTS
Zipprication for 3otipooal *pgtem Cottgtruction Vermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon,(X ) ❑Complete System ❑Individual Components
~\ Location Address or Lot No. 67 Witt ow Avenue Owner's Name,Address and Tel.No.(50 8) ]71-0 310
Hyanniz FQmwood Ste Zing Reatty Ttutgt
Assessor's Map/Parcel6� (tl.ttt H i 0 f1 ow Avenue, yannz 60
- 327/G4�...,.��,--�. ,
Installer's Name,Address,and Tel.No. (508) 398-442y4 Designer's Name,Address and Tel.No.
Nonthen.n Seatcoat-i,ng C Paving, `e7nc.
Sox 995, Dennapokt, MA 02639 .
r Type of Building: ..,
Dwelling No.of Bedrooms 0 Lot Size 1 1,000 "sq.ft.- Garbage Grinder( )
Other,., Type of Building Commejtc-i,aat No.of Persons Showers( ) Cafeteria( )
Other Fixtures
v*
Design Flow 100 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
J,
Nature of Repairs or Alterations(Answer when applicable) Tying exi,6tt.nq Z i.ne into Town
SeueA.
Sewer. Connection Penmt.t #4318
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 Ceriifi t
cate of Compliance has been issued by this Board o Health.
Signed "�� Date:
Application Approved by - !_ =-- -._. - Date`'
Application Disapproved for the following reasons
Permit No. 0() 7 Date Issued 12 62 ,u / �t
THE'•COMMONWEALTH OF MASSACHUSETTS i
BARNSTABLE, MASSACHUSETTS
r.
Certificate of Compliance `
THIS I TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ),
Abandoned )by
at 6 W' i/ow of has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7"I dated ;? O
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
No. J O —7 L/ Fee S i-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
I'Mop0ar *pgtem Construction Permit
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( )
System located at 7 ►�- (�Uv� nvF ka.1,:J /
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:ConstructionU ust be completed within three years of the date of this p rmit� -
Date: (� I Approved by
Date: �I-`7-
7
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: A
BUSINESS LOCATION: 47 Gam.-7Z4 CM2
MAILING ADDRESS: 44M Mail To:
TELEPHONE NUMBER: 7 2Z 9 2X-_ Board of HealthTown of Barnstable
CONTACT PERSON: 13 D P P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601
TYPEOFBUSINESS:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES NO _ k
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers
Paint brush cleaners Any other products with "poison" labels
(including chloroform, formaldehyde,
Floor & furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
1
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: �r �fZ 4o�J �lLoG �St Board of Health
MAILING ADDRESS: (o 7 W t l,t,yvJ AV2 I Town of Barnstable
TELEPHONE NUMBER: 7 7 9 69 7 J- P.O. Box 534
CONTACT PERSON: aoc Hyannis, MA 02601
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities/totallig, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous
characteristics and must be registered
V14 i Please put a check beside each product that you store:
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
WEST SIDE SEPTIC
The Septic System Professionals
331 West Grove St.
P.OMox 794
A&ddleboro,Ma. 02346
Telephone (508)947-5213
TITLE V INSPECTION REPORT
PROPERTY: 67 WILLOWAVE. HYAMVIS
OWNER : FDIC
DATE : JANUARY 20, 1999
In the certification statement, the inspector is certifying that the conditions existing
at the time of inspection are accurately presented in the inspection report. The
inspector is not certifying that the system is adequate for the current use of the
system nor for the future use of the system.
i
C(D
PD7
= _ COMMON-WEALTH OF MASSACHUSETTS
. — ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF E gVrBOI MENTAL PROTEC
ONE WI24TER STREET, BOSTON MA 02108 (617) 292-5500A
�`�Ello TRL? COXE
°D JAretary
ARGEO PAUL CELLUCCI V I� RUHS
Governor e � loner
S8Bi3SllYiFI�CE SEWAGE fXP®SAI SYSTEM Ia5S5PECTI®EMI FORV
PART A �
CERTIRCATION A
- y
Property Ad& 67 Willow Ave P?mme of
Hyannis Ma . Address of Owner.
®ate of Inspection:J a rj, 2 0 19 9 9
Nmm of Inspectoa:$PleV4e priffi6 11 11
9 ama I9EP srpproved system in, 340,of Title 5 1310 CPAR 15.000')
MaNng Address:
Telephoim Number:
CERTIFICATION STATEMUJT
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:
X Passes
Conditionaly Passes
_ Needs Fu lei Evaluation By the Local Approving Authority
ails
Inspector's Sig{na tuee: ®ate: Jan, 2 2 , 1 9 9 9
3
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DE,P)vuithin 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
"?hall submit the report to the appropriate regional office of the Department of nvironmentat'Protection. The original should be sent 70VIU
system owner.and copies sent to the buyer,if applicable,and the approving authority. .
NOTES AND COMMENTS
THIS SYSTEM IS IN GOOD WORKING CONDITION, GETS. VERY LITTLE USE
"LESS THAN 150 GALS. . PER DAY WATER USE, THERE IS ONLY 4 TO 6TN.
-,'OF �;ATER IN THR BOTTOM OF' THE 6FT. DEEP LEACHING PIT.
x
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$�fq Printed on P,acycled Pape,
3 S'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
� — CFRTIFICA*nCN(corAftwed)
Wroaaty Add t.o 7 �a 1` umt
r
17
Date of Inspection: 0
i 10
(INSPECTION SUMMARY: Cheer A, B. C, cr D:
A. SY�Sr i-.M PASSES:
i have not found any information which indicates that any of the failure conditions described in 310 C(VIR 16.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTUA CONDITIONALLY PASSES:
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.
Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances, If "not determined", explain why not.
_ The septic tank is metal,unless the owner or,operator has provided the system inspector with u 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 exfiiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution bolt is due to broken or obstructed pipets;!
or due to a broken, settled or uneven distribution box. The system will pass inspection it(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 +®S�than four fines B year
to broken or obstructed pipe(s). The��te�n �7=Tx
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
p g / CERnFICATION(continued)
Property Address: 6
Owner: � {}
Data of Inspwdon:
Z® -
C. FURT" ALUATION IS REQUIRED BY TIME BOARD OF HEALTH:
Conditions ist which require further evaluation by the Board of Health in order to determine if the system is failing to protect he
public health,s ty and the environment.
,1) SYSTEM WILL PASS U S BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CVOR 15.303 11)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A'My NNEII FRVHICH.MLL PPIO.TECT THE PUBLIC HEALTH AMD SAFE—rY..AND THE EMVAOFMEPff-
Cesspool or privy is wit�fla,
f surface water
Cesspool or privy is wit bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL IL UNLESS THE BOARD OF HEALTH(ABisD PUBLIC WATER SUPPLIER,IF APdtf)DET�b�dIb1ES THAT THE SYSTEM IS
FUHCTIONiNG IN NNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a tic tank and soil absorption system(SAS)and the SAS Is within 100 feet of a surface water supply or
tributary to a surface er supply.
The system has a septic tan nd soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a THE
tank an oil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soi bsorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well er analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility ar 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
ttvised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEV-4 INS.PEC'ti ON EOT,151A
PART,dA i
URTIRCATION (coreOrmerd)
� � -
�r� �ty Adrr
Date of Inspection:
4 --Z� rt
D. .SYSTEM FAILS:
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 C4d1R 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 Pto
Backup of;sevvege iwte4acili"r-sys"cotnponant duwto an overloaded orvioggod-SA oan eawspaol. -�°�
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
spool.
v I in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool.
Static ligr�9e e
Liquid depth in cess, of is less than 5" below invert or available volume is less than 1/2 day flow'.
Required pumping more than es in the last year NOT due 4o clogged or obstructed pipe(s1°
Number of times pumped
onion of the Soil Absorption S stem, cep.:, ool or privy is below the high groundwater elevation. - "•
Any p i Y 't`�
Any portion of a cesspool or privy isveithin 100 feet opa�surfaee water supply or tributary to a surface water supply:' 1
Any portion of a cesspool or privy is within a Zone I of a polic I.
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,a44ach copy of well water analysis for
bcoliform bacteria,volatile organic-compounds, ammonia nitrogen and nitrate nitrogen. — I
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" to each of the following:
The following criteria apply to largo systems in addition to the criteria above:
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:. i1
Yes No
the tVMdth 15 within 400 feet of a surface drinking water supply
_... _ inn sy&8Qt b=a sar)tEsi 200 feet -supply...
:!,�g cVsferri a6 18F.tit8d Eti a nitrogen sensitive area(Interim Wellhead Protection Area=SWPA)or ra mapped Zone II of a public
1'No€tvjno'r aYIiLia'ao e,I s-Li6h 6"ys4tiiti shell Upghadb.the system in accordance with 310 CMR 15.304(2). Please consult,the local regional `
e>°r:rise of t)t,+6 s si arit far fwithoi t imbi mime.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �-
PART 8
CHECKLIST
Property Addrass:
Owner:
Date of Inspe t=
-2® - � �
Check If the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No I
Pumping information was provided by the owner,occupant, or Board of Health.
_ None of the system con*os tints kin pumped4orat.leastwLto flow
rates'during that period. Large volumes of water have not been introduced into the system recently or as part of this f
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A. ! .
_ The facility or dwelling was inspected for signs of sewage back-up.
_V11" _ The system does not receive non-sanitary or industrial waste flow.
►/ _ The site was inspected for signs of breakout. i
t/ All system components, excluding the Soil Absorption System, have been located on the site.
V _ 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:-
Existing information. For example, Plan a4 Y.O.H.
Determined in the fled(if any of the failure criteria related to Part�C is at issue,approximation of distance is unacceptable)
/ 115.302(3)(b)i
L _ The facility owner(and.occaapants,if differc-W froxi owner),wero.proxidad.with lc1amztionon thu;,ar.xnaipzana2nn.4f
Subsurface Disposal Systeins-
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTBOF1 FORM
PART C
SVSSWM SPIFO1RMATIOPI
G'Ja�erty Address: t✓� 7 (,j, V-4
Dzte of Inspection: 8�
( FLOW CONDITIONS
RESIVIENTIAL:
Design flow: _g.p.d./bedroom.
'Number of bedrooms(design):_ Number of bedrooms(actual):_
Total DESIGN)flo:v
..umber of current residents:_
Garbage grinder(yes or no):_
Laundry(separate system) (yes or no):_; if yes, separaxeinspectiom required _
Laundry system inspected (yes or no)
Seasonal use('Ves or no):-
Water meter readings,if available(lest.two year's usage(gpd):
Sump Pump(yes or no):�
Last date of occupancy:__
CORNF.%r@;Cl6ALlIRIDtISTftIAL: 1 ' 1 - Ca-dltKi.�
Type of establishment:
O"ign flow: ��� gpd ( Based on 15.203)
)Basis of design flow—QCP_a���—��� `S �'o I% �$ d CdC'ea�c�_�f` � �� �' 'S. � Z°a t;
t'mLse trap present: (yes or no).V-%D
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)_D
Vafter meteP r@adingS,if available: �,q a�� —
Last date of occupancy:_O6CLo—y0C�cy
OTHER:(Describe)
Last date of occupancy:
GENERAL INFOIdMATION
PUMPING RECORDS and source information:
o —
V—) _
System pumped as pas')of inspection:(yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
`9j'VI"E O STEN1
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
W� Privy
Shared system(yes(ir no) (if yes, attach previous inspection records,if any) .
IIA Technology otei Attach copy of up to date operation and maintenance contract
.Tight Tan!: _ _- Gopy of DtP Approval
r�
XPPTtC97SlVRA E AGE.of al co£r 3n t.n'3;date lrrsfalles 41f known)-and sourco•of,iofomwtion:
Sews carers at"thd fitn (yes or tiro)V'V
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rev!S36d `9 98 Page 6of11
suss ➢RFACE SEWAGE DISPOSAL SYSTEM INSPEC"11 N FORM
PART C
SYSTEM 0FORMATION(contsrmed)
Property Address: f l Gj Nam` e
nsite of Inspection: tv
-zo -fig
BUILDING SEL°O:
(Locate on site plan)
tr
Depth below grader
Material of construction: cast iron 1i40 PVC-other(explain) f
.— — t
Distance from private water supply well or suction line y*%.� P„X� (6 f
Diameter rr Ii
Comments:(condition of joints, venting, evidence of heakage,-etc,)
SEPTIC TANK:b/ 4
;locote on site plan)
Depth below grade: /-
Material of construction: V. oncrete—metal—Fiberglass —Polyethylene,other(explain)
Ir tank is fnetal,list age_� 1s.age_confirrned-by Certificate of Compliance (YeslNo)
Dimensions: �?� S®O
Sludge depth: °`
Distance from top of sludge to bottom of outlet tee or baffle:_
Scum thickness: r•
Distance from top of scum to top of outlet tee.or baffle: w !
Distance from bottom of scum to bottom of outlet tee orbaffle:
How dimensions were determined: `✓ �%b�3Sc�.
Comments: 1
(recommendation for pumping,condition of inlet and outlet tees or.-baffles, depth of liquid level in relation to outlet invert, structura+4ntogrity,
evidence of leakage,etc.)
"s,o. C..3 iJ � ae ✓3 �, ..b 1 ems. ;��tn - —
ti i
C c7 c•v» Lrn S CJ�� C� — I
GREASE TRAP:
(loci e on site plan)
Depth b w grade:_
Material of nstruction:—concrete—metal Fiberglass ,_Polyethylene—other(explain)
I
Dimensions:
Scum thickness:
Distance from top of sc to top of outlet tee or baffle:
Distance from bottom of \bottom outlet tee or baffle:
Date of last pumping:
Comments:
(vecommendatic i f8f jiuminlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,
erdence of leckaaec';eta
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revised 9/ /98 Page 7of11 !
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOFM
PART C
SYSTEM INF-(3RMATION(conSmIed)
Lit Progeny Address-. � .
{owner:
Dote of Inspec-don:
JU HT OR HOLDING'Yd'oPJK-.____(Tank must be purnped prior to, or at time of, inspection)
(loc to on site plan)
Depth b w grade:_
Material offinstruction: concrete--metal Fiberglass_po!yethylene other explain)
UliTSen91Un5:
Capacity: g ns f
Design flow: gall /day
Alarm present
Alarm level: Alarm in via 'ing order:,Yes_ Igo_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and at switches,etc.)
I.
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
f .
Comments:
(note if level and distribution is equal, evidence of
solids carryover, evidence of leakage into or out of box, etc.) -
�Dfvl� L���a ,xa�'� ^�S (C'J a�cs��Tali 6t/tQ�. 9re3n� b a
PUM CHAMBER:
(locate site plan)
Pumps in war �g order:(Yes or NO)
Alarms in working der(Yes or No)
Comments:
(noto condizion of pump c beri condition of pumps and appurtenances,etc.)
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.reVi:se?d 9/2/98 Page 8of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Dame of Inspeddon:
SOIL ABSORPTION SYSTT M(SAS):
(love on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, 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
—o_f�hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) I
o `v.6 v CZ,o' 6n y Z C`�t. -T-7.a GC)t aZ rn C�dt�
CESSPOOLS:
(loc to on site plan)
Number d configuration:
Depth-top iquid 4o inlet invert:
Depth of solids er:
Depth of scum lay _V
Dimensions of cesspo
Materials of construction.
Indication of groundwater: _
inflow (cesspool mu be pumped as part of inspection)
Comments:
(nota condition of soil, signs of hydraulic failure,level of.ponaing, condition of.vegetation, etc.)
PRIVY
(locate on sl Ian)
(t4atorjals of constr ion:__.___ _ Dimprtsions:
Depth of solids:l,�
Comments:
(mote condition of sdil;si eifi Ei C4P:ta ti fei4Wfd;IdV®I of pofidinj;condition of vegetation,etc.) {
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�rEV1SGd 512/98 Page 9of1.1
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• Sl' Bsu RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I
PART C
SYSTEM INFORMATION(contiraied)
Property Address:. � ( ��9c �l-C3i�� �y �Vi e/®�� �1✓�i• �
Owvm':
Date of Pnspecticn:
C1
SO(ET CH 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) g �
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revised 912,198
Page 19 of 11
L0 CAT 6®N
A �' ACT ®-
PILLAGE
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UIL0 A p OR OW93
5-5
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ELATE PERMIT tlSSUED ---
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® ATE COMPLIANCE ISSUED
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SUBSURFACE SEWAGE DISPOSAL SYSTEM 8NU SPEC-1110 1 FCA
PART t:
SYSTEM INFORMAT101A(continued)
Oa e of inspec63n:
MRCS Report name_ — — — --
Soil Type _
Typical depth to groundwater
USES Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
E
SITE EXAM Slope
Surface water f
Check Cellar
Shallow wells
Estimated Depth to Groundwater_Feet
Please indicate all the methods used to determine High Groundwater Elevation:
,rO'btained from Design Plans on record
n.�' Observed.Site(Abutting property, observation hole,basement sump etc.)
-- i
` Determined from local conditions"
_,,,"Checked with local Board of health
I
Checked FEMA Maps '
Checked pumping records
Checked local excavators,installers
Used USES Date
I
Dascribe how at«u established the High Groundwater Elevation. 6PPhL,,A be completed)
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remised 9/2/98 Page 11of11 1... p
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Arion Water Processing
67 Willow Avenue
Hyannis,MA 02601 USA
Tel (508)778-6975
Fax (508)778-6985
Robert C. Livingston
President
D.I.WATER PROCESSING-CONSULTANTS
I Analytical Services Troubleshooting
' System Audits Process Design
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
Qf unsatisfactory- , 4.Manufacturers
COMPANY l!5��a (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS 6r. Class: 7.Miscellaneous
i!5�_/ 'I zts V-c A QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors)
-MAJOR MATERIALS ,• ground
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil (C)
new motor oil(C)
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous:
11 FIT
DISPOSAURECI.AMATION REMARKS:
1. Sanitary Sewage 2.Water Supply
`Town Sewer OPublic
O On-site OPrivate
3. Indoor Floor Drains YES N0_Z_
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES N0-4/ ORDERS:
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
5.Waste Transporter
Narne of Hauler Destination Waste Product
YES NO
1.
2.
Person (s) Interviewed Inspector Date
LOCATION 7 SEWAGE PERMIT NO.
d'a� y� 3-
VILLAGE
AS
I N S T A L ER'S NA DD r=7
Y
11 u OR OWNS
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED e
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No—. 3-/�� Fss....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .
Application for Disposal Works CIonstaution f rrmit
Application is hereby made for a Permit to Construct ( ). or Repair ( ) an Individual Sewage Disposal
System at:
6/7 `Gu�Gccu- vC- / eis / J
•"�1 = motion• ddress.... .................»...» ......4?1 ._ »..... or Lot-No.» ..»...».c»»...._..»...... .. .. .....
ddreap r!.� ....».
� ............. :�11.. Installer .....—....................... .. �a�..�...�ddreas.... ...t-.
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedr ns�oom .......................ExpaAttic (. ) Garbage Grinder
aOther—Type of Building .... ..... ............... No. of persons................._.......... Showers ( ) — Cafeteria ( . )
d er fixtures .................. .._....••--... .......................
Design Flow.- _- �..............j. �Q....gallons per person pe day. Total daily flow.-.-.�%....=.............................gallons.
Septic Tank—Liquid capacity ....gallons Length........ Width....5.......... Diameter................ Depth........
x Disposal Trench—No..................... Width.................... Total Length............._._.._. Total leaching area...................sq. ft.
Seepage Pit No...../............. iameter....d......_..... Depth below inlet.....1�..__..........
Total leaching area.................sq. ft.
Z Other Distribution box (. .. Dosing tank
�_4 Percolation Test Results Performed by.............:. ......... Date..................................
14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch. 'Depth of Test Pit.................... Depth to ground water........................
O Description of Soil..... _ .---.....:.. ...... . ................ ..._..». ...................__
W ...._...
•--•-•-• ---------------------•••-•-•--•-•---•-•••---....._......•-•--•-••-....
- ----•-••• - s_._.._.._ l ....- -
UNature of Repairs or Alterations—Answer when applicab ...........................................................................d ..............
--•-------------------------••-----•--••---•---•----..............................---....................................-----------•--...............----....:....-----•-•--•......................... .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the protiisions of TITLE 5 of the State Sanitary C e— -he unde signed further agrees,not to place the system in.
operation until a Certificate of Compliance has iss b d of health.
Sign ...ter..........................
Application Approved By...... ...... ..... - T............ . . .........:...- ...-... _. ............
Date
Application Disapproved for the f ollouing easo :..............•.....-_._.._._•._............_.__.._..........................._..._.
r
Date
PermitNo............................ ... ».»----_.....
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THE COMMONWEALTH OF MASSACHUSETTS P
t BOARD_.OF HE T`H
Appliratinn for Disposal 10orks 6 trurtiott Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal.
System at
........ ....._ •- ��-- Y.003tion•A�dress..: ............ .�...-- ------ ......
or Lot No.� ..........c.:........»..._....
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ksl' '.�. --...... ...... l'-�!..--... 1.�._ ....... t^
O ` r dress
W :,. . .. .........................:..... ... .�...... � ... ,1.'.........
Installer Address 1
.Type of Building 't Size Lot............................Sq. feet
PDwelling-No. of Bedrooms+ .. .. .....:...............Expans�:Attic ( Garbage Grinder X?,1
04 Other—T e of Building .-_- •----- No. of ersons___.•-•_=•_-- .�ShoA�e�
d hOt er fixtures . ......................................................... .. _.....:......................................�--...........-•---...... Cafeteria
Design Flow_. __.. JS11 2.:gallons per person per day. Total dail flow...................................y/ gallons:
CG Septic:>Tank;;Liquid4capaclty�/� gallons `Length......'. Width Diameter.....:.......
Disposal.Tirench No..................... Width ` Total Length .........Total leaching area:_. . �sq. ft.....
�y Seepage Pit No.....1............. Diameter.....!?....,__.:._ Depth below-linlet....jK........... Total leaching area:..................Sq. ft.
Z ti Other Distribution box Dosing tank ( )
PercolationTest Results ......by................................................. ............. Date............................ ........... `
Test Pit No:-1............a,%jhinutes'per inch,. Depth of Test Pit.................... Depth to ground-water''
(i Test Pit No. 2................minutes per inch: Depth of"Test Pit::............ Depth to ground wafer..__.`. .
O Description of Soil---... �L P- / .�1R,. .._.... ... -------•--..---- �, : i?;?- _ ..............
--• �•----•-��.
--_.
w ...........................-•.._..._......................... --.........:_ . .... .�?o l..�.:........_l°� �....'_. ..x eel! .
- r - ...- •-----
U Nature of 1 e—Tirs or Alterations—Answer when applicabl ._____,•.......:...........................................................................
....................................••---•-•--•---•--•-----...................... r' -•-•- --- _.......... .............•..........._.._ .........
Agreement• \.. Y T
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in actor ce with
the provisions of TITL,Z+, 5 of the State"Sanitary•C e:— he unde igned-further agrees not to place the s stem in
operation until a Certificate of Compliance has bee6 iss b b r of.-health.
Sign ...- . ......................... ........ ........._....
ApplicationApproved By.............................. . ..................................... -�••..........
i wDate i
a Application Disapproved for the following as t: '
............................•--. .......................•. ....._..---._.....__......-_...._....... -•-- ...D .... _..._
Permit No..... .... _.._ ...._. --. _ ,
�.,.�.. .• F «!-�Issued... .:.�.�
ASS CHUSETTS� '•.
THE COMMONWEALTH OF M
BOARD OF HEALTH ' .
..........................................OF.... ........ .. h t
ffprtif utttr of (Cnmpfianrr
THIS IS'•T.O.`CERTIFY, That the Individual Sewage Disposal System constructed,( ) or Repaired
by ... --4 - - stail A- 4..................................................................
..._
has been installed in,accordance with-t prov' ions of TIT 5 of The State Sanitary od abed in the
application"for Disposal Works'Cons uctio . ermrt No. . .w ;; __�__________________ dated...._,,_._.. _... ._..._-.: .._..._...
THE ISSUANCE-/OF THIS, C R CATE SHALL NOT BE)CONSTRU AS A GUARANTEE THAT THE
DATE.......�s'�. �•�NC .ION..SATISFACTORY.SYSTEM Wl L
......1�. :.. ......... ..... ..........._. t i Inspector ------ =............................................. .........._......'
j THE'COMMONWEALTH OF MAS,SACHUSETTS A
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4� BOARD OF HEALTH
l a ,
No / e...a ....OF.............................f , ............... FEE. .. ..
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Peission is hereby nted..... .• -...... �: .... ........................................................ . .....................
to Const r ( a. ndividuat'S Disp " System h`
- .......................... .............
is street
as shown on the application for Disposal Wor struction Permit �,.:.. ....
:... Date d ......
-------•---....:. :. -•_____________•--_.... .......--•---..........._
r Board of Health
, DATE...........................•-----......_........---.........-•------•---.........
.FORM 1255 HOBBS,6 WARREN, INC.. PUBLISHERS -,
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