HomeMy WebLinkAbout0163 HINCKLEY ROAD - Health 163 HINCKLEYS 3
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No. —"—3— ✓W Fees
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppfication for Migonl *p!tem Construction Verrait
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon eX) El Complete System El Individual Components
Location Addressor Lot No.7 6 3 H i n c k.Ley I?O a d Owner's Name,Address and Tel.Nol 6 3 f/i n c/z te y Road
Kyaan.i-3 17a�,3. 02601 HyannV* ,Na �s. 02601
Assessors Map/Parcel all + 046 rA
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8-7 7 5-3 3 3 8
a. /0. 17acomge2 9 Son Inc. a• !• Nacomke2 & Son Inc.
Pox 66 Centenv.i:iee, 17a3,6. 02632 /30x 66 Cen.te2v-igee, Na6.3. 02632
Type of Building:
Dwelling XXNo.of Bedrooms 2 Lot Size 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
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 0 m i t t t n q the e)c i.6 t i n y
.AP_2jrrg0Ac,=,6tgm, Conneci-iny hou.6e y_o Yho cammo-n
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 iss ed by thi o of alth.
Signe Date 81
i8103
Application Approved by, Date 6—U- 3
Application Disapproved for the following reasons
Permit No. U0 3 3?b Date Issued
No. `W�'�t J w Fee
THE COMMONWEALTH OFJMASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
—Application for Oioaar 6poltem Congtruction Perron
Application for a Permit to'Constnict( )Repair( )Upgrade.( )A,bandon M ❑Complete System ❑Individual Components
Location Addressor Lot No.1 6 3 /L.i n c k-C e y Road Owner's Name,Address and Tel.Not 6 3 //,i n c k i e y Road
Ayanz.i s /7a .s, 02601 /Lyann.i , glass. 02601
Assessor s Map/Parce,3 v/ ' 0 /� r A 1,
Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-.3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8-7 7 5-3 3 3 8
a. 1. 8acomge2 R Son Inc. a• 10. Nacom&e.¢ & Son Inc.
Box 66 , (lass. 02632 Box 66 Cente2U.i.eee, tlas-6, 02632
Type of Building:
Dwelling XX No.of Bedrooms 2 Lot Size 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
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairsor•Alterations(Answer when applicable) Omit t.i n q the e x.i e t.i n a_
A ph)ryg0 6;44tgl„v COnnect.inp houze- to .t-hn rommnn 4alswa4
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore*scribed 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 iss ed by this o �7of alth,
R Signed /'" Date 818103
Application Approved by "" Date d-// U 3
Application Disapproved for the following reasons
j
Permit No. 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( )
Abandoned(X,�by I• P• Macom9e2 9 Son Inc.
at 163 11.in ek.L e y Roar/ N/jin n n i A, as g g '` has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2c0 3- 376 dated k-11-60
Installer 2. 0. Ma r n m Q o a P C o Ez Ta r, Designer I. P, rl a e o m 4 v n rP Son
The issuance of this permit shall not be construed as a guarantee that the system will e
Date -I - d 3 Inspector
---------------------------
No. �3' 3� Fee 2��
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
ligpogar 6pelem 'Con5truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon P)
Systemlocatedat 163 11inckiey Road Kyann.is, /lass.
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 pe
Date:_ o �'C 3 Approved by
f
Town of Barnstable
FINE T�
° do Regulatory Services
s
Thomas F. Geiler,Director
* IARNSfABLE,
9w 03 Public Health Division
ATFO��A
Thomas McKean, Director
200 Main St,
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Barbara Pratt 3/6/03
163 Hinckley Rd.
Hyannis, MA 02601
RE: Map & Parcel 311-066
Dear Addresse:
You are directed to connect your building located at 163 Hinckley Rd., to
public sewer on or before Sept 6, 2003.
The Department of Public Works, Engineering Division, has notified us that
your property abutts town sewer lines. The lines were extended because of the
density, and the size of the lots in the area, and the potential for serious health
problems.
Failure to comply with this order will result in a court complaint against you for
failure to comply with a Board of Health Order.
If you should have any questions, please telephone me at 862-4644.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S. CHO
Health Agent for:
TOWN OF BARNSTABLE BOARD OF HEALTH
Wayne Miller, M.D., Chairperson
Susan G. Rask, RS.
Sumner Kaufman, M.S.P.H.
Return receipt requested
Cc: Barbara Childs, Water Pollution Control
Q:health/wpfi les/sewer_hookup
Check list for unconnected parcels:
Name: Nancy L. Johnson
Map/Parcel: 311-066
Prop location: 163 Hinckley Road
Mailing address: P.O. Box 342
Hyannis,MA 02601
Visually check property location
check for any past pumping records a/o 1/1/01 no record of any pumpings since
1985
check water company for water use
check with engineering for permits and if they are within the bounds of connecting
Notify Board of Health to send letter to connect
Date BOH notified: 12/29/2000
Date BOH copy received: 1/9/2001
Date BOH letter sent: 1/8/2001
Date BOH letter expires: 7/8/2001
CHKLIST.DOC
Anderson, Dave
From: Childs, Barbara
Sent: Thursday, February 20, 2003 8:23 AM
To: Schlegel, Frank
Subject: -- �F
Hi Frank,
Do you have anything there for 163 Hinckley Road? I have nothing to show that this account is
connected to town sewer. Notify Tom?
�� say► �
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Town of Barnstable
Regulatory Services
t saxivsrnsi.E,
MASS. g Thomas F. Geiler,Director
1639.
Public Health Division
Thomas McKean,Director
367 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
January 8, 2001
Nancy L. Johnson
P. O. Box 342
Hyannis, Ma 02601
RE: Map &► Parcel 311 - 066
Dear Ms. Johnson:
You are directed to connect your building located at 163 Hinckley Road, Hyannis, MA.,
to public sewer on or before July 8, 2001.
The Superintendent of the Department of Public Works has notified us that your property
abutts town sewer lines. The lines were extended because of the density, and the size
of the lots in the area, and the potential for serious health problem.
Failure to comply with this order will result in a.court complaint against you for failure to
comply with a Board of Health Order.
If you should have any questions, please telephone me at 862-4644.
PER ORDER OF THE BOARD OF HEALTH
o as cKean, R.S. CHO
Health Agent for
TOWN OF BARNSTABLE BOARD OF HEALTH
Susan G. Rask, RS., Chairperson
Ralph A. Murphy, iVI.D. copy: Peter Doyle
Sumner Kaufman, M.S.P.H. Return Receipt Requested
sewe=2
OLTUO I,3 op (l tlo f=JS
MAP/PARCEL
NAM RESIDENTIAL ACCOUNT/PERMIT
LOCATION ( 1,, 3 141►J cat.,.e COMMERICAL WATER ACCOUNT
VILLAGE y �<< , RESTAURANT METER SIZE
OTHER NO. FIXTURES
MAILING ADDRESS DATE CONNECTED
NAME
STREET INSTALLER
TOWN STATE
FIXTURE USE ONLY REMARKS
For Fixture Rate Only:
Water Closet Shower Urinal Other
Sink Lavatory Bowl Dish Washer Other
Bath Tub _ Set Tub Washing. Machine Other
ILI COMNION-WEALTH OF MASSACHL:SETTS
_ n �Ct'MT. OFFICE OF EN-MONAMN-TAL AFFAIRS
-DEPARTMENT OF ENYMONMENTAL PRO
TECTION
ONE WMM STRri'.ROSTo\X4,0210i 1617.1 29MU11,
TR.'DT COL
• _ Secre:i-�
ARGEO PALL CEUUM DA11a B STP.:'??c
. Goveraa: SUBSURFACE SEWAGE DISPOSAL SVSI WSPECTION FORM Caan:atss:oae-
PART'A
CERTBICATM
Property Address: 1 6 3 Hinckley Rd. Nama of OwnwJQbn 5DM / Gran_t
Date of bispeetion:Hyannis 10 J7_6-O Addres'°f Ow men
Marne of Inspector:(Please Prina ft. E. R ob iris on Sr.
I am a DEP approved s inspector tao Saco, 16-w of Tide 6 p10 CMR 16.o00)
CornparryName: Wm. E. Robinson gep is Service
MailirngAddress: PO Box I-07gg, Centervillp , MA
Telephone Number: -7 75_,9 7:2 F'
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reponed 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:
�ses
Conditionally Passes
Needs Further Evaluation By the Local Ap
proving Authority
Fails
Inspector's Signature: 2144w--� Darter'
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP►within thirty 130)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.
NOTES AND COMMENTS
1110,
r. OCT
6 2000DEpr
Parr 1 or n
C: -••^feo o^Rea�Md Panr•
SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM r
PART A
69111 IFiCATION IeenOraradl
Nopm ty Address: 1 63 Hinckley Rd. , Hyannis
awner: Johnson / Grant
Date of 6lspaetion:
INSPECTION SUMMARY: Check B, C, or D:
A. 7SY PASSES:.
have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYS CONDITIONALLY PASSES:
One r more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system.upon
compl tion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no. not determined(Y.N,or ND). Describe basis of determination in all instances. B'not determined*.explain why not.
he septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
omplience lattached)indicating that the tank was installed within twenty 120)years prior to the date of the inspection: or
t e septic tank,whether or not metal,is cracked,structurally unsound.shows substantial infiltration or exfihration. or tank
fa lure is imminent. The system will pass inspection H the existing septic tank is replaced with a complying septic tank as
ap coved by the Board of Health.
Se age backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or ue to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
He Ithl.
broken pipets)are replaced
obitruction is removed
distribution box is levelled or replaced
he system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
i spectron if(with approval of the Board of Heahh):
broken pipets)are replaced
obstruction is removed
i 5
_"f:ti1se 2/9c Page 2of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(eantirand)
PropertyAddress:163 Hinckley Rd. , Hyannis
owner:Johnson / Grant
Data of Inspection:
C. FURTHER EVALUATION IS REOUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine it the system is failing to protect the
public health,safety and the environment.
11 YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMNES N ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND.PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
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 eoliform 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' THER
Palle 3 or I I
M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f
PART A
CERTIFICATION(continued)
Property Address: 163 Hinckley Rd. , Hyannis
Owner: Johnson / Grant
Date of i nspeebon:
D. SY TEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I eve determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
de ermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure
Yes No
Backup of sewage into facility or system component due to an overloaded oreiogged SAS or cesspool.
Discharge or pondmg 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 then 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).
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 1 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. LA SYSTEM FAILS:
You must r dreate either "Yes or "No' to each of the following:
T e following criteria apply to large systems in addition to the criteria above:
Th system serves a facility with a design flow of 10,000 god or greater(Large System)and the system is a significant threat to public
he Ith and safety and the environment because one or more of the following conditions exist:
Yes N
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public
water supply well)
The owne or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of t e Department for further information.
Pot.9ofII
` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prop"Add►ess: 163 Hinckley Rd. , Hyannis
owner: Johnson / Grant
Date of htspeeoon:
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 aystem components have been pumped 1pr at Iaast two weeks and the system has been roeeiving tsanrtsl 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 NrA.
_ 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.
_' 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:
_ Existing information. For example. Plan at B.O.N.
_ Determined in the field(if any of the failure criteria related to Part C is at issue.approximation of distance is unacceptable)
115.302(3)lb))
_ The facility owner land occupants,if diflereru from owner) were provided with information on the propermaintsnaurAwof
SubSurlace Disposal Systems.
I
Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
PART C
SYSTEM INFORMATION
VopertyAddressl63 Hinckley Rd. , Hyannis
Owner: Johnson / Grant
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d.lbedroom.
Number of bedrooms(design):
_,L Number of bedrooms(actual):
Total DESIGN flow. 16 0
Number of current residents:
Garbage grinder Ives or no):L—Q
Laundry!separate system) Ives or no)kk; If yes,separate inspection required
Laundry system inspected (yef or no;
Seasonal use Ives or no):�
Water meter readings, if available (last two year's usage Igpd): 6-,()
Sump Pump Ives or no):t-v
Last date of occupancy/'U/rL�C06 �
COM RCIALIINDUSTRIAL:
Type o stablishment:
Design fl w: opd 1 Based on 15.2031
Basis of d sign flow
Grease tra present: (yes or no)_
Industrial ante Holding Tank present: Ives or no)_
Non-sanitar waste discharged to the Title 5 system: (yes or no)_
Water met readings. if available
Last date o occupancy:
OTHER:( scribe!
Last date ccupancy
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)�d
If yes. volume pumped: gallons
Reason for pumping
TYPE OF,SYSTEM
Septic tank idistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system Ives or no) (if yes, attach previous inspection records,if any)
VA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components. date installed W known) and source of information: Z5 —S
U l�
Sewage odors detected when arriving at the site: !yes or no)
Page 6 ar 11
A.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Ieen6rmed)
'ropertyAddress: 1 63 -Hinckley Rd. , Hyannis
owner: Johnson / Grant
Date of hupeetion: la
BU G
(Locate nSEWER:site plan)
Depth b ow grade:_
Materia of construction:_cast iron_40 PVC_other fexplain)
Disten from private water supply well or suction line
Diamete
Comme s: (condition of joints, venting. evidence of leakage,etc.)
SEPTIC TANK:
(locate on site plan)
l )
Depth below grader �
Material of construction: L ncrete_metal_Fiberglass _Polyethylene_otherfexplain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
a it
Dimensions: G .4 T 4
Sludge depth: .{--L A
Distance from top of sludge to bottom of outlet tee or baffle:' '
Scum thickness:- I 'V
Distance from top of scum to top of outlet tee or battle: +,
Distance from bottom of scum to bottom of outlet tee or battle:
Mow dimensions were determined:
:omments:
(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.) A r- n 6L },d-iL
GREASETRA
(locate or site Ian;
Depth below gra _
Material of constr ction:_concrete_metal_Fiberglass _Polyethylene_otherfexplain)
Dimensions:
Scum thickness:
Distance from top scum to top.of outlet tee or battle:
Distance from bolt of scum to bottom of outlet tee or baffle:
Date of last pumpi
Comments:
(recommendation to pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, tc.)
e . __ 2, Page 7ofII
4
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
PART C
SYSTEM INFORMATION hntinii+ed)
'roperty Address: 163 Hinckley Rd. , Hyannis
Owner:
Date of�on / Grant
GHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
11 care on site plan)
De h below grade:_
Mat rial of construction:—concrete_metal_Fiberglass_Polyethylene otherlezplain)
Dime sions:
Capac ty: gallons
Desig flow gallons day
Alarm present
Atar level: Alarm in working order: Yes_ No_
Date f previous pumping.
Cc ents:
(co dition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan;
Depth of liquid level above outlet invert:
Comments:
mote if level and distribution is equal, e of solids carryover, evidence of leakage into or out of box, etc.)
PUMP HAMBER:_
(locate n site plan!
Pumps i working order: (Yes or No)
Alarms i working order (Yes or No)
Comme ts:
(note c dition of pump chamber. condition of pumps and appurtenances, etc.)
ev S G ,� /
` Pnrc 8 of I I
i SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM
PART C
SYSTEM•((FORMATION(eortun rid)
+oWrtyAddress: 163 Hinckley Rd. , Hyannis
0 r: Johnson / Grant
Date of inspection:
SOIL ABSORPTION SYSTEM(SAS). ti
(locate on site plan,it possible:excavation not required,location may be approximated by non intrusive methods'
If not located, explain:
Type: i
leaching pits. number:
leaching chambers, number:_
leaching galleries.number:_
leaching trenches, number, length:
leaching fields. number, dimensions:
overflow cesspool. number:_
Alternative system:
Name of Tecnnology:
Comments:
(note condition of soil, signs of hydraulic failure, level of Pon frig. daa ID s il, condition of ve etatron, etc.) /
I% si .�4:,2.e9 90 :�y �d R� Ca.t
CESS OLs:_
(locate o site plan!
Number a d configuration.
Depth-top f liquid to inlet invert:
Depth of s lids layer:
)epth of s m layer:
Dimensions of cesspool.
Materials of construction.
Indication o groundwater.
in oM (cesspooi must be pumped as part of inspections
Comments
( te con tion of soil, signs of hydraulic failure. level of pondfng. condition of vegetation, etc.)
PRIVY-
no _
liocat on site plan?
Materia of construction
Depth o solids: Dimensions:
Commen s:
Inote co drtion of soil, signs of hydraulic failure. level of ponding, condition of vegetation, etc.)
PdR(9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i
PART C
SYSTEM INFORMATION Icontinuedl
NopmyAddreas? 63 Hinckley Rd. , Hyannis
.owner: Johnson / Grant
Jate of Inspection:
SKETCH 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)
Q
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i
)
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTWN FORM
PART C
SYSTEM MFORMATION lawodnradl
163 Hinckley Rd. , Hyannis
Owner: Johnson / Grant
Date of fnspaetion:
NRCS Report name
Solt Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked Deep
Groundwater depth: Shallow Moderate
SITE EXAM Slope
Surface water
Check Cellir
Shallow wells
n _
Estimated Depth to Groundwater .Z; Feet
Please indicate all the methods used to determine Nigh Groundwater Elevation:
-Obtained from Design Plans on record
Observed Site(Abutting property.observation hole. basement sump etc.)
Determined from local conditions
✓Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
{
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
73 614
� . _SE.. 9/2 9E page lloru
LO CAT 10 SEWAGE PERMIT NO. I
VILLAGE
f ° r✓r'VfS SE AA# ER
I NSTAL R'S NAME i ADDRESS
u0,5'
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE C0MIPLIANCE ISSUED
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No... ...$� Fps.. .!�... .........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® 'OF HEALTH
......---------
.---
.Town-----..OF....Barnstorble...............
......
( � ,XVVIkation for Bionooal Works Towitrurtion Prrutit
Application is hereby-made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
.....Lot..l37..D..Hinckle_Y_...Rod........................... ................
•.......................•-•-•---............----
Location.-Address -or Lot No.
Nancy Johnson � �
......................_»...e......_....... caner• ... �....1O.Wk77 - ........_ �._._.. Address....... ................
P. Macombe &. •on nc Centerville
• • .. ........................ ..................•----•.............-----.......--•-•......-•--••••-•- •-•-----........----
Installer Address 16
Type of Building Size Lot.-_759___ ___________Sq. feet
U Dwelling—No. of Bedrooms...._..._........................ .....Expansion Attic ( ) Garbage Grinder (rrz )
Other—Type of Building No. of persons............................ Showers — Cafeteria
Otherfixtures --------•----------------------•---•------------•------------------------•------ ----------------------------------•--....._• .....................
W Design Flow.....-`-++ 5...............................gallons per person per day. Total daily flow..........330........_.....--.........gallons.
WSeptic Tank—Liquid capacityl-`�QQ.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width......_............. Total Length...._................Total leaching area....................sq. ft.
Seepage Pit No._.-10-00....... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (K ) Dosing tank ( )
1.4 Percolation Zek Results Performed by--•---. Date........................................
Test ljt No. 1.2or...lfn�tes per inch Depth of Test Pit..12............. Depth to ground water l2-'____nc?...water
f= Test rt No. 22___pX._..j_jpi,9Mtes per inch Depth of Test Pit...1_2.!.......... Depth to ground water_I2.!....np.---water
9 --------------------------------------•--•------••----------.....-••---............-•-•-••-••-•---•-.........................................................
Description of Soil._._ QSubsoil•_-2-!•.•coarse_ sand_,-_ Bony.gravel below
v ---••----•------•-------•---•----------•......-•-••------------•---._.....••--------•----••--•-----------------•--------•--•---••-------•-------•-------•---------------------••......--------•-••------
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 TITL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has Keen issued
,by the V.'1a1-01YK-WA
booard of health.igned---- ` 11� :. ----•--- . •--� Dat
Application Approved By...-... --;0!0..........
ate
Application Disapproved for the following reasons:-•-•--•-••-------•----------•---•--•----•...............•-••-----•-----•-•------------------------•-------••----
-•....................•-•-•-••---•-----••---•---.._...........•-••---••--.....---•-•••-•--••--•-•---...••---------------------------------------•-•-•------------•--•----•-----•-----•-...---•-....••---
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
........... .........Town---...-.OF....Ba rns table
--- ------------------------••-•••••••••••-•••-•.......
AppltrFattun for Diopmtal Works Tomitrur#tun rrutit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
_._-.Lot 117 D Hinckley Ro �d
.._.�. ............................................... ...................... ...............•---.................-•----•----•------------•-----......_.....................--•-
Location-Address or Lot No.
Td_ncy Johnson Hvt�nn s
W. Joseph P. Mucomoer & Son Inc Centerville Address
,.a ........--•-•••--••-•-•------•..........................•-......---•-------•-•-••-------.......... ..----.............•-----......-----•----.......-•-......�•-----•-•...i6.----------------••-
Installer Address
Type of Building Size Lot.•-759---16........Sq. feet
Dwelling—No. of Bedrooms............................................3...............................Expansion Attic ( ) Garbage Grinder (ND)
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures -----------------------------------------••_•.
W Design Flow...........................................................gallons per person per day. Total daily flow__........�330..........................gallons.
WSeptic Tank—Liquid capacitylgP2.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.__.;:_,.......... Total leaching area....................sq. ft.
` Seepage Pit No...1.2DQ)....... Diameter...................:'•Depth below inlet...1.............. Total leaching area..................sq. ft.
Z Other Distribution box (K ) Dosing tank ( )
a Percolation blest Results
1 Performed by.......................................................................... Date........................................
Test It No. 1................ 3n tes per inch Depth of Test Pit.:12.•__,___•____. Depth to ground water._..._....n�.._w. for
LL, Test it No. 2?---fir-__Lmgingtes per inch Depth of Test Pit__„ 2._ _... Depth to ground water!2.1....no.... to r
- ---------- ------•-------------------------
O Description of Soil....L r m & Subsoil 2! coarse sand, Bonyegr_zvel below
x
................. -------------------------------•----•...
W
UNature of Repairs or Alterations—Answer when applicable--------------------------------------------.....................................................
i
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by.the board of health.
Signed....... .......t. �,�� ��N............�.1
_....
I Date
Application Approved By. ( ....,.. ....................... /
Application Disapproved for the following reasons:-----••••• •-•-----•-•----•---•-----------------------•-----------------------------•--•--•---•-- --•--.-----
--------------------------------------------------------------•-----..........----------...---`--------......--•---••---•-------------•-•--.................I............---------.._............................................
Date
PermitNo......................................................... Issued-.....................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town B:zrnst� ble
..........................................OF.................I...................................................................
Tinttftratr of Tompltuna
----T,ff_U IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( )
by...Josen: ......... .�...... - —3 s------..N �, yi"^0�5........----••••-••---•--••-•----•.............•--•---•-.....-•---....--
_.._... _.... ...... ...._.T. _...
Installer
at Lot 137 DHinckleyR" aH�annis Johnson
......-•••_.. ...------ -•- -== --------- ------.--------------•---•----......•.....-----•--._................---•--------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No �6�¢_----_----. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHAL T BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM 1ddlltL FUNCTION.%�SF TORY.-•---- p . .... ..�
DATE................ Ins ector___. _---
-----------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
$ 811 ...........................................OF..................................................................................... FEE_!.....................
7`-` �t��u��tl urk� �on�tr�rttun rruttt T,;A
Permissio> is hereby granted----------------------.................................................... J-&.w s..................................
to Co>,mcq 7borH���l�y) n�Ibdivilt�la e ;age Disposal System
atNo...............................................................................................................................................................................................
Street , y
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
----------------------------- -----
DATE fD �f ,1
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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