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Home My WebLink About0052 SIXTH AVENUE (HYANNIS) - Health 52,SIXTH AVE-JgAl IS A= r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System 41: ............ ..At.�_ __ �---- ---------- Location-Address .1 Installer Address Z Other Distribution box ( ) Dosing tank ( ) U Nature of Repairs or Alterations—Answer when applicable------------ ..t---Ono---- -------'-----------'---------------------------'---'-------'--'--------'--------- '�g -_—__. ' No...................--.-- Fps. ....................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH / Appliration for Uhipaii tl Workii Tnnitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: f )� ......................... ....3.._ ..a�..:::'Y:_- ..,...... -11:?:�:........!_'.:::7y"-�-�'' /�� G✓.0...........................r r?_".a..:_.._s.:: _�.�::-::�.�........... Location-Address t or Lot(k'o. .............. �!, �.:Srr s:.-.' ._ ....•.. L�jg!r,...... fi.,{r-_c•c = •. ...... ?_"`=-`-"-`-=- -'==t-'�-........... J Owner // Address a --•..............................`` � rc..........f•s C¢ t.0 "c'}:. -:......... ......--•---............................... C4 Installer Address UType of Building Size Lot............................Sq. feet Dwelling--No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) PL, Other—Type of Building ............................ No. of persons............................ Showers — Cafeteria al Other fixtures ............................... . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__._____-____-- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-. Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water•.--_-_______-_--___-_.. PL4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •--••--•--•••••................••.........,.........••••-•--•-------.........-•-•-----------._...---......................................................... 0 Description of Soil........................................................................................................................................................................ x U -------------------------•----------------•---...........--•---•---•------......_..------------------•---------------------•------------•-----------.•................................................. W ------------•-----------•--------------------------------------------------•--------•-----------...•-------------------•-------- -•--• ---------------- •--------- ------------- ----------- - U Nature of Repairs or Alterations—Answer when applicable.____---_-- t�?�?�'__ r� .___ �:..• f<<'r' .... t_r ...... -------••••••••.•••••-•-•••••--•-------•--•_.•••-•••--•-•-••-•--------••••-••--••-------•-------------••--•...••••••••---•--•-••-•-•--•-•-•--•••....---•-•---•-......_..•-•••••-•--•-•••----•---------•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS, 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 y the boar deof health Signed " �•'�" !'T.--•-- ----= ' '-- -------•--------- ----------------------- r tt .v- Date Application Approved BY Y ------. -------. Date =' Application Disapproved for the following reasons:----•------------------------•------------------------•---------------------------------------•••-------....... ..............................................••----•-•--------------••......................-----._....------•••-•--•--••••----•------•-•----•••••••-••-----•--•------------••...--•---............. _ Date Permit No......`Z� ` :=.................................... Issued ....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ✓ .t' d~l ? sG dr ClEntifiratr of Tout rlianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......................... ........dy.._! .i........� ............. --------._........----....-------••------•--.................................................. Installer at.....................-_"=.... .1--.4k.....I ---.Et�1........................... --------•------------------•-•--------------------------------- has been installed in accordance with the provisions of �'-�" I� j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------- y__--_'5 4;_:Z------- dated_---------------------_-_________-___-------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................ ... _ .._".&.......-.................... Inspector................. + THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / J I // .!;^Y'.�...............OF............f. f`.z1..1:° r Q_�M: .................................. - J............ NO.......:.....:........... FEE.__........----------- Elbiposal rk inn rnr inn �ernti# Permission is hereby granted......... ............t - =` =; -------------------------------------------------------------------------- to Construct ( � ) or Rep air an Individual Sewage DisrKosal System y� at No................. .........:.�s r ^.�-r f f �. - .z,,.w� �.:a^a-,P ........................................................ t Street as shown on the application for Disposal Works Construction Permit No._a_�!_ _ _ Dated.......................................... Board of Health C DATE.................... -----�- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS I` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION RECEIVED Sixth Ave., Property Address:Hyannisport,Ma Address of Owner: A U G 1 ,,7 0000 (if different) Date of Inspection: 16 June 2000 TOWN OF BARNSTABLE HEALTH DEPT, Inspected by: James Holler I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CUR 15.000) Company Name: Holler& Son Construction LLC Mailing Address:P.O. Box 702,Marstons Mills,Ma 02648 Telephone: (508)420-0280 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 Inspectors Signature Date: The system inspector shall sub t copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: t ®I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below: Comments: B) SYSTEM 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. d' 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 inspectorwith a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (Continued) Property Address:52 Sixth Ave.,Hyannisport Owner:Bunker Date of Inspection: 16 June 2000 B) SYSTEM CONDITIONALLY PASSES (continued) ❑Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: ❑ broken pipe(s)are replaced ❑ obstruction is removed El distribution box is leveled or replaced ❑The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed C) 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. ❑Cesspool or privy is within 50 feet of a surface water ❑Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING 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 to 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 1 of a public water supply well. ❑ The system has a septic tank and soil absorption system and the SAS is with 50 feet of a private water supply well. ❑The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER { r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:52 Sixth Ave.,Hyannisport Owner:Bunker Date of Inspection: 16 June 2000 D) SYSTEM FAILS You must indicate either"Yes"or"No"as to each of the following: ❑I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this determination is identified below. The Board of Health should be contacted to 15.304.determine what will be necessary to correct the failure. Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or Cesspool. ❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow. ❑ ❑ Required pumping more than 4 times in the last year not due to clogged or obstructed pipe(s). 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 with 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 with 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes"or"No" as to each of the following: 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: Yes No ❑ ❑ 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 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 52 Sixth Ave.,Hyannisport Owner:Bunker Date of Inspection: 16 June 2000 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health. ® ❑ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ® ❑ As built plans have been obtained and examined. Note if they are not available with N/A. ® ❑ 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 or the Soil Absorption System on the site has been determined based on: ® ❑ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. ® ❑ Existing information,Ex.Plan at BOH. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address:52 Sixth Ave.,Hyamrisport Owner:Bunker Date of Inspection: 16 June 2000 FLOW CONDITIONS RESIDENTIAL Design flow: 110 gpd/bedroom for SAS Number of bedrooms 3 Number of current residents:3 Garbage Grinder:No Laundry connected to system:Yes Seasonal use:No Water meter readings,if available (last 2 years usage in gpd):No Sump pump:No Last date of occupancy:Currently COMMERCIAL /INDUSTRIAL Type of establishment Design flow: gpd Grease trap present: Industrial Waste holding tank present: Non-sanitary waste discharged to the Title 5 system Water meter readings,if available Last date of occupancy OTHER:(describe) GENERAL INFORMATION PUMPING RECORDS and source Owner System pumped as part of inspection No Volume pumped: Reason for pumping: TYPE OF SYSTEM ®Septic tank/distribution box/soil absorption system ❑Single cesspool ❑Overflow cesspool ❑Privy ❑Shared system(y/n)(if yes,attach previous inspection records,if any) ❑I/A Technology etc.Copy of up to date contract? Other APPROXIMATE AGE of all components,date installed(if known)and source of information: 10 Years,BOH Sewer odors detected when arriving at the site:No SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address:52 Sixth Ave.,Hyannisport Owner:Bunker Date of inspection: 16 June 2000 BUILDING SEWER (Locate on site plan) Depth below grade 20" Material of construction®Cast Iron®40 PVC❑other Distance from private water supply well or suction lineN/A Diameter 4" Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK (locate on site plan) Depth below grade 18" Material of construction®concrete❑metal❑Fiberglass❑Polyethylene❑other If metal list age is age confirmed by certificate of compliance Dimensions: 1000 Gal Sludge depth: 10" Distance from top of sludge to bottom of tee or baffle 20" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 3" Comments: GREASE TRAP (locate on site plan) Depth below grade Material of construction❑concrete❑metal❑Fiberglass❑Polyethylene❑other Dimensions Scum thickness Distance from top of scum to top of outlet tee or baffle Date of last pumping 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 leak,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address:52 Sixth Ave.,Hyannisport Owner:Bunker Date of Inspection: 16 June 2000 TIGHT OR HOLDING TANK:❑(Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: ❑concrete❑metal❑Fiberglass❑Polyethylene❑other(explain) Dimensions: Capacity: gallons Design flow: GPD Alarm level: Alarm working?❑yes❑no Date of previous pumping Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:Zero Comments(note if level,and distribution is equal,evidence of leaks or solids carryover,etc.) PUMP CHAMBkR:❑ (locate on site plan) Pumps in working order: (yes or no) Alarms in working order:(yes or no) Comments:(note condition of pump chamber,pumps,and appurtenances,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(Continued) Property Address:52 Sixth Ave.,Hyannisport Owner:Bunker Date of Inspection: 16 June 2000 SOIL ABSORPTION SYSTEM:(SAS) (locate on site plan,if possible,excavation not required,but may be approximated by non-intrusive methods) if not determined to be present,explain: Type; leaching pits,number one, 1000 gal 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 of hydraulic failure,ponding,vegetation,etc.) CESSPOOLS:❑ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer Dimensions of cesspool Material of construction Indication of ground water inflow(must be pumped as part of inspection) Comments:(note condition of soil,signs of hydraulic failure,ponding,and vegetation,etc.) PRIVY❑ (locate on site plan) Materials of construction: Dimensions Depth of solids Comments:(note condition of soil,signs of hydraulic failure,ponding,vegetation etc.) J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(Continued) Property Address:52 Sixth Ave.,Hyannisport Owner:Bunker Date of Inspection: 16 June 2000 SKETCH OF SEWAGE DISPOSAL SYSTEM Include ties to at least two permanent references,or benchmarks,locate wells within 100'and where public water supply enters house. A� 3 3� L i3 3 2� 3 � � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address:52 Sixth Ave.,Hyannisport Owner:Bunker Date of Inspection: 16 June 2000 Depth to Groundwater feet Please indicate all the methods used to determine High Groundwater Elevation: ❑ observed from design plans on record ❑ observation of site(abutting property,observation hole,basement sump) ❑ determine it from local conditions ® check with local Board of Health ® check FEMA maps ❑ check pumping records ❑ check local excavators,installers ® use USGS data Describe in your own works how you established the High Groundwater Elevation. (Must be completed) r TOWN OF BARNSTAALE LOCATION � � �. SEWAGE # ob, VILLAGE FA YA N ►V ISASSESSOR'S MAP &.LOT _ INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /0 0 0 S LEACHING FACILITY:(type) o /" (size) �f NO. OF BET)ROOMS ✓ PRIVATE WELL OR PUBLIC WATER OR BUILDER OR O WNER� /i_S C1 Al L: DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: — 1 VARIANCE GRANTED: Yes_ No ` m 1 � � c l n /� P LF, 5r