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HomeMy WebLinkAbout1525 HYANNIS ROAD - Health f 09 COACH LANE,BARNSTABLE =298 007 a. � o 4 CERTIFIED !CERTIFIED ,SEPTIC SYSTEM REP0 F,T LOCATION 109 COACH LANE BARNSTABLE , MA 02630 MAP 298 PARCEL 007 LOT 66 PREPARED FOR SELLER. MR. JOESPH E . BENNETT TRUSTEE AN-LO REALTY 725 CANTON ST NORWOOD MA, 02062 - Bi 1.Uh UNKNOWN PREPARED BY HILLIARD HILLER, JR . 41 MAPLE AVE CENTERVILLE , MA 02601 508-778-1472 MOWED APR 1 8 1995 HEALTH DEFT. TM OF BARNSTABLE 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Ad j'ress of property /61`s 44114G,y G-s!!�t/,� q,�,vg�•�,� ,�� oac3v owner' s name /i/P, F. QE.uN,eTT Date of Inspection /91°R/� /e /9915-' PART A CHECKLIST Check 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. LIA 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 information on the proper maintenance of SSDS. OM r v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms _ ;� number of current residents y2s. garbage grinder, yes or no `E laundry connected to system, yes or no Abo seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: 311r3- 3/�y 9� Gam( Last date of occupancy3�y- T '0/p $Z Z Ff/V O�Zi.00i,�G A Na GENERAL INFORMATION //V /qqy Pumping records and source of information: PO System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of 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: U,�f(',vD�vy G ovLp ,yoT F%moo /9.�iY' /Pig c�.¢.'o 4/0 Sewage odors detected when arriving at the site, yes or no ', J f r • 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: !� (locate on site plan) depth below grade: 8 � material of construction: concrete metal FRP other(explain) dimensions:_ /dG " x yea (sd> e- sludge depth /7" distance from top of sludge to bottom of outlet tee or baffle o" 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 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, recommendations for repairs, etc. ) f'vG' T LS Th`ftT %g'4S 6'Z C e_� Tb 1�,R� i�v� i°L'/l�c�p.Gr�,�c,e' f.�'c�•� Ti9,s/I, DISTRIBUTION BOX: y. (locate on site plan) D 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 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. ) r r 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) :�i _ (.locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: 11" Qox N/!o a Ovi G X T /ai��s. 0/0 Fivo okv. 3 7/hr9 T /T /5 /➢ .d 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, recommendations for maintenance or repairs,etc. ) CESSPOOLS (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 inflow (cesspool 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 construction dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of ponding, ' condition of vegetation, recommendations for maintenance or repairs, etc. ) ' 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 1001 " /lJq GofIG/1 L/4,v,E , Jp 1 /� a O 3 Gov�,p ,�/vT LoG.9T� ROTA/,v/NG wi9L� DEPTH TO GROUNDWATER 73 c«-c,� aS w,�rC'` T'rr�-Z 3 / /9oU�5Tri t vT depth to groundwater method of determination or approximation: 37, l,�/9T�� TffaG E i�Po/yJ �3ifRy5Tia�G� llv�Y1 17 a `/2 2vuc l3, -3i 12 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? IV Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? NA . Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped V Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: IV _ below the high groundwater elevation? within 50 feet of a surface water? V within. 100 feet of a surface water supply or tributary to a surface water supply? Ll within a Zone I of a public well? V within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? A� 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 PP Y P q Y Y has been analyzed to be acceptable, attach copy of well water analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen ) and nitrate nitrogen. b 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ma's PART D CERTIFYCATION Name of Inspector H1161A40 ItI41--rX TA Company Name Company Address Pv Box aSo 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 maintenance of on-site sewage disposal systems. Check one: r/ 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. y' 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 r�eowl o PDT vrF. r , b. ' -27ip �� As S /09� - (f oACH Zn/ j PL/4,v P/PO v/OF1J /✓�y TOWN OF BARNSTABLE II LOCATION��°® roll G1 61V SEWAGE # VILLAGE '�j/,tel�/,fj— /�6L ASSESSOR'S MAP & LO' c�7PJ -�- . INSTALLER'S NAME & PHONE NO. ('`cr,��.✓��-v SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ;�"//S (size) Ll dy,�Gior ri NO. OF BEDROOMS� -DD' � R PUBLIC WATER FOR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE 1SSrt1ED: VARIANCE GRANTED: Yes No � i lea. �r Q }�1 or 1� "r (off ll/ LGy No...._...! I l Fig.... , THE COMMONWEALTH OF.MASSACHUSETTS BOARD OF HEAL,,Tjl To'Gt�^ ......_..-.......OF...... ....... .... --- c Appliratio � -flax 13itiplaiial Workii T atuitrurti.on Prrmit Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal Systat- ... !L ........................••-- ocat�on•Address I� or Lot No. 4. W `ner Address a .... . ---• 1 ---•- --•---------•-----------•------------------ Installer Address U Type of Building .j,�J� Size Lot............................Sq. feet Dwelling—No. of Bedrooms_.__.. ......___�.__'.'._�_.________________Ex a sion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _______________________-_- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ................................................. W Design Flow..............._.._® � �j�gal�ns person per day. Total daily flow-__-_____3�...................................gallons. WSeptic Tank—Liquid capacity_ .ga�ength................ Wi th..---------.---- Diameter__-.--_--.__-- Depth.._.---_-.--_.- x Disposal Trench—No- ______________ ____ Width...._ Total L --_---_--"-"__.. Total leaching area..------------------sq. ft. Seepage Pit No....... ...._.. Diamete __________ _ _____ epth below i et._....._.........._ Total lea twig area------------------sq. ft. z Other Distribution box (Al Dosing tank ( ) ® /�c , Percolation Test Results Performed by----------------------------------------------------..................... Date-----•------------------------------.... aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water...-_-_.--__-..-_.--_-- �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__.-.-_-_-___---_-_-.--- 9 ----•----------------------------•-------------------................................................._...•-----•------•-------------•-------...._......---- 0 Description of Soil_______________________ __ x .............••-•--------•-------------•----...------. --- - -- ------------------------------------------------- ------------- ------- ------- U W ------•--------------------------------------------------------------------------------------------------------•------------------------............................................................... 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 Article \I of the State Sanitary Code— The undersig d further agrees not to place the system in operation until a Certificate of Compliance has b is by the boar f alth. or igned.. .. -- - -•--•- -.....� D to Application Approved By - ,-------- 3- ate A Application Disapproved or the following reasons---- ---------•.....--••---- ----•----------------"-••---------"---------•------•-•-----------...... PP PP f f 9 r` ""-•-•"--•--•"---------•--"------""-"-----•-"----------------------------•-----------"--•----------"--------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date No....... f.7..... Fss. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA -rLj - OF..../. j. .. ................................................. l" Appliratiou -for Diovoottl Morks Touotrurtion Vrrutit 2 y�--77 Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System?at: ................---­---------------(Ld...................................... .... .......................... y Location-Address / or Lot Ivo. I -------------------------------------------•--------•----------------------•-•-•---.--•----•--- /��— !/Owner/ Address a .............'-------=='�.'-="-----•--ZZZ--r---------------•----------------------------- ---------------------------------•----•----------------------------------------------------------- Installer Address Q Type of Building _ Size Lot............................Sq. feet U Dwelling—No. of Bedrooms._.___5 Dwelling Attic ( ) Garbage Grinder ( ) p`-, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) P-I Other fixtures --•------ ------------------------- - - w Design Flow______________�Q__-_-_____-____---gallons r person per day. Total daily, flow----------_3•�_©_._U--------------..gallons. 04 Septic Tank—Liquid capacity-f.Oefl--gal`I'o 4rLength________________ Width................ Diameter---------------- Depth.______-.----- xDisposal Trench—No..................... Width_-__.____ --------- Total Length..................._ Total leaching area-.--.--___-_--_--_sq. ft. Seepage Pit No......I...... ITO-- g t 1.Diameter______ a________ e th below inlet..............: Total leachiu trea.._._____.._..__.sc it. z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by...... ------------------------------------------------------------------- Date---------------------------------------- Test Pit No. I................minutes per inch Depth of "Pest Pit.................... Depth to ground water_-_--..-.--..--.----_. Test Pit No. 2____•-___--_-_-minutes per inch Depth of Test Pit-------------------- Depth to ground water-------.-_---_-_---..___ ----......-•--------------------•-•------------------•----•-•-•-.........._---•--•--•-----•--.-----•......................................................... 0 f-Description of Soil----------------------- = ---- ------------------------------ --------------------------------------- --------------------------------- x e � ' U w VNature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n lss by the board_,of 144ealth. igned----- (- -----------=-C--i.--t/-----L.!?!cG�'--'`--. D to Application Approved BY .. � ae Application Disapproved for the following reasons---------.......................------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......!...[_:a''v`'.�..............OF.... .�.1.r ...................................................... ,rrtifiratr of funutplitture + f THIS TIFY.,tThat tyre Individual Sewage Disposal System constructed (�) or Repaired ( ) y....... - •-------#•--••- Installer at........... ............. --------- .. --...------�/Vic.-�.,C.. __ ---1 ......................................................... has been installed in accordance with the provisions of Article XI of The State Sanitary Code as descri-ed in the application for Disposal Works Construction Permit No....... ....... dated...-.ZA/�RA-NTEE THE ISSUANCE OF THIS CERTIFICATE SHALL NOT EE CONSTRUEDAS A G THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS �. -_ 7 `7 BOARD OF HEALT . / � �' ' ..................OF... Gfi�,!.�.�. --......... ..--------------...........y� ................ No.......... FEE---. Dio o0 l ork Cloastrurtioit rrutit Permission is hereby granted ---------------• L --------------­--............................................................... to Construct ) or Repair ( )'an Indivi al VSewa ',Dis osal Syste Street as shown on the application for Disposal Works Construction Permit -No----z--------------- Dated._., /.._y,_..7 ........ ••-----•-•------•------.\... Board of Hea DATE.......................................................................=........ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS L " d '--Assessor map and lot riumber ... SE TIC SYSTEM MUST B sh s Asses ° A..AN STALED IN LIANCE: , 41 , �4 I S COMP wiTH A:xTf^I_.E„II; STATE p Sewage Permit number#:::...� I. .... ........ Sltr'glTA'�Y E AfVJ ... .:. :. ..,. REGULATIONS. TOWN. THE IDLE TO +.. .1v OF 1� 1'.�1 1—� �Q O BASIISTADLNAM i 9. �o may a• A'I" WT APPLICATION FOR'PERMIT TO :. �� i a"fit.............................. ............................................. t` ,. TYPE OF CONSTRUCTION :..... `, s} ............ ......... ....................19?.. "I - rt TO, THE INSPECTOR OF BUILDINGS: r� ' `� The undersigned hereby,applies for a,permit according to the following information: y! Location-.......`........:... .............. .... C . ...L,A.A''.C-.........................:...................:. ...:... Proposed Use' �*n� .... CL�:: �! � t ,:��•r''.C''�......... :.` Zoning District .....!.90 :.:. .. . ::,......... ..Fire District .. !4 �t c r . .. ... .. .... ...... . ' Name of Owner /is.t ".....!f.. r��ddress f� .; '... /;t!t�Eiya`S J.....................ff 51, Name .of Builder .. .Address .....:.. Name of Architect ....... ....... ...............Address ............ ......:. i .... r , Number of Rooms :... ..../..7 Foundation ...... .. ....... ......... ............................................... 17­ di• Exted for ,�........ t.... ......S f.... .....� Roofing .... �� #.Floors^= ff. i .tG�f c .Interior , !r S� F J�IaC._,/e' f l Heating �.! .. .t.:! 2 1�. !? .... 6� ,rc f' P'lumbing ..... 4 �P'" i''e��'/iL' !''e j g �. .... Fireplace �.. :..... .. ...:.:. ....:.:. . .:..... :....... Approximate Cost .: ..00. 0 r;• ...... Definitive Plan 'A roved b Plannin Board pP Y 9 ,` ,— 9 L"• Area �..� ...� ,. ......... �e Dicigrarm, mof-"Lot•ancl'-R .lu:ny^ if- DlmenSlOnS. •+4 -"'-`3"'^'^...'-""'-'^T"—.--- - ';,^.^ - Fee ".:'"..... .. .... ...... ....:....... SUBJECT TO APPROVAL OF BOARD OF HEALTH jUvc:a' IL k'P sir {'t,! i ,�� . `': � .i`•�c � '7/ p�i. •eke I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable r garding the above construction. ,1 �,•'�` ;y!r ,L`4' Name ..f.t ...�. �. r...... ...............................J............... iki t ^ dt y f r,••t t Y, ,. �.�: LL .. �'�- �� li.. �i a �:;.:- fi�,i.; y 4t �ka v — 1 xt 'e::+ y+ +�' 0"k x