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HomeMy WebLinkAbout0355 WIANNO AVENUE - Health 355 WIANNO AVENUE, OSTERVILLE - A = 140 175 No. r / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Migpogaf *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair(>,)an On-site Sewage Disposal System at: Location Address or Lot No. f C Owner's Name,Address and Tel.No. 355 i,>AN"►d D. �c�s �� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,q.:5,C �� 5!�� Ze of Building: Dwelling No.of Bedrooms 4 Garbage Grinder( ) 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 Nature of Repairs or Alterations(Answer when applicable) s "cyl/z" ,��0 Gy IT d�Ad m Date last inspected: 3 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 iss by this Boar of H h. Signed Application Approved by �- Application Disapproved for th follo ng reasons Permit No.��� Z" Date Issued���1/- yr` .r `_�• ¢....•. -� •^•' ��. � .� _..,,,n,..�,.� -snc'� ! �.~ .. ..a- � .r H 1 i. _ ..+. ...L •s ,, ,' � ,-y � No. 1 716 , Fee tr� I THE COMMONWEALTH OF MASSACHUSETTS p PUBLIgHEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS- :2pprication for Mi4poot6pgtem Construction Vermit f Application is hereby made for a Permit to Construct( )or Repair O an On site Sewage Disposal System at: Location Addressor Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �. Wpe of Building: Dwelling: No.of Bedrooms J6 Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures `"` 4' Design Flow ~ gallons per day. Calculated daily flow gallons. { Plan Date Number of sheets Revision Date Title; T, Description of Soil----<- Nature of Repairs or Alterations,(Answer when applicable) -C � 'Gvl � O Gti. �a �dd Ivy` • 'a. - .c �r..a.}rev. Date last inspected: .3 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 iss by th's Board-of H th.,. »..�. Signed G. Date-/d 11 ` Application Approved by Application Disapproved for th64ollmking reasons i Permit No.�/ �^ 7S746 Date Issued 14 {� ____ ---_-— __------ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS i Certificate of Compliance j THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(-Y)on for5.� as has been constructed in accordance- with the provisions of Title 5 and the for Disposal System Construction Permit N . + � dated /B—" *- Use of this system is conditioned on compliance with the provisions set forth below: No. ! Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mir opal .5tem' Construction permit � Permission is hereby granted to to construct( )repair()()an O -site Sewage System locate at �- N 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 completed within two years of the date below. r Date: (/ ' �� Approved by i a OiArino A v0 9 k N 3a Dot $'x 4 TAVI Mew CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANSI I, hereby certify that the application for disposal works ' construction permit signed by me dated ,concerning the .�, property located at -;X S AUi-AN NO A'il 9 , a-slE A u, meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are nor private wells within 150 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 DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. jr / , ' TOWN OF BARNSTABLE LOCAON ' �� /I v - SEWAGE # d VILLAGE �i' U/1, ASSESSOR'S MAP&LOT Q-17� 'E INSTALLER'S NAME&PHONE NO. 1"/0 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) e. ' 1 (size) 0DB NO.OF BEDROOMS BUILDER OR OWNER H/-1�C �Sf7C� PERMITDATE: /`©"'l/ -- �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 pq/� on site or within 200 feet of leaching facility) /i/� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by `CJ C-S2 FLL 3 L-u cn� BRUCE MACALLIST'ER 7 SHORELINE CONSTRUCTION 87 POND STREET" 6t ®STERVILLE, A 02555 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIZORM address of property ��� �1'J'��gp Ave oCT )wner ' s name )ate of Inspection PART A CHECKLIST S � heck if the following have been done : i/ Pumping information was requested of the owner, occupant, and 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 site was inspected for signs of breakout . All system components, excluding the SAS , 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods . ✓ The facility owner (and occupants, if different from owner) were provided with i.nformation on the proper maintenance of SSDS . S SUBSURFACE SEWAGE- DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS .f residential number of bedrooms 2 number of current residents 11b garbage grinder, yes or no � laundry connected to system, yes or no ,yo seasonal use, yes or no [f nonresidential , calculated flow: 4ater meter readings , if available: C;(\ �,✓�� Last date of occupancy v GI::NERAL INFORMATION Pumping records and source ofinformation: /Y 0 tec, u2� _\f-) System pumped as part of inspection, yes or no if yes , volume pumped _3,Cooc' A `. Reason for pumping,*-,-) �,�� 'tui- CAI`% �vrdt SCE Type of system ivo _�—Septic tank/d- ' -`� "�` � /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: 0 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:_ ( locate on site plan) depth below grade : /F3 � material of construction: �oncrete metal FRP other(explain) dimensions• E �( �/ /O X S sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Cdepth ents: ommendation for pumping , condition of inlet and outlet tees or baffles, of liquid level in relation to outlet invert, structural integrity, • ence of leakage, recommendations for repairs, etc. ) Vaje N'��fk�nT� 5olio olRS S DISTRIBUTION BOX:---/\/O ( 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. ) /TC 1, 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. ) 10 "e' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION continued SAS) :�� required, but may be )IL ABSORPTION SYSTEMf possible; excavation not Locate on site plan, l ' proximated by non-intrusive methods) f not determined to be present, explain: 00 C CY�J ,ype .eaching pits and number .eaching chambers and number Leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number level of ponding , Comments: signs of hydraulic failure, repairs, etc. ) recommendations f maintenance o ` 6v— (note condition of soil , condition of vegetation, �eCcrv\�11c..�� F?v9,n CC S OOLS ( 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 um ed as inflow (cesspool must be p P part of inspection) hydraulic failure, level o•f ponding, L Comments: signs of airs, etc. ) (note condition of soil recommendations for maintenance or rep condition of vegetation, PRIVY : plan) ( locate on site p materials of construction dimensions depth of solids level of ponding , Comments: ns of hydraulic failure, airs, etc. ) (note condition of soil, signs condition of vegetation, recommendations for maintenance or re 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 ' ZIJI 73 a DEPTH TO GROUNDWATER _C214 depth to groundwater method of determination or approximation: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA or not determined (Y , N, or ND) . Describe basis of ndicate yes , no, If "not determined" , explain why riot) etermination in all instances . Backup of sewage into facility? onding of effluent to the surface of the ground or or Discharge p surface waters? � Static liquid le vel in the distribution box above outlet invert? volume< 1/2 day cesspool <6" below invert or available Liquid depth in p flow? JLping 4 times or more in the last year? Required pum P number of times pumped structurally unsound? substantial Septic tank is metal? cracked? tank failure imminent . infiltration? substantial exfiltration? Y Is an portion of the SAS , cesspool or privy ' below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a zone I of a public well? feet of a bordering vegetated wetland or salt marsh within 50 not the SAS) ? (cesspools and privi es only , within 50 feet of a private water supply well? seater than 50 feet from a private water less than loo feet but g " ualit analysis? If the well supply well with no acceptable water copy of well water analysi has been analyzed to be acceptable, ounds, ammonia nitrogen for coai.form bacteria, volatile organic comp and nitrate nitrogen- :; 1 • 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector rvc eC-e�� Company Name Company Address �. 7� S \ 01 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails to adequately 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 Date Original to system owner Copies to: Buyer (if applicable) Approving authority TOWN OF BARNSTABLE LQCATION Ave. SEWAGE # __rVu e -n0(1 VILLAGE S le✓'!�� ��� ASSESSOR'S MAP &LOT U INSTALLER'S,NAME&PHONE NO.-RX,cle r SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 2 r _ksl- tom:l (size) 000� �. NO.OF BEDROOMS 6 k BUILDER OR OWNER hlz Cu s�ek PERMITDATE: 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 facilliii Feet Furnished by /% G W,�� �� � I� � �, �� � �. �', � r ��}-� I 0/' �V I .� y =j d a . ��� , �- No. ... dc�r (, , ..ate....... THE COMMONWEALTH OF ASSACHUSETTS BOARD ® HEA T ... of ......... ..,............... A*p iratinn -fur M-4puiittl lVorks Towitrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - -i 1-4 ---------- --------- ------------- Location-Address or Lot �J_tGt_Yt No 1J1 .._0- D------------------------- ------------------------------ : ---------------------_____-__---____----- Owner Address s ., Installer Address Q' Type of B ilding Size Lot............................Sq. feet U - welling—No. of Bedrooms------3-------_-------------------------Expansion tic (Ile,) Garbage Grinder ( ) p-, Other—Type of Building ---------------------------- No. of persons..______--____-____---__-.__ Showers ( ) — Cafeteria ( ) 44 Other fixtures ------------------------------ -- W Design Flow--------------------------------------------gallons per person per day. Total daily flow---------------------------------------.....gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width------.......... Diameter-----........... Depth---------------- x Disposal Trench—No...................... Width.................... Total Length-------------------- Total leaching area.--.-._---_-...-----sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------- -------------------------------------------------------------- Date_-----------------------------------.... Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground Water--.-_-..-----.--.- -.._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.__----__-__-.--_-_--- 9 -------------------------------------------------------------------------------------------------------------------------=---------------------------------- ODescription of Soil-------------------------- -------------------------•-----------------------•---._.------------------------------------------------------------------------------------. c., ------ ---Y x �� — a U Nature of Rep irs or Alterations— wer when applicable.. _.__ _.._____ ________fib..__ S,l .. �_L � Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the;provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar of ealth. Si ed c�_ t2 '11�_-:_----- _"' ............................... Date y Application Approved By.-`.:: -- -- ----- - f 1 -_"..._. ' Date Application Disapproved for the following reasons:...................... -- -- . --- --••--•------------------------------•••-----------------------•----•_...--------------------------------•----------------••------•--------------------------•----..._..._._..----------------•--------- / Date Permit No......................................................... Issued.......�-�-��'..�-- ---- --•------ -----.. (� Date FEB.. THE COMMONWEALTH OF ASSACHUSETTS BOARD Qf, HEALTH` , OF..........4641 .... ......... Appliratio n -for Uiii oiial Workii Cnowitrurtion Vrrmit Application is hereby made for a Permit to Construct ( ),or Repair ( ) an Individual Sewage Disposal System at .`.r Location-�Address �r or Lot No. .................... ................-------. -------•------ Owner r Addre Installer Address Q Type of B*juilding Size Lot............................Sq. feet Uwelling—No. of Bedrooms-_.__ _________________________________Expansions Attic (1{/a) Garbage Grinders,( ) p, Other—Type of Building --------------------------•- No. of persons..____----.................. Showers ( ) —,Cafeteria ( ) Q' Other fixtures ........................... .. W Design Flow.................:..........................gallons per person per day. Total daily flow_------------------------------------------gallons. WSeptic Tank—Liquid capacity__-__-_-__gallons Length................ Width------.......... Diameter--------.------- Depth------------ x Disposal Trench—`No- -------------------- Width.................... Total Length..................... Total leaching area-._...------.-------Sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area--------------- ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation-•4Test Results Performed by-------------------------------------------------------------------------- Date........................... ------.------ ,� Test Pit No. 1................minutes per inch Depth of Test Pit--______.-_-_.__--.- Depth to ground water.---_-----------_.------ f� Test Pit No. 2-----------.----minutes per inch Depth of Test Pit-------............. Depth to ground water__._--_- _--.___--- �+' .-•------•---- ----------............................................................................................................................... - 0 Description of Soil-------------•--------------------------------------------------------------------------------------------•------------------------------------------------------------ - ----- . -- V - w 1' , 'p�t c� -----------A----�/`----- = -;ru , .._ l/ UNature of Repairs or Alterations— nswer when applicable.. ...__ _ .:________ ____ __ _.._, - __ . ----- ------ ---- Agreement: 1P - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions'of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar ,of ealth. Si e Date : Application Approved BY• " :... .j Date �.Application Disapproved for the following reasons:--------------------- —--- :.. ----------------------------------------------------------------------=----------•-•----•---•---------..••---------•---==------------------------•---------------------------------------------_------ Date Permit No. -= Issued. Date _THE COMMONWEALTH OF MASSACHU.S,ETTS BOARD_, H EAL.,TH OF 'Y rdifirate of T"Umplianre S IS TO CERTI UY, Tha he Individual Sewage Disposal System constructed ( ) or Repaired by... . . . ........... ------• ---- -............. Install ------------------ has en installed in accordance with the provisions of Article XI of The State'Sanitary Code as described in the application for Disposal Works Construction'Permit No.. -- - ________________ dated _ ___�,��. ...... THE ISSUANCE OF THIS CERTIFICATE SHALL;NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SA ISFACTORY `(� DATE------------�~ Z.J....................... •---- . -- ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT LL ` . --.. .......;.............. a No �7 / j ... FEE .✓''y i� ttl Workiitrizri t err i Perris_jssion rs hereby grant d"_.. � !__ ,d►__ -. _.___'. __ ,___ _ _.�__ ..._.. to Con Inc ( ) or e �iinvid-ual Sewage Disp al 5yste�nas sStreet hown the application for Disposal' forks Construction mit Dated___ _.......�__�_........ -• �---- - oard 0, 1 h - - i DAT ---= --� - FORM 255 HOBBS & WARi�'"INC.. PUB1_tSHERB - - e� iLOCQTION : 5EWQC;E PERMIT UO, VILLAGE 4 - - - - - - — a4: 7-T 5 ' WAE ADDRESS BUILDER 5 Q �E QDDRESS 0 / we — — — — — — - - DbkTE PER"VT ISSUED • 2� DATE COKAPLI WaCE ISSUED ; 0� 1 ,� I i I' ��', f� �/O � I I `�'' p � _ �. a ���� � �-----� �. ji �� ��