HomeMy WebLinkAbout0249 HICKORY HILL CIRCLE - Health 249 HICKORY HIL•L'CIRCLE
OSTERVILLE
A = 120 .012
No 4210 1/3 BGR
ESSELTE
1010/0. �
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No. '"'o f[' — 0 t0 Fee `n
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer: `.0
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pphration for Oigool bpztem Com5truction Vertuit
Application for a Permit to Construct(N,)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ``�� / Owner's Name,Address and Tel.No.
�vei
141A
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
p f
Type of Building:
Dwelling No.of Bedrooms Lot Size I S,S5 n sq.ft. Garbage Grinder( )
Other Type of Building 6h A,1-i No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow j J D gallons per day. Calculated daily flow :330 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank if,,'�k,;,:, i�Ca� z.l Type of S.A.S.
Description of Soil M i
Nature of Repairs or Alterations(Answer when applicable) 3 i l ll C� 11., ,. u,hL
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 Board gfjkhlth.
Signed Date of J zo 1
Application Approved by Date e Z z
Application Disapproved for the following reasons
Permit No. 'Z.ejV / —026 Date Issued ?i Z G
---------------------------------------
SZ
No. '- b Feed
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes /
HEALTH DIVISION -T WN F BARN T A v PUBLIC HEO O SABLE MASSACHUSETTS
s
Application for Oie;po$al *p!tem Cow5truction Permit
Application for a Permit to Conl9a(` Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. t 'Owner.'sName:Address and Tel.No.
65 v r� 1 ,Aic �Mt-FL tJ
Assessor's Map/Parczl
Installer's` ame,Address,and Tel.No Designer's Name,Address and Tel.No.
y,)r 1 0- (On-,17 �cr
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size {S.45S o sq.ft. Garbage Grinder( )
Other Type of Building o, <j No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 17 gallons per day. Calculated daily flow 3 gallons.
Plan Date Number of sheets Revision Date
t Title
Size of Septic Tank _e,•,4�,,,. )00,0 C�a)I-- Type of S.A.S.
'Description of Soil 1 r-Q
Nature of Repairs or Alterations(Answer when applicable) _ 3LD C u,11
Date last inspected:
Agreement: `
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of- filth.
Signed � Date of D 1
Application Approved by Date Z Z Z D
Application Disapproved for the following reasons x
Permit No. 7 fffu / —0 9 6 Date Issued
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS -
` t.
BARNSTABLE- MASSACHUSETTS
(flertfffcafe of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( '>b�Repaired (>t )Upgraded( )
Abandoned( )by
at o�L, �� �� , 1) "C t r c has been constructed in accordance
with the provisions of Title 5 and the 6 Disposal System Construction Permit No. Zw/-0 6 dated Z -Z Z - 0 ' .
Installer Sec,_ ' Designer
The issuance of this pe it s 11 no be construed as a guarantee that the systet�w311 fu$ction-a(designed.
Date �/(_61Z-� Inspector �-1
- r
No. '^"y � 9'6 ---________________ '__---------------------------------------
�-� Fee �
-THE COMMONWEALTH OF MASSACHUSETI S "
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
=i000a[ 6pztem Cori.5truction Vermit
Permission is hereby granted to Construct( )Repair Upgrade( )A andon
( )
System located at a 4 5 P,L l e. .-c_i
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/ust be co pleted within three years of the date of this it. S _
Date: ZI` Z16
� Approved by
TOWN OF BARNSTABLE
LOCATION' Hi cKary li"11 SEWAGE # 2001 -096
VILLAGE O S j e: ..i 11 c ASSESSOR'S MAP & LOT J` 0/Z
i
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY WOO
j LEACHING FACILITY: (type) ck--6<,,S (size) 311 A I
NO. OF BEDROOMS
1
BUILDER OR OWNER_-vic + G rc;ce
i
PERMITDATE: 1-11--01 COMPLIANCE DATE: 2 A4;
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
I Private Water Supply Well and Leaching.Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wedand:and Leaching Facility (If any wetlands exist
within 300 feet of Teaching facility) Feet
Furnished by
YJ
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Y
1/6/99
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 (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated t-j�,,, , o j, concerning the
property located at J 77 f, ,�,n �; d� Ca:c)ik meets all of the
following criteria:
i
• This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There,are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There:s no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation..[Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located with 250 feet of any vegetated 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 Surface Elevation (using GIS information)
B) G.W. Elevation the MAX. High G.W. Adjustment. 3.6,
DIFFERENCE BETWEEN A and B N" rrj
G'
SIGNED : DATE:
[Please Sketch proposed p f system on back].
'NOTICE
Based upon the above information, a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cut
��nce
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c,,a5V'#,a t''yt 71"z +3"Q�,Slope
34'
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs.
Department of
Environmental Protection
Wllllam F.Weld
Governor
Trudy t:oxe
Secretary,ECEA
David S.Struhs
Commissioner
'/ UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
LI? �/i c�Lar� �, PART A
0 04 r(/t.f/C CERTIFICATION
Property Address: y Address of Owner:
Date of Inspection: f -- j (if different)
Name of Inspector: W.E. Robinson Sr.
Company Name, Address and Telephone Number: W,E. Robinson Septic Service
P.O. Box 1089
Centerville MA
CERTIFICATION STATEMENT ••77 _ 77
I certify that I have personally inspected the sewage disposl s�sie��t 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:
1/Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
8
Inspector's Signature: 1J k Date: J tT 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) tt
SSES:
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.
B) A STEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain wiry not)
_ The septic tank is metal, 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 8/15/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(611)556-1049 a Telephone.(617)292-5500
40 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: yq �'cKdr y '4`ill S C i r cl e CIS PPv i f`�
Owner:
Date of Inspection: ' ..� .
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):
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
C] FURTHER EVA UATION 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 heals , 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:
esspool or privy is within 50 feet of a surface water,
esspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
a
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM I FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH-AND SAFETY AND THE
ENVIRONS1EN
_ The sys em has a septic tank and soil absorption system and is within 100 feet to a surface water supp:y or tributary to:a
surface water supply.
_ The sv ten) has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The s stem has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The yslem.has a septic tank and soil absorption system and is Jess 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 fro pollution from that facility and the presence of ammonia nitrogen and nitrate.nitrogen is equal to or less than 5
ppm
D] SYSTEM FAILS:
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 determin tion is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
_ Backup of wage into facility or system component due to an overloaded or dogged SAS or cesspool.
_ Discharge o ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool. i
(revised 8/15/95)
- t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: .2yq djaa/ y ,jk// C,rcl, OS7`e/a,A-1
Owner: Ai b ks
Date of Inspection: / 3
D)SYSTEM FAILS (continued):
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 1/2 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.
El LARGE SYS EM FAILS:
The following criteria apply to large systems in addition to the criteria above:
TI1e design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
an the environment because one or more of the following conditions exist:
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.
i
(revised 8/15/95) 3
Il
' 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: 13 85
Date of Inspection: 3—01
Check if the following have been done:
dumping information was requested of the owner, occupant, and Board of Health.
_done 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.
Vfhe facility or dwelling was inspected for signs of sewage back-up.
system does not receive non-sanitary or industrial waste flow
site was inspected for signs of breakout.
—Lb/system components, excluding the Soil Absorption System, have been located on the site.
I Xe 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.
size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_t1rhe facility owner (and occupants, if different from o%%,ner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SYSTEMINSPECTION FORM
SUBSURFACE SEWAGE DISPOSAL
PART C
SYSTEM INFORMATION
Property Address: oZ�/9
Owner: Gj CjaJ
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3.70 gallons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):_,�Z
Laundry connected to system (yes or no):
Seasonal use (yes or no):
Water meter readings, if available: A,L�
Last date of occupancy: 1 -3"9
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design fldw: gallons/day
Grease trahpresent: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanita�y waste discharged to the Title 5 system: (yes or no)_
Water met I
r readings, if available:
Last date f occupancy:
OTH : escribe)
Last date o occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_A/
If yes, volume pumped. Za&-4 gallons
Reason for pumping: 11 A
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)
Other(explain)
APPROXIMATE AGE of all components, date installed,.(if known) and source of information: d:�r c-,
Sewage odors detected when arriving at the site: (yes or no)Aell-
(revised 8/15/95) S
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
.SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: concrete metal FRP_other(explain)
Dimensions:
a- $
Sludge depth: O 3 ,
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_ I
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler
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, etc.) T�n�l� G�i�v h- � 1- o/� /'Z D A,-/L Q t" V
I - x3-9 4,
GREA RAP:_
(locate on Re plan)
Depth below grade:
Material of c nstruction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickn ss:
Distance fro top of scum to top of outlet tee or baffle:
Distance fr m bottom of 5rom t� bottom of outlet tee or baffle:
Comments:
(recommendati n for pumping, condition of.inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evide ce of leakage, etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) .
Property Address: �y �,Ckl io �e%. O Sf e v�l�+✓
Owner:
Date of Inspection: ) 3—0, �✓
TIGHT PR HOLDING TANK:_
(locate site plan)
Depth below grade:
Material of co struction: _concrete _metal _FRP other(explain)
Dimensions:
Capacity: allons
Design flow: allons/day
Alarm level:
Comments:
(condition of inl t tee, condition of alarm and float switches, etc.)
WV
DISTRIBUTION BOX: (/
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distributiur, is equal, evidence of solids carr)'o•,cr, evidence of I kage into,or out of box,.etc.)._�%�,L:SI
l�o Ac, C to.N t It
PUMP CHAMB R:_
(locate on site p n)
Pumps in workin order.(yes or no)
Comments:
(note condition f pump chamber, condition of pumps and appurtenances, etc.)
R
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: oP-y I 4 ��1��0�/ Aills /•U/
Owner: i b
Date of Inspection: 2 3
SOIL ABSORPTION SYSTEM (SAS):��
(locate on site plan, if possible; excavation not required, bufmay.be approximated,by non-intrusive methods)
If not determined to be present, explain: _� �� Y a r / ��
s r�
F-,WfWV1P
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number.
Comments: (note condition of soil, signs of hydraulic failure, level"of pond ing, condition of vegetation,etc.)
CESSPOOLS: _
(locate on site plan)
Number a configuration: T
Depth-top of 'quid to inlet invert:
Depth of solids ayer.
Depth of scum la er.
Dimensions of ces pool:
Materials of constr ion:
Indication of groun ate::
inflow (ces ool must be pumped as part of inspection) -
Comments: (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,'etc.)
PRIVY:_ r
(locate on site pla )
Materials of const)uction: Dimensions:
Depth of solids: N
Comments: (note condition of soil,.signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) $:
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
CP
n� L Lk)� ~ a ~
s/o ;
i
DEPTH TO GROUNDWATER
Depth to groundwater. T' _feet
method of determination or approximation: 6,0 %) �` G 1�1� ► `� ?L 5 1 ��o /--�3=g Zr✓
(revised 8/15/95) 9
No. �� �/ ? Fee �
• TA COMMONWEALTH OF MASSACHUSETTS -
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0[pphratton for Dtgogal *pgtem Congtruction Vermtt
Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
249 Hickory Hill Circle Grace Gibbs
Osterville MA
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Septic
P.O. Box 1089
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder to)
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
Description of Soil sand
Nature of Repairs or Alterations(Answer when appplicable) install 3 high capacity
stonepacked infiltrators & d—box
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 d of Healt
Signed ��✓1 j Date _/ ~
Application Approved byZ. d�2�
Application Disapproved for the following reasons
Permit No. 2 l 0) Date Issued %C�
q/ 49
No.
Fee U
COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for 0i!6pogal *p5tem Cow5tructiou Permit
Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
249�Hickory Hill Circle Grace Gibbs
Oasterville MA
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Septic
P.O. Box 1089
Type of Building:
Dwelling No.of Bedrooms 3 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
Description of Soil sand
Nature of Repairs or Alterations(Answer when ap licable) install 3 high capacity
stonepacked infiltrators & d—box
Date last inspected: i•- f�=''_
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 ar q€Healt44
Signed �' Date �6
Application Approved by
Application Disapproved for the following reasons
Of
Permit No. � rt' ? Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(.x)on
by W.E. Robinson Septic for Grace Gibbs
�- 249 Hickory Hill Circle has been constructe.4 in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. & dated 14
Use of this system is conditioned on compliance with the provisions set forth below:
No. Fee w y
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwiqpoar *pgtem Cottgtructiou Permit
Permission is hereby granted to 249
W.E. Robinson Septic Service
to construct( repair( x)an On-site Sewage System located at Hickory 1 circle
Ostervi le
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.
All construction must be co leted within two years of the date below.
Date: Approved by !V
f
i
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION I'EltMfl' (WI'I'IIOU'I' DESIGNED PLANS)
F
,
I ij rL,S o L' hereby certify that the application for disposal works
construction permit signed by me dated �/�`/ 94, , concerning the
located at c��l "11 c. t c P �/j �5 �- meets all of the
property -
following criteria: i
Y ,
• There are no wetlands within 300 rector the proposed septic system
• There arc no private wells within 1 So feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNED
G ^-��`` DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF HAPNSTABLE NMI MEI'.
)Attach a sketch plan of the proposed system. Also if the licensed installer posesses it certified plot plan,
this plan should be submitted].
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C , TOWN OF BARNSTABLE
LOCATION f�S�h'E2.�,(IC, SEWAGE # � (�
VILLAGE),yg Dili CcRCII— ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS 2, PRIVATE WELL OR PUBLIC WATER
-BUILDER OR.OWNER
e ® e
DATE PERMIT ISSUED: r I�i
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No _
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commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of RECE1V w®
Environmental Protection
JAN 19 .1995
VAIllC*wearn F.weld HEALTH DEPT.
Trudy Coxe TOWN OF BARNSTABLE
3eerot.,y ECEA
David B.Struhs
Commissioner
p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A s'/YI i �1
CERTIFICATION
Property Address: >> Address of Owner: 1
Date of Inspection: / ! co (If different)
Name of Inspector: W.E. Robinson Sr.
Company Name, Address and Telephone Number: W.E. Robinson Septic Service
P.O. Box 1089
Centerville MA
CERTIFICATION STATEMENT g-7 ��777
I certify that I have personally inspected the sewage dispos l s sfer i%t 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
_ Co ditionally Passes
ds Further Evaluation By the Local Approving Authority
VFails
Inspector's Signature: 1LJ Date:
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.
INSP CTION SUMMARY:
Ch k A, B, C, or D:
A] SYS EM 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.
B] SY EM CONDITIONALLY PASSES:
ne or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
ses inspection.
Indicate y , 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, 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 8/15/95) 1
One Wlrtter Street • Boston,Massachusetts 02108 • FAX(617)SWI049 • Telephone(617)292-5500
iAJ Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2, �� o"� GJ'c d / f//
Owner:
Date of Inspection: —S_ 7µ
B]SYS M CONDITIONALLY PASSES(continued)
ry in the distribution box is due to broken or obstructed
level Sewag backup high static water e eI observed P or breakout or hi
pipe(s)s or due to a broken settled or uneven distribution box. The system will pass inspection if(with 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 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.
2blh/chealth, safety and the environment.STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING.IN A MANNER
HICH 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) SYS EM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENV RONMENT:
_ The cvstem nas a septic tank and soil absorption system and is within 100 feet to a sur(ace,water supply or tributary to a
surface water supply.
The system hay a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well
The systen,has a septic tank and soul absorption system and 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
D] �tdetermined
ILS:
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 .
.the failure.
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.
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner. _ cSIYIJ f
Date of Inspection: S S
D)SYSTEM FAILS(continued):
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 1/2 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. 4
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 SYSTEM FAILS:
Th following criteria apply to large systems in addition to the criteria above:
The d sign flow of system is 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:.
he system is within 400 feet of a surface drinking water supply
t system is within 200 feet of a tributary to a surface drinking water supply
_ th system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
pilblic water supply well)
The owner or oper for of any such system shall bring the system and facility into full compliance with the groundwater.treatment program
requirements of 31 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised.8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done:
Vpumping information was requested of the owner, occupant, and Board of Health.
_vNone 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.
J./The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow '
vThe site was inspected for signs of breakout.
f/AII.system components, excluding the Soil Absorption System, have been located on the site.
L/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.
i/The size and location of the Soil Absorption System on the site has been determined based on existing information or
1/approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
q 'SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:, a gallons
Number of bedrooms:
Number of current residents:?
Garbage grinder(yes or no): A/
Laundry connected to system (yes or no):,°�—/ l
Seasonal use (yes or no):_&�' 9
Water meter readings, if available:
Last date of occupancy:,1 —s —7n 4
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow:__gallons/day T
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)-/L/
If yes, volume pumped. gallons
Reason for pumping:
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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: o v rz S
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) $
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
q SYSTEM INFORMATION (continued)
Property Address: 2- 41
Owner: Lyn, o..fh
Date of Inspection: -
SEPTIC TANK:�/ \
(locate on site plan)
it
Depth below grade:
Material of construction: concrete_metal . FRP other(explain)
,
Dimensions: 4- -f
Sludge depth: b " ,
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: �2-"
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, etc.)
GREAS TRAP:_
(locate on ite plan) ,
Depth below rade:
Material of con truction: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bott m nt Frtim in hottom Ot OLMet tee or baffle:
Comments:
(recommendation r pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
VVI
(revised 8/15/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
p )SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT O HOLDING TANK:_
(locate on .s e plan)
Depth below rade:
Material of con truction: _concrete_metal _FRP—other(explain)
Dimensions:
Capacity: allons
Design flow: allons/day
Alarm level:
Comments:
(condition of inlet tee, ondition of alarm and float switches, etc.)
DISTRIBUTION B
(locate on site plan)
Depth of liquid level abo a outlet invert:
Comments:
(note if level and distribute n es equal, evidence of.solids carr�,o:er, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:—
(locate
(locate on site plan)
Pumps in working ordComments:
(note condition of pumdition of pumps.and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /
Owner: sW f�1
Date of Inspection: / 4
SOIL ABSORPTION SYSTEM (SAS):1�
(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, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation,etc.)
ro i7, = �oC P't Cds
CESSPOOLS: _
(locate on site pla
Number and configura•on:
Depth-top of liquid to in t invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool mu be pumped as part of inspection)
Comments: (note condition of oil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of s il, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SAY/STEM INFORMATION.(continued)
Property Address:
Owner: M f�
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
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DEPTH TO GROUNDWATER
Depth to groundwater. Lb feet
method of determination or approximation: )e b c� t3 6 l�
(revised 8/15/95) 9