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HomeMy WebLinkAbout0018 BAY STREET - Health 18 Bay Street, Osterville A= -.j J/' J q V � a e I i i i i 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 05Te_4ViLl.Le_, FM ECEIVE® Owner' s name W !LL I Am j,�.,)A I G� fT LL�� Date of Inspection 5 a l95 AY 3 1995 PART A CHECKLIST T�' TA�LE o Check if the following have been done: _ X Pumping information was requested of the owner, occupant, and Board of Health. X 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. X As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. X All system components,onents� excluding the SAS have been located on the Y site. X 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility .owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. t 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM ..INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of 'bedr o s Ll number of current' residents No garbage grinder, yes or no ES laundry connected to system, yes or no NO seasonal use, yes or no If nonresidential, calculated flow: 11193 - 495 = //(a, 000 GF3LLcvvS Water meter readings, if available: 0q&55y.9 Last date of occupancy GENERAL INFORMATION Pumping records and source of information: 11U57'►gLl.4Z0 - 198L9 I �1w�nPinl6 - � � of ►NsPti-r7yA) System pumped as part of inspection, yes or no if yes, volume pumped 1000 6gU-0NS Reason for pumping: i'n A"i A)T7or►►Nft-Nce- Type of system 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: 19$9 lUO Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: I.000 66L OA) (locate on site plan) depth below grade: (o IftUFCS material of construction: _concrete metal FRP other(explain) dimensions• 9 1(" LotjG By y ' t,, n W ODE sludge depth distance from top of sludge to bottom of outlet tee or baffle a" scum thickness y 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, recommendations for repairs, etc. ) 5E1°?7 7 ,U)= Pum PEA f e2 i n5PeG7lo� f 2 D e rJe.2 DF o )Vee DISTRIBUTION BOX: _ (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, recommendation for repairs, etc. ) U-CL J.fox , ruo 5aub r A Qay o,re� , 6 C)nb t)-W)( No t caK_,%e, PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) i 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM --- PART B SYSTEM INFORMATION continued 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: LOCArer> On A5 f2o)x C^?-,� Type leaching pits and number 1 - (0 FOOT 66y 1, FOOT LbecP W)I N leaching chambers and number oZ FPtT OF STWC, leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations ,for maintenance or repairs,etc. ) Cones Send ND 'W- P-AvU C- 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 materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, .signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) s 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' VHC O F rtOUS�- 13 m , sc-PnG T 119-/V L LEtKN pir OSeQ'('IL 1rit')y- Z2`6 It -r�-r ' �--�7 ou 18 i ebx 06 ro�r 3) ' DEPTH TO GROUNDWATER 2-5 ICC7- depth to groundwater eSTimAT method of determination or ap proximation: �try- ie5i- ►h 19" 1 y FovT 6 I nc VO UVIT-CA e!) 5) Dr) To or 1 hLt, F eSTi 0-6 Fecr TO WH-TcA 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) _[VD Backup of sewage into facility? MO Discharge or ponding of effluent to the surface of the ground or surface waters? N Q Static liquid level in the distribution box above outlet invert? N Liquid depth in cesspool <611 _ below invert or available volume< 1/2 day flow? ri p ce--sPOOL- N Required pumping 4 times or more in the last year? number of times pumped A)O Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: f� below the high groundwater elevation? PJO within 50 feet of a surface water? O within 100 feet of a surface water supply or tributary to a surface water supply? N0 within a Zone I of a public well? AID within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? Nc� within 50 feet of a private water supply well? NQ 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Dort 6,w `6u rn iou_5 Company Name OceRK) Ct)nr,eA cz-rn 6 Company Address 1P 0- )5 ox 6 s 9 C)5ickvi Ile, rnA, oa65S Certification Statement I certify that I have personally inspected the sewage disposal system at this adress and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regrading upgrade, maintainance and repair are consistent with my training and experience in the proper function and maintainance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails to adequetly protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature P 9 Date 5 la)q 5 Original to system owner Copies to: Buyer (if applicable) Approving authority TOWN OF BARNSTABLE LOCATION / J9A y s RF-E I SEW G&4 - VILLAGE n ))€ ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. qagjaN Af MPUS SEPTIC TANK CAPACITY LEACHING FACILITY:(type) CA<� 'J�;r' a 'S�Q'N£ (size) Xh NO. OF BEDROOMS ` PRIVATE WELL OR PUBLIC WATERrug/i C BUILDER OR OWNER `/� A)R1 r-J T DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No n d, r LA u) oS u 1: I�s /D 6x i � TownOfBarnstable Public Documents Inspectional Services Building Division OSTERVILLE ... Search in document More Details Annotations Entry Properties Modied Created Path Template BARNSTABLE_BUILDING Fields Village StreetNumber StreetName 1 2 3 4 5 7/2/24, 9:58 AM 0018 BAY STREET https://itlaserfiche.town.barnstable.ma.us/WebLink/DocView.aspx?id=698367&dbid=0&repo=TownOfBarnstable&searchid=c614fd42-f8b2-4b69-9efb-561dc6bac4e6 1/1 J: 7 7, 4 JW,�­ 70WAI OPAA kt0TA5MA559550R57nAP_' -LOT 17. R . : __7 Z 7-0POP'M LFA MTgW4KS: FRONtS_10.114DES.I REAR.JO J.FF Ir- 1:i&;• _.M.4 sEF,nc TAwK East.wvL. ct�lltp FAC LI_fy. - ---------- L 9- t4O6 s,5 L 4r lit TrAvgLLEP W�Y, pl M117.1 L . ; TO IL 1141' 7- SECTION- 6E j 4—A TE57'HOLE L065 DESIGN FOR 3.9EWR00M ffDVS& T ay,v 12,000 CA-pis,sd4- PERC-RATE EST Z MIN41M. M, GATE: -61jo -LOMRATC-110 6ALJCPAY MITME55- 5EPTIC TAWK:530 (l.C,) T REOP'0.SEPTIC TANK000 .:A\! W-4 EL i6.8ti LEACHING F LITY 41 7 TOTAL WPM OF 649•0 C40 Ar 7 iol Fw 9M.it d .;9.>l C 1115.N� 12 NOTES k I Wk" I-PAYL"CMSL3 t TAKEN PROM COTIn _.,JXUApRAWfiLE MAP 9-14bWICIPAI-MATER: /5 AVAILABLE 5 I PESI&M 7-OAMAG POR ALL PRECAST VAUrs;AAS-O-M4b-44 r4' 4.PIPE.10IMrS SMALL 08~E MAT5JT Pa. NO In1gTER .6.COMSTRUCTION 09TAILs TO Ele Jq ACCOM*&4CX kiffil NGOUNTER�D. COII-I.AF MASS.STATE eNvimommemrAiL cove timEx G.Jr/05 PLAN P679 PROPOSED JAMJCJMLY AMP 511OM&NOT Uf _LEAN MSD.54,4D. AR UW AFINE H, W/7 Caj;y-enqlnew,,m LOCUS.L�qj A� D&ycT.OS-1j."LLr- w OF -MALA k I VIL CIVIL E14GINEEFW. Cl Z: I -REFERENC-1 Rl I f7:- LALND SURVeYORS CONC.6 OUNDT PREPARED MR: OAP"'of d Ca I; ARNE Ffl_0JftLP%,PE.� 9zr.main st.yarynovth,ma TEST MOLE wiWiM --board of hea146,_. SCALE' DATE 4(0 APPROVED' THE COMMONWEALTH OF MASSACHUSETTS 1 _yR �`"" ��B`OARD OFnHEALTH jF) ( �`� .............�.V..Vv..�--------oF._'.....�.A.J� N..��fY� _........-------- Appliratiun for Ropaoul Ulvrko Tonstrudiun Frrmit ' Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System ..____U� .:_....t/k� - . sr...: ss1 u ... ._...: _....................................... .....�.._. _ Location� .P . 9... .tu;... .... ...................... ....---• .........or_Lot-No................................_....... «�� •� L WT Address ' . ..� 1.� ...l..0..»........................... .... .....•--^_-^-•^__.............«..-'___'.Address ........................_____._._.._...._ V �+ Type of Building � Size Lot----67p `D Sq. feet .� Dwelling—No, of Bedrooms........................................._..Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building p ( ) • ( ) ............................ No. of ersons._.................---_-•--- Showers — Cafeteria QOther fixtures ......................................1 �..._-----•--•--•.............--••----•-•---....--• .................._------•-----•--- W Design Flow................ --gallon g gallons per p�sen qer Total daily�iow_.-------_�.s✓�.Z2 .....____._.g allo s. WSeptic Tank—Liquid capacity.tf.gallons Length_�_�._:__ Width:...;.((.___ Diameter..... .. Depth.�D.. ._ x Disposal Trench---No. .................... Width....................Total Length.................... Total leaching area........____ q: ft. ..4 3 Seepage Pit No...-._.. ......... Diameter.......1.a.... Depth)below inlet........ Total leaching area_.4�sft. Z Other Distribution box Dosing tank Percolation Test Results Performed bW 1,.2..C.1 ,�..xx Date_.....�� �� Test Pit No. 1...... ...Lminutes per inch Depth of Test Pit..... ...•.. Depth to ground water.. A.�..... G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... Description of Soil...Q.r. Z --._L _i.`r :.......�Ztt 1.4 'u... ..Mf; W .....................•-........................................................................................................_....--.. ...................-.................... ---------- UNature of Repairs or Alterations—Answer when applicable....._.� e •-:-:;.............................................................. ..............................................................................................................••--------------=------------•----••----•-----............-•-•---------•-•--•--•--------. Agreement: The undersigned agrees to install the 'aforedescribed Individual Sewage Disposal System in accordance with the provisions of,ITLw 5 of the State Sanitary Code—The undersigned further agrees not to place-the system in p ntil a Certificate of Compliance has been iss a board operation u o / Signed.. ! `.y....... 1.:... Date Application Approved By.. (l"!11,A. . .......... . . ............ ....................................... Date Application Disapproved f okhe,following reasons:................................ ..............................................................._...... :.«« ................................... .. ..•--. .._...................................................._.......---•-------------................................... -----••-••-_..._ Permit No._-' _ .•: - �.......................__ Issued.___._....__._.. ....................D� � _._.. •Permit No.)" F R THE COMMON EALTH OF MASSACHuse-rrs BOARD OF HEALTH OF Appliration for %yo-Bal Works (gaustrurtion Permit Application is hereby made for a Permit to Construct or Repair Individual Sewage Disposal Syd—ILt: 1_r)-T t nn-a .. .................................................... U;ti­-Add—, or Lot No. LL.L!A.�A W.&!.r*T±Lr.... ........................................ ............... J- 0.ner Add ess • 4.......71j.&/ q ...................*................ .............*­...................... --------------"*...... InstallerCq Type of Building Size Lot.... fed Dwelling—No.. of Bedrooms............................................Expansion 3 Attic Garbage Grinder Other—Type of Builditig ............................ No. of persons............................ Showers Cafeteria Otherfixtures .......................................0..e;.................. ........I......I.............................................................. Design Flow.....1­.......!__1.1(_?....,,.T.galJons per person per 4ay. Total ily f101A•.......... .............golon.. Septic Tank—Liquid capacity. — -gallons Length.M,7K'....Wit 4,16r..Diameter................Depth.5,:24-.P Disposal Trench—No.....................Width_...................Total Length....................Total leaching area....................sq.ft. Seepage Pit No.........i.......... Diameter.......).. Depth below inlet........ Total leaching area.2A,!;.Csq,ft. Z Other Distribution box (N)_ Dosing tank ( ) - Percolation Test Results/ Performed by Z;J i��G Date................... .Wto ground ..I Test Pit No. I.......`:?�rninutes per inch Depth of Test ounWwater....� Test Pit No, 2................minutes per inch Depth of Test Pit.....................Depth to ground water........................ ....................................................................................................... 0 Description of Soil...n. ............_...........S ........................................... . ...... ... .. ....... .. ..... ........................ ............... ---------------------------------------------------------------------------------- ........................................................................................................... ----------------- --------------0......................................................................... Nature 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 undergigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by She board. I ed... ..........:.fir ........ .. ... ..... ......12.................... ign .;............. 'S'Application Approved By... .... ....... .......... ........................................ Date Application Disapproved for the following remow:............................................................................................................ ............................................................................... ............................................................................. /,q_ / 7 Date Permit No.--Cj.............. .3............... Issued................................... Daft THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH r0lp..A ��........ (gerfiftritte >af Tompitance THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed or Repaired ............................................... ............. ....... .... .....at_ ................k 1? Ira ......................................... .......................................... ----------7..................... has been installed in accordance with the pro/lisions of TITLES 5 of 1he State Sanitary Code.3s describ in the ---- i ) . application for Disposal Works Construction Permit No..... - ......... dated..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE TVAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................... - 7j - 5, 14 ..... ­ Inspector._............. ....... .................................... ......................Zv 7........... ---------- --------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH- FEE ................ 0 F.. .............. N o ?..?���7 ....1i................ Varkz Tonotrurtion Permit Permissionis hereby granted....................:........................ ............................................................................................. to Construct o R Indiyi Ual Se"affe.Disppsal at ep3'r T.at No...... VAI�- �* i 1 4.................... .........../---------------------- �s......... ............ as shown on the application for Disposal Works Construction Permit No. --� P................7........... ...........................................1� .. ........................................... PATE.. ....... ...............................