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HomeMy WebLinkAbout0113 FIRST AVENUE - Health L14 S FIRST'AVE�u STERVILLE l.. A= 7 0 I i cc�� a ® a Na�..�- Fas........................... -• 1 THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOAR® OF HEALTH TOWN OF BARNSTABLE -'�-� / — `/— 93 Appliratiott for Diripmi tl Workii Tottotrurtiort Vinnit Application is hereby made for a Permit to Construct ( ) or Repair (6,y--an Individual Sewage Disposal System a 1 rs S �� /� or Lot No. �lclf ._... A ._...... _..o.. �� �----- ----..�.sA...�`-�........................................ Installer Address UType of Building' Size Lot............................Sq. feet .., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.---------.-.--.------------ Showers ( ) — Cafeteria ( ) a' 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. 3 Seepage Pit No..................... Diameter.............-.--.-. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,.� Test Pit No. I-_----------..minutes per inch Depth of Test Pit.................... Depth to ground water.--..................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P6 --------------------------------------------------••-----••--•-•---••-•----•----............-•----.....................---•----._.........._...••••.......... 0 Description of Soil.......................................................................................................................................................................... x c, ...... -------- W ....................................................................................................................................... --------- U Nature of Re airs or Alterat}ons—Answer when applicable... d` .-.-.._. . S .. .l© - r ------------------•--........................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—'The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ssued by t board o health. Signed . - .1�.�"... ."�... .. ........ Dare Application Approved BY - ..��-�..-.. � /. .... D� :-..�! . ..._---------`................................................... Dace Application Disapproved for the fol7owing reasons: ........................................................................ -- ................................. ........ ... . ..... .................................................................. ......... .... .. ... ............................ ........................................ Permit No. .....7 ... ... .. ...... Issued .:.... ..... ...................................... ...... Dace � - b. v •,,,., .-, -v= e ti -.. �. .:yr a,� +i-v "'4+ �.+. -v"`.:i•' „g•4,, v v'�,,.:. .... a rw��,i•i....�t�w.r -— t aw � +�,r O v a, No�3..^.. V Fm: ...........©........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , pphration for Dbipwiul Wnrk,i Tomitrnr#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair (,,n Individual Sewage Disposal System at• /� / sfP��� l L•ocitwn-:\d14Frss, �' or Lot No. lPft �� ......................r._i....... --------------------__- ner ..............� ,._..._..._....._.,_.._--ItOistaller._. __ Addres........................................... PQ s VType of Building Size Lot............................Sq. feet ..� Dwelling— No. of Bedrooms-------------------------------------_------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ..............•--------------- -- I W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth................ Disposal Trench--No. .................... Width-------------------- -Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter............-------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed b ............................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.--_----------------_. py t 0 Description of Soil....................................................................................................................... ----------------••......................... UW ............................................................. -------------------------------------------------------- ------_-- -----i•-----------................................................... Nature of Repairs or Alterations—Answer when applicable.--� 'CQ.-2.-_._._ ---------------------------- ___------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has�i'ssued by the board of health. Signed Dare G` Application Approved B �.......�,,.:............�_:..:n-� � �_.... -- %...-....�......cl..�. PP PP Y J Application Disapproved for the,ollowing reasons: ..... ................... .... ..... ............ . . . .............................................. ..... .. . ...................................................... ........................................ Permit No. -----1/ . 17....../................................... Issued .._.------------------pa------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (fErtificate of (110 plinuric THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired f Installer .� .. ...._....... ,� ......._ ------------------ -- ........v.�. .,..,�/.. ........ ------------------------- has been installed In accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -----7...r7>.-_..j... ............... gated ..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE .. -......_. ..-1...-.5 .�_..._... - Inspector . ......-1-�'..-----.._..... ..........._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ir o No.?T.7Z..... FEE ...................... Uiginoal Varip Tn/nitrnrtinn Vrrntit Permission is hereby granted_ ;f.- ��.r to Construct ( ) or Repair (�) an Individual Sewage Disposal System / l�s, \'+ r str�e v as shown on the pa plicatio f r Disposal Works Construction Permit No..9� ....... Dated........................................... -• Board of Health DATE........... _......•••. ........ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE r �- LOCATION �` , j Z�2& ��/ SEWAGE #,�5 r VILLAGE OLocv t f lASSESSOR MAP S � S & LOT f INSTALLER'S NAME & PHONE SEPTIC TANK CAPACITY LEACHING FACILITY:(type) O a c° NO. OF BEDROOMS j PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER ����O ow DATE PERMIT ISSUED: �—' ,RA, DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes '-'No t = •D ,�\ —,-, CO\L11ONZWEALTH OF MASSACHI:SETTS EXECftRrE OFFICE OF EN-MONME\TAL AFF_AJR';, _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE INTXTER STR£E7.BOSTON ALA,0210c (61:j 292-55ov TRU DY COL SecretarY ARGEO PALL CELLLiCCI DAVID B STP-•uc Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTUA DISPECTION FORM PART A CERTIFICATION Property Address: 1 1 3 First Ave. Name of Owner Farnham Address of Owner: Date of Inspection: 0 s t e r v i 11 e Name of Inspector:(Please Prino Wm. E. Robinson Sr. I am a DEP approved s eM inspector to Section 16-340 of Title S(310 CMR 16.000) ComparryName: Wm. E. Robinson eptic Service MaAngAddress: PO Box 10 9. Centerville dA Telephone Number: CERTIRCATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: �' Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: z;',v a Q a� Date: 5 ,z e—C."_•L The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS y:mil 01 r OCT 2 0 2000 Bows of aAmtsfa�. KALLn+oEPr. rev se Pagel or t? -led o-Reo-ord Pane, - SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION (continued) NepertyAddress:1 1 3 First Ave. , Osterville aw„er: Farnham Date of Inspection: INSPECTION SUMMARY: k B, C, of D: A. SYS 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. 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 ompletion of the replacement or repair,as approved by the Board of Health,will pass. Indicate ye ,no, or not determined(Y, N,or NO). 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 complying septic tank as approved by the Board of Health. 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 Iwith approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipelsl. The system will pass inspection if Iwith approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/96 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:Owner: � 113 First Ave. Osterville Date of Inspection:F 7 r nhamv� 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 W ACCORDANCE WITH 310 CMR.15.303 I1)(b)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 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 ANY)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 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 then 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 . ' .e,,., SE:a c�/ �/G� PaRc3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 113 First Ave. , Osterville Owner: Farnham Date of Inspection: D. SY TEM FAILS: You mu t indicate either "Yes" or "No" to each of the following: 71 have determined that one or more of the following failure conditions exist as described 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.the faiiure. Yes No 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 pipels). 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. LAR E SYSTEM FAILS: You must indicate either "Yes" or "No' to each of the following: he following criteria apply to large systems in addition to the criteria above: T e 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 h alth and safety and the environment because one or more of the following conditions exist: Yes 0 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 own 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. rev' sed Pagt 4 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Prop"Address: 1 1 3 First Ave. , Osterville' Owner: Farnham F f Date of Inspection: 0_4 Check if the following have been done: You must indicate either"Yes" or "No as to each of the following:: E- 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 of the Soil Absorption System on the site has been determined based on: VI/ _ Existing information. For example, Plan at B.O.N.. Determined in the field (of any of the failure criteria related to Part C is at issue, approximation of distance 115.302(3)Ib11 is unacceptable! The facility owner land occupants,if ditfereru from owner) were provided with information on the proper maintenaarAL-0f SubSurface Disposal Systems. w ,;' e a Y revised 10/2/58 PaRc5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ►roper>Fy Address: 1 1 3- First Ave. , Osterville Owner: Date of InspK"nham FLOW CONDITIONS RESIDENTIAL: Design flow: VSif g.p.d.rbedroom. Number of bedrooms(design): Number of bedrooms (actual):-5 Total DESIGN flow ?/sd Number of current residents: �iC+ Garbage grinder(yes or no)LA-,o Laundry(separate system) lyes or no):,A-a If yes, separate inspection required Laundry-system inspected (yes or no) Seasonal use (yes or no):,//&,0 Water meter readings, if available (last two year's usage (gpd): 1999 294, 000 gal. Sump Pump(yes or no): /-0 1998 272, 000 gal. Last date of occupancy: T—�A e-:c-- CO MERCIALfINDUSTRIAL: Type f establishment: Desigr flow: gpd ( Based on 15.203) Basis design flow Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-san ary waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available: Last dat of occupancy: OTHER-�(Describe) Last day- of occupancy: VVVV 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 STEM Septic tank idistribution 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. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other nn n APPROXiiMATE AGE of all components, date installed lif known)and source of information: Sewage odors detected when arriving at the site: (yes or no), re sec 5- 2; iC Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyAddress: 1 1 3 First Ave. , Osterville Owner: Farnham Date of Inspection: 17 BUIL, NG SEWER: ILocat on site plan) Depth b low grade: Materia of construction: cast iron 40 PVC other(explain) Distan a from private water supply well or suction line Diame er Com ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_' _ (locate on site plan) Depth below grader Material of construction: 1/concrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal,list age_ (sage confirmed by Certificate of Compliance (Yes/No) � L Dimensions: ' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 2 Scum thickness: 7— w t Distance from top of scum to top of outlet tee or baffle: 4 Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: ('J 'omments: (recommendation for pumping, con ition of inlet and outlet tees or baffles, depth of liqui level in relation to outlet invert, structural integrity, evidence of leakage, etc.) b-6 .a �i1+2 Y� s�3 w w GREA TRAP: {locate site plan) Depth belo grade:_ Material of onstruction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain), Dimensions: Scum thickn ss: Distance fro top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: Date of last umping: Comments: (recommen ation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence leakage,etc.) - c re��_ScC 9�2,�5D PaRc7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cortt mmd) &rap"Address: 1 1 3 First Ave. , Osterville Owner: Date of Irsspg-t nham 9—OZ TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (local on site plant Depth elow grade:_ Materie of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensio s: Capacity: gallons Design fl w: gallons!day Alarm pr sent Alarm le el: Alarm in working order: Yes_ No Date of revious pumping: Comme ts: (conditi n of inlet tee, condition of alarm and float switches, etc.) y DISTRIEUTION 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, etc.) 6 PUMP CHAM ER:_ (locate cn sit plan) Pumps in wor ing order: (Yes or No) Alarms in wo king order (Yes or No) Comments: (note conditi n of pump chamber, condition of pumps and appurtenances, etc.) revlseC 5�2�cJC Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION, FORM PART C SYSTEM INFORMATION(torttinued) 'rop"Address: 113-.First. Ave.',' _Osterville Owner: Farnham Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_ ' flocate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: t leaching chambers,number: -41 leaching galleries, number. a y leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: •° Name of Technology: ,.. , ;:• Comments: (note condition of soil_-signs of hydraulic fai✓lure, I vel of ondi g. damp soil, cond(ion of vegetation, ac.l 1- s i' • Z v A CESS OLS:_ r (locate site plan) Number a d configuration: �•. L Depth-top f liquid to inlet invert: w ' Depth of sods layer. )epth of sc layer. Dimensions o cesspool: r Materials of c struction: " Indication of gr undwater. t inflow (cesspool must be pumped as part of inspection} Comments: (note condition f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)` R t PRIVY: _ (locate on site Ian) s „ . 1 — Materials of cc struction: _ • Depth of solid r Dimensions: - Comments: (note conditi n of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) , f .. Pagr 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) '`open'Address: 1 1 3 -First Ave. , Osterville )weer: Date of Ir,spKigAnham 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) I Yeti-_sec 5;'2/9E ldgv10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icon %Jedl rOa'tyAddf°u' 1 1 3 First Ave. , Osterville Owner:Dante of k,F"-.�I,ham 9 („ NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Deep Groundwater depth: Shallow. Moderate SITE EXAM Slope Surface water Check Cellar Shallow wells 9. Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from DesignPlans on record Observed Site lAbutting property, observation hole. basement sump etc.) } Determined from local conditions __L/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) rev=Sea 9/2 95 PaFc11of11