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HomeMy WebLinkAbout0121 FIRST AVENUE (HYANNIS) - Health 121 First Avenue, Hyannis A= i• b TOWN OF BARNSTABLE LOCATION �� Z! 1 r7T z7Vf SEWAGE \M.LAGE Al' ASSESSOR'S MAP& LOT �`� INS' ALLER'S NAME&-PHONE NO. ��� � SEPTIC TANK CAPACITY //G //ll LEACHING FACILITY: (type),Z��%�fi,�/yd (6 l (size) /w X Of�x� ' NO.OF BEDROOM BUILDER 0 OWNE PERMPTDATE: COMPLIANCE DATE: 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 Furnished by } t f - O� Ov Q CwI :t A �� . � —_ � - �_ ... `. _ V .. � � ��'' 'e��. ., �. ���t 1 A �.. . 3��Y '��� ��,. . _ ,-3 _ +t, r -y,. n _� - .._- .. ._r �� TOWN OFF BARNSTABLE LOCATION ! �,-S /7v SEWAGE # VILLAGE W 14v a i S jJo ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 �o M AO S l� TOWN OF BARNSTABLE LOCATION ,*"" SEWAGE # VILLAGE ASSESSOR'S MAP & LOT �� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY %SDO G4 G LEACHING FACILITY: (type)ZZ2i4 0 (( L_ (size) AX 51e X NO.OF BEDROOM 7 BUILDER 0 OWNE PERMITDATE: -Z_;;, COMPLIANCE DATE: _1ffj7F_ 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 Furnished by ,0 er Etc O I 0 r Zd Del Nu Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for ri5/pogal *pgtem �tConotruction Permit Application for a Permit to Construct( )Repair(Y)Upgrade( )Abandon( ) Lk/Complete System ❑Individual Components Location Address or Lot No. IL/ c1f.T7-R'e� Owner's Name,Add ss and Tel.No. l� a�iJlS � j y-� Assessor's Map/Parcel W, �! � p Installer's Name,Address,and Tel.No. /J Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/Cp Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flows gallons per day. Calculated daily flow < y� 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). l�` 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 this B ZdHe Signed Date Application Approved by Date Application,Disapproved for the following reasons Permit No. Date Issued I - .No. / Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: • v o Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS '0(ppYication for33izpozar *pe;tem Construction Permit Application for a Permit to Construct(. )Repair(1✓)Upgrade( )Abandon( ) le/complete System El Individual Components Location Address or Lot No. IZ/ F�rS� Cj�/� Owner's Name,Address and Tel.No. Assessor's Map/Parcel (�f,11./Q"a�jr.�®p J"" Ei74 604e4el Installer's Name,Address,and Tel.No. r1 Designer's Name,Address and Tel.No. Borr�Gfl�j'- C'©ysr: 77/-931 Type of Building: u Dwelling No.of Bedrooms �t Lot Size sq.ft. Garbage Grinder(-,(-P Other Type of Buildin No.of Persons Showers( ) Cafeteria( ) Other Fixtures J Design Flow �� `r gallons per day. Calculated daily flow ,7 W gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /3­009e Type of S.A.S. 4—C`'� �yY Description of Soil SOX 4,�r Z , Nature of Repairs or Alterations(Answer when applicable) 10, �� /z' ✓�/ /� 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 net to place the system in operation until a Certifi- cate of Compliance has been issued y this M94"k _ Signed Date 'Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued `. ------------ ---- — _------- —/—=--1--- THE COMMONWEALTH OF MASSACHUSETTS 2- BARNSTABLE, MASSACHUSETTS CertificatN.e of Compliance THIS IS TO CERJIFY, that;he On-site ewage Disposal System Constructed( )Repaired ( ✓)Upgraded( ) Abandoned( )by Dl D e at z CT'GLe' � n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '� dated Installer Designer �' v The issuance of this permit shal the p s ed as a guarantee that the ill functionJ as i sign d)r ' Date i l Inspector ————————————————————— O l Fee � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS �Dioogar Opgtem Construction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at Z-/ ` 1/57~ �!/L"•. L!/. ` C�°`i'/t'%S Ql'/ 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 followj1pe-ted ocal provisions or special conditions. Provided: Constructio> tus/be cwithin three years of the date of th' pe pt. �11A Date: Approved by f ti • 1/6/99 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 PERNUT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated ✓ /Z �� , concerning the property located at l z / t�/�/5�1��� '�V-�Ir X e is all of the following criteria: - The failed system is connected to a residential dwelling only. There are no commercial.or business �es associated with the dwelling. v The soil is classified as A I percolation / CLASS and the pe o atlon rate is less than or equal to 5 minutes per inch. ere are no wetlands within 100 feet of the proposed septic system ere are no private wells within 150 feet of the proposed septic system /There is no increase in flow and/or change in use proposed 1� There are no variances requested or needed. K The bottom of the proposed leaching facility will not be located less than five feet above the UM'% m adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor lethod when applicable] if the S.A.S. will be located with 250 feet of any vegetated 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 Surface Elevation(using GIS information) B) G.W. Elevation +the MAX High G.W. Adjustment.Z.( _ DIFFERENCE BETWEEN A and Bi SIGNED : DATE: ! [Sketch proposed plan of system on back]. q:health folds:cert ;y �(L\,s � J � O r P t \ L t Lel 2 3 — TROY WILLIAMS 1 SEPTIC INSPECTIONS �. Certified by MA Department of Environmental Protection TO 08) 385-1300 19 Hummel Drive orB 19,g South Dennis, MA 02660 O, �0rrq�F Commonwealth of Massachusetts Executive Office of Environmental Affairs Department. of Environmental Protection -William F..Weld C"Mmor Trudy Coxe LL A C'Merm l Celluxi David B.Stru sh Conunbdoner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1(.ZG:�nn CERTIFICATION Property Address: /02 ! /S f /7✓t , W. ►C u S c2r—a P,L wr o s h a . /,y /g 7 /`� Address of Owner. �a r�cam` f Date of Inspection: ( 7 (If different) r. , ! I ,�-v-. i Name of inspector. ,3 and ter✓�� (i.) Company Name,Address Telephone Number. 0 6 go y 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 Date: The System Inspector shall submit a copy df 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 A; B, C,or D: A),SYSTEM PASSES: V 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: A1/4 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 not) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or enfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health (revised 11/03/95) ) � _ :�4 � ,. '' �,....,.f '�,F ��;. wrl 9 4e''. �. x�a,.,.i� eel---� ::.ri 4�' 07 w 3 �. Y� y'`::. � f ��' r 4 �� r 'tS �M e��r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addre" 0� r S 74— t Owner. o t� Date of Inspection: 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): 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 Cl 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 DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY.AND THE ENVIRONMENT: Cedap f�,rkl 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) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING 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 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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Q Owner. Date of Inspection: —0t—r, VLn V "t �. D1 SYSTEM FAIL:1�2 / /C� 7 I have determined that the system violates one or more of the following failure criteria as defined g 10 Cl►Dt 15.303. The basis for failure. this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or pondiag 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 leas than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(a). Number of times pumped 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 leas 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. El LARGE SYSTEM FAILS:/ V The following criteria apply to large 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: the system is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface dri eking water supply — the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance 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. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECMST Property Address: /oZ l S T /7 c Owner. Date of Inspection: Check if the following have been done: _J,eK=ping information was requested of the owner,occupant, and Board of Health. / jz9one 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. N67As 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. ZThe system does not receive non-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. 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 A//-7 tesa, 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. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address /p2 / S ✓ (.. Owner. Date of Inspection: RESIDENTIAL• FLOW CONDITIONS Design fjow: �G gallons Number of bedrooms: 3 Number of current residents: U Garbage grinder(yes or no):_j%Zo Laundry connected to system(yes or no):—�C— S Seasonal use(yes or no):-C S Water meter readings, if available: (o Lest date of occupancy: Se, �i. (, +.j: COMMERCIAL/INDUSTRIAL: Type of establishment: Design fl0w:__zal.1ons/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: GENERAL INFORMATION PUMPING RECORDS and source of information: / /v0 �: J ��lp,yof 'k r s ystem pumped as part of inspection. (yes or no) /Vo If yea, volume pumped: gallons Reason for pumping. TYPE OF SYSTEM Septic tank/distnbution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yea, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 0✓1 C/ / ) v J C.l`O ro fJ ,5 J -,71-1 O✓. c C� �'Z1 �/1 J✓t -L Sewage odors detected when arriving/ at the site: (yes or no) Nd (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: IoZ/ /S f /54Ue Owner. 9�S Date of Inspeotlon: SEPTIq TANK:��i 9 (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) ` 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 baffle: Distance from bottom of 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, stnwtural integrity, evidence of leakage, etc.) GREASE TRAP: /9 (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 of 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.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /qu c. Owner. Date of Inspection: 2 TIGHT OR HOLDING TANK /V A-) (locate on site plan) Depth below grade: Material of construction: concrete_metal_FRP_other(ezplain) Dimensions: Capacity: gallons Design flow: gallona/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: /Vh (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: IV/4 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �/ SYSTEM INFORMATION(oontinued) Property Addrea� �� �� /j1U- Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS),_ (locate an site plan, if possible;ezcavation not required, but may be apprmmated by nos-intrusive methods) If nat determined to be present, erplain: Type: leaching pits, number;_ leaching chambers,number:— leaching galleries, number- leaching trenches, aumber,length: leaching fields, number,dimensions: overflow cesspool, number: b 1- 6 �(S ' O v c✓7 �c0 Comments: (note condition of soil, signs of h ulic failure, level of ponding, condition of vegetatioa,etc.) J7 J_ 4^ CESSPOOLS:_V (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer._ 1;2 Depth of scum layer-- e A//,: Dimensions of osspool:_- ( ail e Materials of construction: Indication of groundwater:- Al-/— inflow(cesspool must be pumped as part of inspection)_ Sri Comments: (note condition of soil, signs of hydraulic failure, level of n po ding, condition of vegetation, etc.) PRIVY:_/`1(17 (locate on site plan) Material of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1,21 /S,�- ✓e . Owner: Oe—S �,o Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM:- Include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i rro`^ G�y swv 1 I DEPTH TO GROUNDWATER Depth to groundwater, feet — adjusted high groundwater level method of determination or approximation: p i 9