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HomeMy WebLinkAbout0062 GALLEON WAY - Health 62 GALLEON WAY, MARSTONS MILLS A= 098 051 TOWN OF BARNSTABLE V "OCATION �`�� �_ ,cc'CK SEWAGE # Z40 " yid VILLAGE ASi E(SSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 'e- SEPTIC TANK CAPACITY 0 0 I LEACHING FACILITY: (type)) (size) NO. OF BEDROOMS BUILDER OR OWNER A I?gi a' PERMITDATE: —:5 —O/ COMPLIANCE DATE: /"' s Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility . Feet Private Water Supply Well and.Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � ,� r � �:� /// k J �i.. i � �� �� � `�� �� ��, � f� �a �� � � � � � �� � �- c �� � � � �� � - � � � No. lN�r —T!6 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ✓/ Zippfication for ;Migpoga1 *potem Con0truction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 6 2- 6 Cc kt®" `- CiL Lt 69,44 Owner's Name,Address and Tel.No. Assessor's Map/Parcel o-01 _ Q r /J/J le �d Installer's Name,Address,and Tel.No. ] , "!i Designer's Name,Address and Tel.No. M i �e_ teq� Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. 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 Size of Septic Tank 1 Dao 65p< Type of S.A.S. 1 k , /4e Description of Soil 0 Z �r p 'r- I'la r 69-e-k & �.� 2 f 'LO Nature of Repairs or Alterations(Answer when applicable) tr e_ le 11 X `3 9 z 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 Boar f Health. Signed Date����_7) t3 Application Approved by Date w/ d Application Disapproved for the following reasons Permit No. Date Issued Zf TOWN ORB:ARNSTABLE 4 r . LOCATION I �� ::t r: C .� SEWAGE VILLAGE ,(//Lim l s I ASSESSOR S MAP & LOT O 9 QS I INSTAf.LER S NAME&PHONE NO. .. t, f SEPTIC TANK;CAPACITY �SS LEACHING FACILITY: (type)` "�7 l/' (size) L NO: OF BEDROOMS J B'IIII_1J.. OWNER PERMITDATE —' �.—b/. COMPLIANCE DATE: % _ rt Separation`Distance Between'the: r 1 Maximum Adjusted:Or Table to the Bottom of I eaching.Faclty Peet Private Water Supply Well anc�Leaching Facilia (If any wells::ezist on site'or within:200 feet,of leaching<,fality); Feet v Edge of..edand_and Leaching Facility(If.any wetlands exist within.300 feet of leaciiin facili Feet . ;. .. .. . .. g. ty) Furnished by 1 � t4 , . � . ----- J 5 n f,F No.7,eM — q16 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,f PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ZIPPYication for 30i5pogal 6potem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon(- ) El Complete System ❑Individual Components Location Address or Lot No. G Gc itO t'" a-K 0 5� Owner's Name,Address and Tel.No. Assessor's Map/Parcel% �d�. or r« n Installer's Name,Address,and Tel~No f t Designer's Name,Address and Tel.No. JC `\ Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixturesa Design Flow 3 G gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of SepticiTank ! pao 5�x /Type of S.A.S. .JI'l k ft' lr �! �.3 dhr /1f Description of Soil; Q'— 'G p 'r i,(a r U -e ti Nature of Repairs or Alterations(Answer when applicable) Ll' [47 y c_-1AP 11 X 3 1 X Z 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 t i Boar s Bo f Health. Signed _ Date 62 L S s d Application Approved by - Date 6/ Application Disapproved for the following reasons Permit No Date Issued /Z f ----------- -------------------------- THE COMMONWEALTH OF MASSACHUSETTSt BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by // t e- —1P C- e t at (o e:;4 I ( e :�tH 6—J Gt e-i S v has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. C)r' g16 dated "z s- y Installer It, 2 e Q r Designer The issuance of this erript sh 11 not be constr ed as a guarantee that the syst ill f q ' desig e . Date / , �� Inspector f ----------- ——— — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigpooal *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon ✓ System located at 'ZI (VI- e O CA Ljet d S and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this t. Date: Z S Approved by ' op 7? X /U.,? X Z L -r- - 5/25/01 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, Al- 1\ L4 , hereby certify that the engineered plan signed by me dated (o . �" d(, concerning the property located at Co 4 ( Lo meets all of the following criteria: 6/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 P minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent-present. There is no increase in flow and/or change in use proposed •,41 h-r`e are no variances requested or needed. The bottom of the proposed..leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation (using GIS information) B) G.W. Elevation + adjustment for high G.W. = 2 DIFFERENCE BETWEEN A and B SIGNED : DATE: l6''' (9 ) 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:percexmp �,� i i a-...�- J ♦t� 09Y, ® / SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F l� Address of property (o,Z G KI W4 Si ' owner' s name 6AULOA1 , Date of Ins ecticn p °p A 199 A PART A 5- CHECKLIST V, �y�"�E co Check if the following have been done: 5 Pumping information was requested of the owner, occupant, an bard of Health. one 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. L----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 information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 4�l SYSTEM INFORMATION 1.3�y FLAW CONDITIONS '-If,-'residential 3 .number of bedrooms f� number of current residents n� garbage grinder, yes or no laundry connected to system, yes or no -Al seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: 6L System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping : Type of system optic 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 Sewage odors detected when arriving at the site, yes or no I � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:' (locate on site plan) depth below grade: /V material of construction: _4-�concrete metal FRP other(explain) dimensions: 2_ �— X �.� W X A /Fr sludge depth — .2� distance from top of sludge to bottom of outlet tee or baffle /2-" scum thickness _ distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outleL 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, eviden a of. leakgge, reco endation or repairs, etc. ) 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, evid G e o 1 ak into or out of pox, recomme dat 'on for re airs, tc. ) PUMP CHAMBE (locate on sit Ian) pumps in working er, yes or no Comments: (note condition of pump ch co di ' n of pumps and appurtenances, recommendations for enance or repairs, c. ) 1� ' t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : 0" (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 and number leaching chambers and number 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, rp ommendation for aintenan e o r airs,etc. ) CESSPOOLS (locate on site plan) : 1 number and, configuration depth-top o uid to inlet invert depth of solids lay depth of scum layer dimensions of cesspool materials of constructio indication of groun er inflow (cesspo must be pumped as part of ns ction) 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 pla materials of construction dimensions depth of solids Comments: ' (note conditi "'of soil , signs of hydraulic failure, evel of ponding, conditio vegetation, recommendations for maintenanc r repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE 1 :SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' I-tLj- t _ - E - 23 /} - T = 33 DEPTH TO GROUNDWATER 4- depth to groundwater method of determinat;gn or approximation: 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) Backup of sewage into facility? 1' Discharge or ponding of effluent to the surface of the ground or surface waters? Static iquid level in the distribution box above outlet invert? A Liquid depth in cesspool <6" below invert or available volume< 1/2 di flow? Required pumping 4 times or more in the last year? number of times pumped A Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS , cesspool or privy: /y below the high groundwater elevation? � A/ within 50 feet of a surface water? Al within 100 feet of a ace water supply or tributary to a surface water supply? —A,—) within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? P PP Y less than 100 feet but greater than 50 feet from a private water g supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water ane ' for coliform bacteria, volatile ganic compounds, ammonia nitrog and nitrate nitrogen. r TOWN OF _9,q-JZA;5+,-4 BOARD OF HEALTH S(IRS(1RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION -TYPE OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME �cs PART D CERTIFICATION NAME OF INSPECTOR /'V -27--L COMPANY NAME tt CyI 6 9-"0) COMPANY ADDRESS 75 � C-4& AIA- 6:� 3a Street Town or City State ZIP COMPANY TELEPHONE 'T ) 3 46,2- 3 6 FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system a 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 maintenance of on site sewage disposal systems . Check ::�.System System PASSED The inspection which I have conducted has 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. System FAILED The inspection which I have conducted has found that the system fails tc protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this i e tion form. Inspector Si nature Date OZ / 7 _/ �f5 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc No...f�.. ..� .. �`�` F�s., a.............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH -.1 — ----- ..-----_----------OF...��!✓.� Appliration for Disposal Works Tonstrnrtiun Prrmit Application is hereby made for a Permit to Construct-(V) or Repair ( ) an Individual Sewage Disposal System at: ..... _----.......................................................................... ------------•--••...............-----•. ! I ocation- dress — r Lot No. caner Address 14 Installer------------------------------------...... ...------------------------------------------Address---------------- ............. .--------' UType of Building Size Lot5F��.`� .......Sq. feet �. Dwelling—No. of Bedrooms.......N.?...............................Expansion Attic ( ) Garbage Grinder ( ) a .Other—Type of Building A ___ ____________ No. of persons----- .................... Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------•-----.--------------------------------------------------------------------------------------•--.---------------- W Design Flow..............SS.......................gallons per person per day. Total daily flow..... 4.............................gallons. WSeptic Tank—Liquid capacity_/ ...gallons Lengthf©__4........ Width. ........ Diameter................ Depth.4...�L__. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.....Y 2...._.sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by----GVOC,0M ... .................... Date_. /...._..._.._ 14 Test Pit No. 1....4Z......minutes per inch Depth of Test Pit---/r2. ..__... Depth to ground water...��_�J_....-_. (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------------------------------------------------------- ------------------------------------ --------- O Description of Soil.... ✓ .. c?i L...... t/�rr��C.....-'----- QV1.yt---`S�N�-------------------------------------------•--..... W V W x ---•----•-------------------------------------------•------------•----------••--------------------------•-.....------------------------•------------•----'---------------------------•-------------•---- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•-------------------•-----------------------------------........----------------•----------------------------------------------------•----------------------............---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11-E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued the boa d of health. Signed, ti,!g / ..... Date Application Approved BY = 1--- ... --------•--------•--.--••-- -..... s� X1___.**............. Date Application Disapproved for the following reasons---------------------------------------------------- ----------------------------............................ -- ------------•---------------------.....------------------------....-------•--------------------------------....- ......-•••--•--- Date Permit No................................ ......................... Issued-...........-.........-................................. Date No...t9.Z-n223:..�� - Fss.30...-............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �f? <✓.... ................OF..}e .................................................. Appliration for DispaoFal Works Tomitrndiun rrmi# Application is hereby made for a Permit to Construct (y) or Repair ( ) an Individual Sewage Disposal System at: �O 6'vez���� kip /��s���s mil,�/s /lfls_s ............................................................................. ._....._............._.._......._ /Location- ddress _ r.._...Lot No...... .................. 2 ........... ........ ............ .....�� :.. a r(, / ,Owner Address ...--••--.... — 2 _/l�J .................................... ...............•--...--------•...............-•-••---.........--•................-•----........... Installer Address _ Type of Building Size Lot _` _`'-_........ feet ., Dwelling—No. of Bedrooms_._...................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type e of Building �'%�e�--�� yp g �......................... No. of persons....�..............._----- Showers ( ) — Cafeteria ( ) dOther fixtures ------ ---------•------------------------------------.------------••--•------------•-- W Design Flow.............:.�.,�_..............._.......gallons per person per day. Total daily flow.....�3 d............................_gallons. 1:4 Septic Tank—Liquid capacity.��-'-?....gallons Lengthz,2.A....... Width��._.'.._..... Diameter---------------- Depth.L-'� ...... Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area----Y:r 1......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._....W... 7.......... ..................... Date...0k1Z/-•.................. Test Pit No. 1....taZ?.......minutes per inch Depth of Test Pit__ ........ Depth to ground water--- ....... Gx, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ................................................................................................. o x Description of Soil--- ............ / ----------- V ......---••-----•-----------------•-•-••--------------------•--------------•--•-------....----•---------------------•------------...-•-----••--------................................................... W x --..................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------•-------....--------•---------------••-----------------------•-------•-----•-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI TLE 5 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 bo�rd of health. / Signei AA_a ...klFGt1^'..........I .. .................................... ../ � �'/ Date Application Approved By........--e. .-,t�...._. f.�-f ''................ .............................. Date Application Disapproved for the following reasons:......................••.-_•-----------...--•-------------------------------....----...__..__.__.__---•..._--._ -•----------------------------------------•-.-----••-•-------••----------••-----------...------•-•------•-----------......------------------•-------------------•--------•-----------------------•--•--- Date PermitNo.......................•--------•----•----------•---.... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................OF.....,��`�l.�i✓ 7t�L.. .._............................... �rrtifirtt#r of f�rrni�r�t�tnrr THIS IS TO CE ����I Y1 , That the Individual Sewage Disposal System constructed (� ) or Repaired ( ) by.....\= ?'............: r! %� ..........................................................................................................................•... Installer at..........�b7---- ...... -----= liJi has been installed in accordance with the provisi�5n`s of TI L; 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit ."................. dated................................................ THE ISSUA E F THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM NAIL U TION SATISFACTORY. DATE.....11..,... :. /�... Inspector.... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH cvn/...........................0 F.. 6�i?Ni71.. ......................................... N&/_. ..... FEE.`�.............. i n'ott nr �aa. rnr#irrn ernti# Permission is hereby granted_ =' �G�� � ,----------- ---- ......... ............................................. to Construct (>< ) or Repair ( ) an Individual Sewage Disposal System at Noe or.......fin 6./lYYf nQN._......w-4 . /' ''257_s Street as shown on the application for Disposal Works Construction Permit No..................... Datpd.......................................... DATE......................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ------------ 'I- 91 t6 -QW4� 0 A Sry W>OT 44 p n- %A Z6 c>(= -LoAr-4to-ic, Pal!s f:b OEM -os OF /0 Afj o OA4ie-�LA- w ou -ro ekujcw- Twi AJCC V.DA."Cf _"4 tTL *,5 Ic 00 r TA FR:W�o -T4eo(-4Hw tA s -2,A 1-0 ej�:, J&j i L7r t)f oi X6 41 <D jr.4 Al=> 0 0 0 0 C>cn Z c lb EE V,�^C4 E� %4 5 6 A 5-rA-,P T' 'I A.U e�6 t)S J6 All' => L f#1 cio 5 F. Lj�= GA e 'LL6jS REV- P02,�00 ?CV- DAY A -mop 3:� Old' EA- A-5 5,C,A,L..f;. e 4(z Tzw(54 0 me "OPW IV 46 IA"-S S c Z;>� FkASA . 24 Gec-A C .C",Me YA-014 -T(4 I OF \VA OF As 3 77 67 P P LOT N PM (4 .4G 6 7 V lY 0. �4 a E:it .7V 7, 4 2-'7 a NINON.- MOM