HomeMy WebLinkAbout0041 VIOLA LANE - Health 41 VIOLA LANE,.MARSTONS MILLS
A= 043 006.005 _
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/ TOWN OF BARNSTABLE
LOCATION/ y/ L)f'&(j SEWAGE # 2y
VILLAGE �/�oyf ///� ASSESSOR'S MAP 6z LOTOq-3yy�
INSTALLER'S NAME & PHONE NO. (�ot✓-n►4� 3 u•l��G�
SEPTIC TANK CAPACITY l 000•
LEACHING FACILITY:(type) ` ' (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: '
VARIANCE GRANTED: Yes No
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No.1L'.4,a Fx$.... ....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
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Allp iratinn for Eiapnaal Works Tnntrnrtion ramit
Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal
System at:
...... ,fc._ ...,CA.�.. ..........c�T .....I.----•--•----•-••-------
Location-Address ° or Lot No.
_. ...►z.. , ►.5 h----------------•------•---------. ......1,n A...4-7 ...............................................................••...
owner Address
................ .........
---...• ...----•------•......•. -•----. ------•--.._..-------•........-••-•-••---..
Installer Address
U Type of Building r Size Lot....?_s 54----Sq. feet
Dwelling—No. of Bedrooms___.C._ !"z .........................Expansion Attic ,4/6) Garbage Grinder WO)
Other—Type of Building No. of persons............................ Showers — Cafeteria
Q, Other fixtures ----------------------------------------------
W Design Flow..................................4F4i7._gallons per person per day. Total daily flow.............................30.0...gallons.
WSeptic Tank—Liquid capacity ann.gallons Length.3.- Width.: .�:n(d.._ Diameter...____......._. Depth..!.'
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...VYlR. 0 .(...__.. Diameter Depth below inlet.... a........•... Total leaching area._ .6.7..7_..sq. ft.
Z Other Distribution box ()Q Dosing tank ( )
~' Percolation Test Results Performed by.-__---�!___t c®bz ........................................ Date...g/zg _._____.____.__.
a Test Pit No. 1.'_. -------minutes per inch Depth of Test Pit________ ________ Depth to ground water--- _
A
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground wate 6. QF��s
a'
Q ` • STLYYIVN G
Description of Soil ;- P..�. !L�� rl. ------------------- ...•----------------- . ......� -----
ca
V ..............................•• ---WILSON....
-•--•----•--•-- -------------•-----•----------•---•----•-•-•---•-----•--•---•.------------•------•-----••-----------------------....---.....-••--•-•-•---•--••......---- a -U.30216
-V Nature of Repairs or Alterations—Answer when applicable.____________________________________________________...............
--•- -••••-----••------------••._...••-••••-•-•••••-------------•---•-•-•-•••••----................----••-••-•---------•-•-----------•-•-----------••••--•---------••---•-••--
Agreement: G/i6�YG.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acco ante with tt.f-8p
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 been issued by the board of heals .
SignedL47� ------------------------------------- ------ - ------------
Date
Application Approved BY ---------- .. - ��� - --�'--
Date
Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------------
---------------------- ............-.
Date
PermitNo. .........�. ....................... Issued .......-- -- -- ................------.--------------..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 ruve� ?----------.....OF...... ......---------•--............-.........................
Appliration for Disposal Works Tonstrnrtinn Famit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
yzf ::+!...44"1�............................................../l, fir!..--•---••--------- ---••-•--.............................----
-q^ Location-Address or Lot No.
......................_.=.Afe::L&a... - try A/l.Ct/-c? Ll!.......... .....................................................
-- . .�
Owner Address
Czi
.......... .... .........
................... .....................................
Installer Address
d Type of Building Size Lot____�.5;. Z!Z ---Sq. feet
U Dwelling—No. of Bedrooms-__-f c: �..........................Expansion Attic #4) Garbage Grinder (�®)
Other—Type of Building No. of persons............................ Showers — Cafeteria
C4 YP g P ( ) ( )
P4 Other fixtures -----------------------------------•-------..------- - --...
W Design Flow..................................: =.,gallons per person per day. Total daily flow_._......................__._.?...galIons.
r
WSeptic Tank—Liquid'capacity../.�'�.gallons I,.ength.?..:, ..... Width.#..'nm.... Diameter_____________ Depth...:=�....
x Disposal Trench—No..................... Width.................... Total Length.......... .-:...... Total leaching area....................sq. ft.
Seepage Pit No...fDV......... Diameter-----tCi......... Depth below inlet.....-........... Total leaching area.�.5--7_..sq. ft.
Z Other Distribution box ()Q Dosing tank )
~' Percolation Test Results Performed by..__._,✓_..-�!�5.�? .......................................... Date.._g ��......_
1-a Test Pit No. I...............minutes per inch Depth of Test Pit.__....6........ Depth to ground water.....
OF
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water .
a, ................ -r---------- ----•----- -STEPHENS'
... - .... .. ..
O Description of Soil-----U ----a......1yc'Y-`... =` 1 .......�. 'Yfit
`j -.g— r r'�L litlri9...rr�-ral7�..a................................................. V1 LSOU- y
:1 --------------- ------------- No.3U216�
UNature 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 TITLE S of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of healt .
9 w
Signed ....................n,!.z4-------- ............................................... ........................................
�f Dare
Application Approved By ..--------e ... ��.- ...-..Fa.
Application Disapproved for the following reasons: ................... .. . ......................... ........................................................................
—......................------.......-'----------' --------------------................................................'---.._--.......................................................... ................Dare ..............—
PermitNo. ---------- I21.. .4!;k ............... Issued -------------------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- OF . '. .Cw ............................ "........._.........
CITPrttftrate of TomlaItttxt e _
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( � ) or Repaired ( )
by---------C'.'s " ......0 . 5 e...............-..--.----
Installer
has been installed in accordance with the provisions of TITLE 5 gf The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..... ,c .o� ............. dated ................--.............-.-..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRU6 AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----------------------------------------------------------------------------- ....... Inspector .........-- ...----------- ------ .......:...........------. --------------------------
THE COMMONWEALTH QF MASSACHUSETTS
BOARD OF HEALTH
c��(............OF.... .......................
• No... FEE. ..4��.............
Disposa Works Tons#r to ,unfit
Permission is hereby granted........ .. :: .... .__:....._. ..fie �? ..... �.!�?�'�
.
to Construct ( 1-Tor Repair ( ) j Individual Sewage Disposal ystem
at NO.�6 i 'T t ,%6 ._.,1�,!kll i/�.r,.� J'c' T ° 'jr. .---------
...... ......... .
Street Gp
as shown on the application for Disposal Works Construction Permit No.e1.:e ! Dated..........................................
----------------------------------------------------------------•••...•••...•.....-•-•--_...._
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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0 0 (.0 ASSESSORSNUPH TM
PARCEL N0:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
Address of property ( �f;'p ( ( -pZsf-6W "
Owner's name Keg m od n2 2�p2
Date of Inspection
cx cRT T A P R..2 A 1525
HEALTH`D�PT.
Check if the following have been done: MWN OF BARNSTABLE
Pumping information was requested of the owner, occupant, and Board 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.
TY�e 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 information on the proper maintenance -of SSDS.'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
'If residential,]
Ynumber)ofCbedrooms
number of current residents
/V garbage grinder, yes or no'
_ laundry connected to system, yes or no
_&- -seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available.q'4 >4i 000
0
cis - i� ono 13 �
cCu 4 lL- Last date of occupancy
GENERAL INFORMATION
Pumping records and source of informat' n:
4eyM DP_ !�uJ /Ue
System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type 9f system
Septic tank/distribution box/soil absorption system
Single cesspool ,
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any) '
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: ,
bet, Xi
AL Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:/6�
(locate on site plan)
depth below grade
material of construction: C--C-oncrete metal FRP other(explain)
dimensions: ,
^ 7 sludge depth
1�] !' 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
Id " 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,
evidence of leaka recommendations for repairs, et . )
AIA
if
DISTRIBUTION BOX: ✓
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
PUMP CH ER:
.(locate on 'te plan)
pumps in ing order, yes or no —
Comments:
(note condition of p chamber, co ion of pumps and appurtenances,
recommendatio or maintenance or repai etc. )
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION. continued
SOIL ABSORPTION SYSTEM (SAS) : t/
(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 pf vegetation, recommendations for maintenance pry reps ' s etc. )
CESSPOOLS (locate on site plan) :
number and configur ' on
depth-top of liquid to 1 invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of constru on
indication of dwater
inf spool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan)
materials of constructio
dimensions
depth of soli
commen
(note condition of soil , signs of hydraulic failure, le f ponding,
condition of vegetation,. recommendations for maintenance or repairs,etc. ) .
f 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE �7' =SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
C
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation: -"
G'!L
t Y
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?
l) Discharge or ponding of effluent to the surface. of the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert, or available volume< 1/2 da
flow?
Required pumping 4 times or more in the last year?
number of times pumped
k
Septic tank is metal? cracked? structurally unsound? substantial r
infiltration? substantial exfiltration? tank failure imminent?
ar Is any portion of the SAS, cesspool or privy:
'y 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?
_rA/ 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) ?
N within 50 feet of a private water supply well?
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 ana-
.for coliform bacteria, volatile organic compounds, ammonia nitrog f
- - and nitrate nitrogen. -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART D
CERTIFICATION
Name of Inspector
Company Name J 6�' `� S� �cs
Company Address ? SA
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
maiitenance of on-site sewage disposal systems.
Check one:
j L----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 (9`7 5
li
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
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