HomeMy WebLinkAbout1761 SANTUIT-NEWTOWN ROAD - Health L
ANTUIT-NEWTOWN PUIP COTUIT
TOWN OF BA/RNSTABLE °
f0,CATION
/7 Aecu To N 9d SEWAGE # b" -'57
VILLAGE C o r Q-/' 7` ASSESSOR'S MAP&LOT4'�`� 0�
INSTALLER'S NAME&PHONE NO. d IPA eG A"o//e 2
SEPTIC TANK CAPACITY /SOO (%A 1
LEACHING FACILrrY: (type) T (size) X
NO.OF BEDROOMS -3
BUILDER OR OWNER RO li e
PERMITDATE: / COMPLIANCE DATE:,
Separation Distance Between the:
_ Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 3 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 „I/
within 300 feet of leaching facility) "� Feet
Furnished by _9• Fvl�2 2
e.A
Q�
b, 30
a
No. x/O1t Ae, IAA oc
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYicatfon for Migaal *proem Con!5tructiou Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. t f l 0.7 5,7-312-1
1741 NGWUwA RID- CoTZuf IM4 fzo&" J. Y-o"tes-
Assessor's Map/Parcel� I—F /9 I(f I I V-1 ppvt " A-viN"ow S t M P 2.1101
Installer's Name, ddress, d Tel.N Designer's Name,Address and Tel.No.
Type of Building: _
Dwelling No.of Bedrooms Lot Size, b sq. ft. Garbage Grinder( )
Other Type of Building � A M Af 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 /. /� � T Type of S.A.S.
Description of Soil
&Naturrf of Repairs orAlte tions(Answer when applicable) / OCR " '
/ ... d L.
Date last inspected: /`✓ y
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 oard of Healt . p
Signed -�2i Date
Application Approved by ' Date , 4::�f
Application Disapproved for the following reasons
Permit No. �� Date Issued ``
No.` /tomallow� / i/ 71(1
THE COMMONWEALTH OFASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
ZtppYicat on for 3DtgpogaY *r em Cow5truction Permit
Application fora Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
17(vi NEvtt),Ja RV- CuTat1' V4A 'RUPegaT 1. Y,ot<Vr1�. �1Q-�S7�3�Zt
Assessor's Map/Parcel — -
1(o ow—r iZl)
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ?
�ri XG f It 14-.4-4 T.414,4-
r
5
TI ..pe of Building:
Dwelling No.of Bedrooms Lot Size! 0_ sq.ft. Garbage Grinder( )
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 1
Title 1
Size of Septic Tank /_ ®� .4 Type of S.A.S.
9
Description of Soil'_ m"Li
�'
«Natu a of Repairs or Alte ations(Answer when applicable)
Date"fast inspected:
gBement:
The ndersigned agrees to ensure the construction and'maintenance of the afore 5sdtibedion s sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not'io place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Healt .
Signed J I Date
Application Approved by
Application Disapproved for the following reasons '
re 7�1�✓
" ✓-Jj.t :3�.
Permit No. °�,, ? ,'L.. t Date Issued
- ——————————— ———————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY;that the On-site Sewage Disposal System Constructed( :°`-)Repaired ( )Upgraded(4 'f
Abandoned( )by
at has been constructed in accordance
with the provisions of Title 5"and the for Disposal System Construction Permit Not dated&&
Installer Designer % '
The issuance of his permit shall of be co ued s a guarantee that the,5..ystem i1.I function as designed.
Date �r•""' � 'Inspector C7 /1�-�✓)
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS f
1wigw6ar 6potem Con5tr.uction Permit"
Permission is hereby granted to Construct )Repair Upgrade( =-✓✓__AAbandon,
System located at ����
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.'
1
Provided:Construction must be compleetted within three years of the date of this a it..
Date: ��^" � 6 Approved by 0
s
t
CERTIFICATION OF SKETCH AND APPLICATION.FOR,A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated l I o2 ! , concerning the
property located at `71104-4fl eets all of the
following criteria:
j/• There are no wetlands within 300 feet of the proposed„septic system
f
• There are no private wells within 150 feet of the.proposed septic system
f e
f/ • The observed groundwater tables 14 feet of greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
�• There are no variances requested ouneeded.
SIGNED : G�^e if1���% �— DATE: c
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER A J-
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
I
IOWIA-
I�.Sl
C�
Sao � �
a a�
{
REM I�
commonwealth of Massachusetts
Executive Office of Environmental Affairs NOV Jl'. 2 1996
Department of
E ironmental Protection
Wi tem F.Weld
Gommor
Trudy t^,oxe
R IV)
8aenatary,EOEA
o d--3 David 0. Struhs 4
°onina"°^°' NOV 2 2 1996
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
� �,,,y, PART A HE LTH MPT.
Ste, CERTIFICATION TOWN o�EA�;;�="
Property Address:170 IZd" CGS. Address of Owner: 4
Date of Inspection: 10.9-9(a (If different)
Name of Inspector: W01.0w%
Company Name, Address and TelephonffiRgOn
septic
50$-7731986 43 TOMahaWlk Dr.
CERTIFICATION STATEMENT Cetltef'Vllle
I certify that I have personally inspected the sewage dis' '"pos�'sy�2632his 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:uk�-,!'hYn Date: /per
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. 1 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
i
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.appro�ing authority:
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEE ASSES:
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.
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 determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why rot)
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.
7
(revised 6/15195) e! .
One Winter street • . Boston,Massachusetts 02108 a FAX(617)656-1049 a Telephone(617)292-SM
r' 0 Printed on Esiyded Papa
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection
B) SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water lev rved in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven d' i ution box. The system will pass inspection if(with approval of the
Board of Health):
broken p' (s) are replaced
obstr ion is removed
d' ribution box is levelled or replaced
The system required pu ping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with a roval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER 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 DET MINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AN AFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet a surface water
Cesspool or privy is within 50 f of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE B ARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONIN N A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system h a septic tank ano sort absorption system and is within 100 feet to a surfw-e waiei supp:) or Uibuta(y W a
surface wat supply.
_ The sv s±e - ha a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The sy em has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The sten,hay a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
s ply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
ree from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
PPm
D) SYSTEM FAILS:
I have determined that the system viola one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified w. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
!Backup of sewa into facility or system component due to an overloaded or dogged SAS or cesspool.
Discharge r ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cessp
2
(revised 8/15/9
I ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DI SYSTEM FAILS(continued):
Static liquid level in the distribution box above outlet invert to an overloaded or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert available volume is less than 1/2 day flow.
Required pumping more than 4 times in the la year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption Sys m, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or priv is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool o privy is within a Zone I of a public well.
Any portion of a cessp of or privy is within 50 feet of a private water supply well.
Any portion of esspool 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
cofiform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following/ee
apply to large systems in ad ion to the criteria above:
The design flystem is 10,000 gpd or reater (Large System) and the system is a significant threat to public health and safety
and the envir because one or m e of the following conditions exist
the is within 400 t of a surface drinking water supply
the is withi 00 feet of a tributary to a surface drinking water supply
the is I sated in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
pub .supply well?The owner or operatorsuch system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 C0 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B.
CHECKLIST
Property Address: �1�� PCw40wr% k • C04
Owner: bMAld 50 2
Date of Inspection: (0-q Q(o
Check if the following have been done:
ZPumping information was.requested of the owner, occupant, and Board of Health.
,lone 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.
_L'O4s 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.
The system does not receive non-sanitary or industrial waste flow
✓The site was inspected for signs of breakout.
✓AII system components,^'cluding the Soil Absorption System, have been located on the site.
10 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 or
approximated by non-intrusive methods.
/Thefacihvr ov.nc, ;an occupants,, if d;fferen! frorr owne-) were provided v0th information on the proper maintenance of Sub-
Surface Disposal System.
fzevised 8/15/95) 4
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 114P( Newk-m R6.• Co+.
Owner: DM 5002031
Date of Inspection: �0•g-46
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:_
Number of current residents: O
Garbage grinder(yes or no): NO
Laundry connected to system (yes or no):
Seasonal use (yes or no): ✓wo
Water meter readings, if available:neoo oV
A6w uAtoo)4 A+ -04v, or-myecien.
Last date of occupancy:0AwY1
COMMERCIALIINDUSTRIAIi
Type of establishment:
Design flow: eallons/day
Grease trap present: (yes or no)
Industrial Waste Holding Ta present: (yes or no)_
Non-sanitary waste disc ged to the Title 5 system: (yes or no)_
Water meter readings f available:
Last date of o panty:
OTHER: escribe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information
44 ?'gun of &*.-AS4AU
Systemkumped as part of inspection: (yes or no) 1� Srsfe.*\ Ohl At -Am OF.�n��s�;o� .
If yes, volume pumped gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
ngle cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of:all components, date installed (if known) and source of information: _ fi/h?.,,A
Sewage odors detected when arriving at the site: (yes or no) 1�0
(revised a/15/95) S
r •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner-
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP _other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge.to b om of outlet tee or baffle:
Scum thickness: '
Distance from top of scum top of outlet tee or baffle:
Distance from bottom o cum to bottom of outlet tee or baffle:
Comments:
(recommendat n 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.)
GREASE TRAP:_
(locate on site plan)
Depth below grade:.
Material of construction: co rete _,metal _FRP _other(explain)
Dimensions:
Scum thickness:
Distance from top of_cum to top of outlet tee or baffle: .
Distance from bo crom t- bottom of outlet tee or baffle -
Comments:
(recomme ation for ipumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity vidence of leakage, etc.)
(revised 8/:5/95) 6
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete metal _FRP _other(explain)
Dimensions:
Capacity: Aallons
Design flow: allons/day
Alarm level:
Comments
(condition inlet tee, condition of alarm and float switches, etc.)
I
DISTRIBUTION 60 Oft 51�2
(locate on site pla
Depth of.liqu level a/outl :
Comme s(note level and d:strib %tde^ce of Solid, ca•\n\,Pr evidence of leakage into or out of box, etc.)
PU/nts:
(loc )
i
Puorder:(yes or no)
Co(nopump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7 w
r ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 170 New+own 2b Col..
Owner: DM
Date of Inspection: I OOA(a
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:
le/cesspool,
nu ber:_
lers, number:_
leries, number.
lehes, number,length:
les, number, dimensions:
ovpool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS: ✓
(locate on site plan)
Number and configuration: teal
Depth-top of liquid to inlet invert: drV
Depth of solids layer: zi, on W
Depth of scum layer:
Dimensions of cesspool: a- 6xR- If MY
Materials of construction: rBAt BleE
Indication of groundwater: Noel.
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of h draulic failure, level of ponding,,condition of vegetation, etc.)
�lon 5 dry A4 ,lime of nseeditbn
A 'n POD( G r B Bloc9 tu►l'f4l Jo El" 9'j".3 ao t 4o 6X3 8/e-k eveIF/ow ry NO iMe s Ala,,, inle t.
PRIVY:LA ft e4S -
(locate on site plan) .
Materials of construction: Dimensions:
Depth of solids:
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'Property Address: /Vew4o4yN, QCl Cod•
Owner. Pori 50VLq.
Date of Inspedior �.
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
�eAt� 4
gob
0y
f K Pso
1610 day
o � Hc4e
DEPTH TO GROUNDWATER
but iA we l�i.Jr CoAdAbn
Depth to groundwater:_ 4 feet (( T11►tdc�'-^
method of determination or app oximation:_VO c6tykf hAlA A ise( kbit . goofs dry W'-+, ke S140 /,ices
&revised 8/15/95) 9
t
t
14
sb''yV �'1'ti
THE COMMONWEALTH, OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT gn'DWN THAT
septic
43 Tomahawk Dr.
Centervi A 02
William E. o ins Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
April 20, 1995
Acting Director of the ' ton of Water Pollution Control