HomeMy WebLinkAbout0027 WASHINGTON AVE EXT. - Health 27 Washington Ave., Ext., Hyannis
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.\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
g DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
WILLIAM F.WELD TRUDY COXE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
17 Washington Ave Ext
Property Address: Hyannis, MA Address of Owner: Robert Sylvia
Date of Inspection: 3 2 9 F_ (If different)
Name of Inspector: Wm E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: WM E Robinson Septic Service
Mailing Address: PO_ Box 1089 CentPrvi 1 1 P i AAA 02632
Telephone Number; -5()8Y 7 7 S—8 7 7
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:
_Vse Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: k Date: 3 "9
The System Inspector shall submit a 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:
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] S STEM 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.
In(icate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with 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.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/hvww.magnet.state.ma.us/dep
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 Washinton Ave Ext, Hyannis
Owner: Sylvia
Date of Inspection: 3_;.—9
BJ 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
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
Cj FUR HER 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) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
HE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
NVIRONMENT:
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 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 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
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 Washington Ave Ext, Hyannis
Owner: Sylvia
Date of Inspection:
D] SYSTEM FAILS:
You st indicate ei;,.er "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 determine what will be necessary to correct
he failure.
Yes o
`Backup of sewage into facility or system component due to an 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 112 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 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 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 GE SYSTEM FAILS:
You ust 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 o ner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requir ments of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 17 Washington Ave Ext, Hyannis
Owner: Sylvia
Date of Inspection: 3 -a^ 7 19—
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 ii 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 of the Soil Absorption System on the site has been determined based on:
The facilitv 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 B.O.H.
— 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)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 17 Washington Ave Ext, Hyannis
Owner: Sylvia
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:cab g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):A Q
Laundry connected to system (yes or no):V--3
Seasonal use (yes or no): ti G
Water meter readings, if available (last two (2) year usage (gpd): 1 2/9 5 — 1 2/9 6 39, 000q
Sump Pump (yes or no):A 1 2/9 6 — ' 1 2/9 7 48, 750g
Last date of occupancy: 3—off-g
COMMERCIAL/INDUSTRIAL:
Type f establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_ -
Industri I Waste Holding Tank present: (yes or no)_
Non-sa itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available:
Last�te of occupant}:
OTH : (Describe)
Last da t occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) J
If yes, volume pumped: gallons
Reason for pumping: A- L:—L^./
TYPE OF STEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (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:
Sewage odors detected when arriving at the site: (yes or no) 1` O
( /25 97 revised 04 e 5 of 10
/ ) Page
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Washington Ave Ext, Hyannis
Owner: sylviag-
Date of Inspection: 3
B DING SEWER:
(Local on site plan)
Depth below grade:
Mater al of construction: cast iron —40 PVC _other (explain)
Dist nce from private water supply well or suction line
Dia eter
Co m ents: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grader
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:
Sludge depth: (3
Distance from top of sludge to bottom of outlet tee or baffle: 4/3
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle: F I
Distance from bottom of scum to bottom of outlet tee or baffle: /`)
How dimensions were determined: /(.-& J
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,51ructural
integrity, evidence of leakage, etc.) iL i l,) 4 T',
GREA E TRAP:
(locat on site plan)
Depth elow grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dime ions:
Scum. hickness:
Dista ce from top of scum to top of outlet tee or baffle:
Dist ce from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
Comm nts:
(recom endation for pumping, condition of inlet and outlet tees or baffles; depth of liquid level in relation to outlet invert, structural
integri , evidence of leakage, etc.)
(revised 09/25,/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Washington Ave Ext, Hyannis
Owner: Sylvia
Date of Inspection: 3 —;L- 9' $'
TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(Iota on site plan)
Depth low grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimen ions:
Capaci gallons
Desig flow: gallons/day
Alar level: Alarm in working order _ Yes; _ No
Date o previous pumping:
Comm nts:
(condit on of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_V
(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.)
P )cat
CHAMBER:_
(Ioon site plan)
Puin working order: (Yes or No)Als in working order (Yes or No)Cents:
(ncondition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Washington Ave Ext, Hyannis
Owner: Sylvia
Date of Inspection: 3—0.—9 /
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:_
leaching chambers, numberI.—
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, level of ponding, condition
�aof,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: L
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
in`low (cesspool must be pumped as part of inspection)
Comm nts:
(note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials f construction: Dimensions:
Depth of s lids" _
Comments:
(note condi ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page a of 10
Ii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Washington Ave Ext, Hyannis
Owner: Sylvia
Date of Inspection: 3
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
I
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Washington Ave Ext, Hyannis
Owner: Sylvia
Date of Inspection:
x
Depth to Groundwater 1,!�— Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
observation of Site (Abutting property, observation hole, basement sump etc.)
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 yourown words how you established the High Groundwater Elevation. (Must be completed)
7 s ,/4 3 -,Z-9'9- Iasi ,.mow S y 6
l {
(revised 04/25/97) Page 10 of 10
f 'i
TOWN OF BARNSTABLE
CF?HE Taw
OFFICE OF
11saa9TSBL : BOARD OF HEALTH
1 MMd p�
°o t639• gee 367 MAIN STREET
a MAY k HYANNIS, MASS. 02601
August 12, 1998
Robert Sylvia
P. 0 Box 207
Barnstable, MA 02630
Dear Mr. Sylvia:
During the public hearing held on August 11, 1998,the Board of Health voted
unanimously to uphold the cease and desist order issued to you by our agent, Thomas
McKean, on July 14, 1998, concerning your bird feeding activities at 17 Washington
Avenue Extension, Hyannis, Massachusetts.
The Board of Health also voted unanimously to order the Health Agent to assign a staff-
person to monitor this situation on a regular basis. A health inspector will be expected to
view your property at least once every two months in addition to investigating any
complaints received.
At the hearing,the Board members heard testimony from you and from several of your
neighbors. The Board also observed photographs showing more than one hundred birds
on the roof of your home and at your property. Other photographs were observed
showing bird feces on roofs, sidewalks, and streets adjacent to your property. Our Health
Agent, Thomas McKean, reported in the cease and desist letter that there were excessive
amounts of bird feces on the roofs of neighbors' homes, on sidewalks, and on the street.
Your bird feeding activities were clearly the cause of sources of filth and the cause of a
public health.nuisance.
You shall cease and desist any and all bird feeding activities at 17 Washington
Avenue Extension,Hyannis for six(6) months, from this date until February 11,
1999. After February 11, 1999 you will be allowed to install three (3)bird feeders,which
provide song-bird seeds only, at your property located at 17 Washington Avenue
Extension Hyannis.
You are reminded that you are not allowed to place any bread, meat, nor any other
food products on the ground, on the roof of your home, nor anywhere else outside
your home at this property at an, time.ime. Such an action would be a violation of the
Town of Barnstable Board of Health Nuisance Control Regulation No. 1, identified as
Part VII SECTION 1.00, punishable by a non-criminal ticket citation of$40.00.
Sylvia
Failure to comply with an order of the Board of Health pertaining to M.G.L.c. 111,
Section 122 may result in a fine of up to $1,000 per M.G.L.C. 111, Section 123.
PER ORDER OF THE BOARD OF HEALTH
usan G. Ras R.S.
Chairperson
Board of Health
Town of Barnstable
SGR/bcs
d
sylvia
Town of Barnstable P U
,, Board of Health 7 f i4�9,
P.O.Box 534,Hyannis MA 02601 I 5 0 4A
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kaufman,M.S.P.H.
Ralph A.Murphy,M.D.
July 14, 1998
Mr. Robert Silvia
17 Washington Avenue Extension
Hyannis,MA 02601
ORDER TO CEASE AND DESIST DUE TO PUBLIC HEALTH NUISANCE AND CAUSE OF
FILTH . . . . . . .. .... ..
The property owned by you located at 17 Washington Avenue Extension,Hyannis Massachusetts,was
inspected on July 13, 1998 at 3:00 p.m.by Health Inspector Edward Barry,because of a complaint of
numerous wild birds defecating onto neighbors homes,vehicles, swimming pool,and other personal
items.
The health inspector went to your property and observed numerous bird feeders containing seed,breads,
and other food items. There were several birds feeding at the bird feeders. There were large numbers of
pigeons, seagulls,and other wild birds perched on the roof of your home and surrounding homes,on tree
branches,and on the electrical wires adjacent to your home. Excessive amount of bird feces were
observed on the roof of your home and on many areas of your property. Excessive amounts of bird feces
were also observed on neighbors homes, swimming pools,sidewalks,vehicles,and many areas of their
homes. Your bird feeding activities are clearly the cause of a public health nuisance and sources of filth.
This is not the first time that we have attempted to address this problem. We have been attempting to
work with you informally and formally in response to previous complaints over the past two years.
However,the situation has progressed to the point where the large numbers of wild birds have become
sources of filth to the neighbors and a public health nuisance.
You are ordered to cease and desist all bird feeding activities at 17 Washington Avenue Extension
Hyannis,immediately upon your receipt of this order letter.
You may request a hearing before the Board of Health if written petition requesting same is received by
the Board within seven days of your receipt of this cease and desist order letter.
This order signed by the Director of Public Health constitutes as an order of the entire Board of Health of
the Town of Barnstable. Failure to comply with an order of the Board of Health pertaining to M.G.L. c.
I I I, Section 122,may result in a fine of up to$1,000,per M.G.L. c. 111 Section 123. You are also
subject to non-criminal ticket citations of$40.00. Tickets may be issued on a daily basis if you fail to
comply with this cease and desist order.
PER ORDER OF THE BOARD OF HEALTH
Thomas A.McKean,RS,CHO
Director of Public Agent
cc: T. Geiler
TOWN OF BARNSTABLE
LOCATION /7 4 N Gt d JV X Ar SEWAGE# 4 a d'
VILLAGE `/A /V/Y /S ASSESSOR'S MAP&LOT—a 0
INSTALLER'S NAME&PHONE NO. N/01,E /P0/31 N S 0 JY, 77j-- 7
SEPTIC TANK CAPACITY
LEACHING FACILITY: —po "��-O G ft L- C h� (J�fi S h
(type) (size)
NO.OF BEDROOMS C9—
BUILDER OR OWNER
a
PERMU DATE: 7' 9 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
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Fee$5 0 . Ves
No.
r 9
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Mgooal *pgtem Comaruction Vertu
Application for a Permit to Construct( )Repair(Kx)Upgrade( )Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. 7 71 —8 2 0 7
` 7 Washington Ave Ext, Hyannis Robert Sylvia
ssessor'sMap/Parcel 17 Washington Ave Ext, Hyannis, M
Installer's Name,Address,and Tel:No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
Wm E Robinson Septic Service
PO Box 1089 , Centerville, MA 02632
Type of Building:
Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder(no)
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 sand
Nature of Repairs or Alterations(Answer when applicable) Tit 1 P 5 SQ n�—Repair consisting—
of 1500a tank, D-Box, and two 500-gallon stonepacked precast-
leach chambers .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this of Health. /� r�
Signed �/� Date o2 `c�-
Application Approved by Date
Application Disapproved for the following reasons
Permit No. ZZ � Date Issued ;Z?7— �y�
TOWN OF BARNSTABLE
LOCATION T ILA LSIZZ16- SEWAGE #
VILLAGE -S ASSESSOR'S MAP & LOT -3 0
INSTALLER'S NAME&PHONE NO. 13121,Y0 j/- -7 71-'.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) J. 2-
NO.OF BEDROOMS C9—
BUILDER OR OWNER un� S
PERMIT DATE: 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
Edgeof Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
Q<
120
y $50.00
qo /e
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for �Dig;pogal *p,5tem Construction Permit
Application for a Permit to Construct( )Repair PCx)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
J
i
Location Address or Lot No. Owner's Name,Address and Tel.No. 7 71 —8 2 0 7
7 Washington Ave Ext, Hyannis, Robert Sylvia
ssessor'sMap/Parcel i 17 Washington Ave Ext, Hyannis, M
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6q_ Designer's Name,Address and Tel.No.
Wm E Robinson Septic Servica
PO Box 1089, Centerville, MA b2632
.Type of Building: ki
Dwelling No.of Bedrooms 2 1 Lot Size sq. ft. Garbage Grinder(no)
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 sand
Nature of Repairs or Alterations(Answer when applicable) Ti tl A 5 Rani—in RApair consisting—
of 1500g tank, D-Box, and two 500-gallon stanepacked precast
leach chambers.
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 operatio t�nl�a certifi-
cate of Compliance has been issued by this of Health.
Signed Date o2 `
Application Approved'by Date •*2�-��,
Application Disapproved for the following reasons
Permit No. ^ Date Issued - 10
——= — —————————-—
THE COMMONWEALTH OF MASSACHUSETTS
Sylvia BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired gx )Upgraded( )
Abandoned( )by
at 17 Washington Avenue Ext, Hyannis, MA has been constructed in accordance
°A with the provisions of Title 5 and the for Disposal System Construction Permit No. f/.7 dated 2 ^ 2:2-7r 4'.F'
Installer. W R Robinson Septic Service Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
--Date Inspector
--------------- - --------------------
No. A?f"l�,k Fee$5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
a
Sylvia lwigogal *pgtem Conmruction Permit '
Permission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( )
System located at 17 Washington Avenue Ext
Hyannis, MA 02601
Installer W E Robinson Septic Service
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 it.
Date: Approved b
'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 PERMIT (WWITHOUT
ENGINEERED PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated /°" concerning the
property located at 17 Washington Ave Ext, Hyannis, MA, meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any 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 Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED: DATE A -a d
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be:submitted).
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