HomeMy WebLinkAbout0105 SCUDDER'S LANE - Health 105 SCUDDER'S LANE,BARNSTABLE
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TOWN OF BARNSTABLE 1
LOCATION. ((, ate Lu t� SEWAGE #
VII.LAGE ASSESSOR'S MAP&LOT- 'U/
INSTALLER'S NAME&PHONE NO. L n[.
SEPTIC TANK CAPACrTY �U
LEACHING FACELrrY: (type) Rrr-c)qS7- (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 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 facility) Feet
Furnished by 1QeD_��w. �' ( ��hs I
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ASSESSOR'S MAP N0. PARCEL hq-- d,017451
LO.CAT `IO SEWAGE PERMIT NO.
fp_�f-ht UY kw�-t .
VILLAGE
N4TVLLER'S NAME i ADDRESS .
' ,0160d. P•66x u l�r o ff'
R OR OWNER , f
DATE PERMIT ISSUED
DAT E COMPLIANCE 1SSUE0
Z 0
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FA
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...._...._. ...OF -f ' ! -------------------------------------------
Application for 11ispoottl Varks Tonstradion rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( -fin Individual Sewage Disposal
System at:
.�..........� .... cc��. �eJ .._.. �`��.............. .........�..R � l k ..._......._ ...-----............_..._..
Location-Address or Lot No.
_ _.._�:j�.;r.�.a_4V.......................•--- ....
.... ...........................................................
Owner ,�+ddress
a .....------.�L.'�- 1�!4:' .t2.....���e J�(L....... �.. c�?� `l %� .................................
...• --- --- q
Installer Address
Type of Building Size Lot.............................S feet
aDwelling—No. of Bedrooms....�--�......................................Expansion Attic ( ) Garbage Grinder ('1.)�'
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .----------••--------------------•-•-------.................------......._......................:..............................................
W Design Flow.............'^.;;..._.._.... gallons per person der day. Total daily flow....3.�C..........................gallons.
WSeptic Tank 1 Liquid'capacity �...�gallons Length....-........._. Width_........... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No......L............. Diameter....l_. '__...... Depth below inlet.....1Q........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date.......:................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
Nest Pit No..2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
:= --•--•.........•----------- ----------------------------------------------------------------------------------------------------------
ODescription of Soil----•-•...........................•--•---•--------•---•------.....------•-•-•-••----•---•---•------------------------.....-•---......--•-----..........---••-•-•--:.----
W -•-•-...-•-•......................................••-•-----•------...........•--•--............-••••----•--•----•--•--------------- •--•••-•••........._.....--•--•--•-.._..............••......
UNature of Repairs or Alterations—Answer when applicable__ t E -1....... to 'b ..�.a�`...
-----------------•----------------.....-•---••--•-•.............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'I'AU 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 health.
.
......•... . -- .--•.. -- ...... ......... -- ------------ ��..... �....
` Date
Application Approved By.........................
:
_:_.:..__
,, Dte :..
'
Application Disapproved for the following reasons:.................................................... ..................................
-
...........................................-..............................................................................................................:..............................................
Date
Permit No. .......... ...... . �C, --- --...._ Issued.--•- �- .Y . .. .`�'X. ........__
IF 7'"
co T
No....:y..�......_..._..�. F.A J
THE COMMONWEALTH OF MASSACHUSETTS
-BOARD OF HEALTH
...........................................
Appl ration for DiSpusal Works Tonstrudiun jJrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( --)-an Individual Sewage Disposal
System at:
.._...-.....a n ..... v�1d) .....!-: ::............ ...... .o r .to 1►e .._ ,.....................-_..........
Location-Address or Lot No.
.=r- :1_(V-------------- - -- ........... ........S.ya..o. ..........------.....--•--.._......_........
e ✓Owner Address
G � �.Avl ✓J St°W�J / .................. . ............................................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
a'
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures -------------------------------------------------- ---------•--
W Design Flow............... ......... ...gallons per person per day, Total daily„flow.... 1�..........................gallons.
WSeptic Tank Liquld`capacrty.... . gallons Length._.:.....:_ Width.......K.... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length............�....... Total leaching area....................sq. ft.
3 `Seepage Pit No....... ............. Diameter....l -..__.... Depth below inlet.....jb........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
"'" Percolation Test Results Performed by.................................. ...................................... Date------.................................
1.4 Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f=, Nest Pit No. 2................minutes per inch Depth of, Test Pit_...:.....____..._.. Depth to ground water._.._......._...._......
,:
x - ......-•--••....•• .........---•-•...: .............••---..............................................................
O Description of Soil.....................
W -------------•------------------•--.......----- --- ---------- -
.-- --------•-•--••--------•- ; :.r - - - _._.........._................
-- '
x ..--••-•--•••-•----- -•-•...............•-•----•-:.._..--•--•••••••............•.._...........•-• ---•.......--••••----------------•••---••-•••••-•-...•---•.......••••••......•.........------•-_....
V._ Nature of,/Repairs or Altercations—Answer whemapplicable..`��e�4z�!(.�.......¢.4.�.._:�Y'��L-..
Agreement:
-,The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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 board of ltealt
�-- sign ;� a e a�
••. ..... -------
Date
ApplicationApproved By_•-.._--- --•-•... ..........----------------------------------------------------•• � - D
-Date
Application Disapproved for the following reasons:.............................................................................................................
Date
Permit �No.... :` - -..-.. Issued---------,�.f-�.Lf. 1.. �...............��yr
` Date G
THE COMMONWEALTH OF MASSACHUSETTS
BOARD�t OF=`-HEALTH.
��.............�...... zfve
........................
(Irr#ifirttfe-,�f faint ltttnrr
THIS IS TO CERTIFY-That the Individual Sev6age Disposal System constructed ( ) or Repaired
n r 'Installer
has been installed in accordance with the provisions of TIT 5 o e State Sanitary Code a described in the
application for Disposal Works Construction Permit No. •._ ..._-•.._... ._... ��� dated_.-._____I_L�1 .�.�� ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �����-•.-�•••--•-•••--..........,
DATE...............�`. ' . .......................... Inspectot ? . .e::..........
-r-
THE COMMONWEALTH OF MASSACHUSETTS
Al
BOARD OF HEALTH
7T(pG :c !�:� ..........OF : I.wS : . .. _ ............................
No......................... FEE
Otsposal Works Tunstrttrtiurt Prrntit
Permission is hereby granted......... Qa ..L=E4N 7 .....:-< ,/7---k... �. .:..................................................
to Construct ( j or Repair ( ,) anAndividual Sewage Disposal System
atNo..........1.A1 .....:5: -�,- �..�r....�.� . .---........° l w_ ..tea Sf..................•----.................--------------- •--........
Street
as shown on the application for Disposal Works Construction Permit No�7..G_.��.0 Dated............fl���//�:�......
�. / /�� Board of Health
DATE `� ..............•----••----- --------
TOWN OF BAPUNSTABLE 1
LOCATION SEWAGE #
VILLAGE vi7rs�y c �b FP . ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. GA
SEPTIC TANK CAPACITY 1600
LEACHING FACILITY: (type) Parr �15� (size)
NO.OF BEDROOMS
BUILDER OR OWNERU
PERMTTDATE: 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 facility) Feet
Furnished by 44 &A9z- f hs
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ASSESSOR'S MAP N0. PARCEL
O L ,CAT'il0 SEWAGE PERMIT NO.
VILLAGE
NSTA LLER'S NAME i ADDRESS .
R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED. ��� ��
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8088QRFACE BEAAGE DI8POSAL 8Y8TTZM INBPECTION .PORK
Address- of property %O
Owner's nameb��!c
Date of Inspection (l .
PART A
CNECKLIBT `
Check if the following have been done:
Pumping information was requested of the owner, occupant,. and Board of
Health.
V None of the system components have been pumped for at least two ,wee&s
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.
L/ As built plans have been obtained .and examined.. Note if they are.,not,
available with N/A.
V The facility or dwelling was inspected for signs of sewage back-up: -RR
yt
The site was inspected for signs of breakout. . }; JA
;
{£ y • • E. - b t3',( k §daf xP`,j5y�,+Y.,a fin" .
system.. components, :Iexcluding they SAS,, have been-Located on
All�
site. &Fin
k
>..,. N, g w K 1
The septic*tank�tmanholes were uncovered, opened, and sthwinterior of?
the septic tank• was inspected for condition of. baffles orM•tees, „f >
material of construction, dimensions, depth of 1 iquid, depth of sludge, depth of scum. t^ +
4,0
zgsf , ,
V The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods. 1o ,`y,
A
The facility owner (and occupants, if different from owner) , were
r, • ,,, <
provided with information on . the _proper .maintenance •of. SSDS
ti � � EP
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$;'''�+.x 9dnt l•.,e S. ai,..». .. M 7..� M,, Mr f # 7St i'r°�
r'a j�; �+r;u t 4t r,•'r ' J '}Y;;±ff r.1� �: � tt�*+��i��i�'fit`,' I
�.` i";i u tr b 1 , s r• _ _ ,, + S � ,",.',. r
qN rt .. .,.'y- gti•t ? N.tNNfy'^yF:
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SUBSURFACE SEWAGE DISPOSAL BYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS.
If residential
number of bedrooms ,.
number of current residentssR
garbage grinder, yes or no,
laundry connected to system, yes or no
seasonal use, yes or no
a. . If nonresidential, calculated flow:
Water meter readings, if available:
:a ,
-e5�e Last date of occupancy
dY;a
GENERAL INFORMATION
Pumping records and source of information;14
$ :;
`System pumped as'rpart{,,Of inspection, yes or n0"
x,ktif yes, volume`. pum ed.
tIx'�°Reason for,.4pumping.r.::�„
Pr
Typ of system:..,<,r ,
ikea "fix
� *� tSeptic tank/distribution box/soil absorption systemIT
� z, 131 , :
r Single cesspool
F *. Overflow cesspool`- rF`
Privy
Shared system (yes or no) (if yes, attach previous inspection
records,' if any)
Other (explain) <f' ?
Approximate age o•f'all. components. Date installed,' if known. ,.Source oft
information: " u,
, ��fin
Sewage odors detected when arriving at the site,,' yes or. no = • ,�#
R i,rf
i}�''Yh - - _ ,•h R+ rj� .fly,{�
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
SYSTEM INFORMATION Continued
SEPTIC TANK: V
(locate on site plan)
depth below grade:_
material of construction: concrete metal FRP _other(explain)
t
dimensions:
sludge depth a
distance from top of sludge to bottom of outlet tee or. baffle #7`
mot. scum thickness 4 .F
distance from top of scum to top of outlet tee or baffle
` distance from bottom of scum to bottom of outlet tee or baffle' " - if
Comments.
(recommendation for pumping, condition of inlet and outlet tees,or:baffles,
depth of liquid level in relation to out•let.,invert, . structural,,integrity;T,
evidence of leakage, recommendations for repairs, etc.)'
9 P
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i
1
DISTRIBUTION BOX:
..(locate on site plan)
depth of ,liquid level above outlet invert
'� A-rt�i..l�d� �5., +'v t F �"+:-'L i y ��' t +�`•d c 'i
�. � ., :.e s t�e r g��}. a .' •�ry� ,�`as.�'�, r� rah ? -
` ° b° (note!,.. . level sand :distribution is equal,,.,evidence of<y solidscarryover:,
F 'evidence of leakage into or out of box, recommendation sforjrepaiisE etc.)
t
4PUMP CHAMBER:-.-,.-.-'.-,—,
(locate on site plan) ,
9
P 1J
pumps in working order, yes or no
h� T {i�Y3- Comments• f r. .. .. f $�.} ,`. ' ,�+C,
t� #,
•':.: �,4 µ� "w• yt"c� ? �rrE�'
�'��;#, (note condition•of' pump,,°chamber, condition. of pumps and ,appurtenances;�� ,�x
k �a74r3fta�1 r €saaiaw "�N
_! {:.recommendations*for maintenance or repairs,etc.)
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y V - .. ��- . ,..-LLB.a.,„�.�r, ,.,i: w�"'h&'�,;�'01
+,..'�,.,>- -.
f5' flY
"Y r ti i)NA
s fP a r v' ar5 e ,��
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM';
PART 8 � .f..-
SYSTEM INFORMATION Continued
SOIL ABSORPTION SYSTEM (SAS) : '
(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 :h• .
leaching galleries and number :..,
leaching trenches, number, length w-. =
leaching fields, number, dimensions `. ^,.
overflow cesspool, number
comments: ,` � 5 � s 0
° (note condition of soil, signs of hydraulic failure, level of ponding; . ,
condition of vegetation, recommendations for maintenance' or repairs,etc;) .
• st y ^f, CESSPOOLS (locate on` site plan) :
number and configuration
depth-top .of 'liquid to inlet invert
. ,depth of solids layer
depth of scum layer, A
` dimensions of cesspool ,.;.
materials of construction
indication of groundwatersia
a inflow (cesspool must be pumped as
of inspection)
i u'+.F. � .k 1.; •i s:! 4 s . r v� t *ti 7 .a�my'tf••i4�' �.'
40. � `+ "et„,a •+r W+-a•- +wow -a�'' %8 w i;,..- + �
Comments•tr Y N, :. x
• jw/� � i 3 . 1 .{;'"' FC f w aY1 fir � r,
' (note Kcondition of `soil;: signs ofhydraulic°,failure,..lever of ponding,
condition-of�vegetation, recommendations;•for maintenance-orl, I afrs�etc I
• r
K
C Px1, �`
( IM
locate on site plan)
; :materials of construction F x ,s` _•
xrT dimensions
solids
cf f
t tH 1q� ,,Comments x
IiM ".v r(note Tcondition ,of soil., signs of hydraulic failure, level of on �� Ycondition
of vegetati:on,• recommendations for maintenance or repairs;
rd51847G;.,=-y4„r.<,..,. .. - - _ '•.:vw.,.vkr.•... c. ;. £y.
r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
,FORM
PART 8
F/ SYSTEM INFORMATION Continued
Y SKETCH OF SEWAGE L:SPOSAL SYSTEM: �t
F
. include ties to at least two permanent references landmarks .or benchmarks
locate all wells within 100'
b o t'Soo S,TWA-�
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�."`xN ti''y bT✓'x��'<r 1 - .. ,'r } �}�4,y���i.
DEPTH"TO GROUNDWATER
., 7 '}� h,y r, r '7, i 6 s r t at � s:•i g r, �s�° � .�'f,�� ,
�'��+. t,�' .,�s ..� •. :5 � ��' 1..x > .,��'F ��r�a ,� � i ���" ., '� a �t'� �#t 4F.M r �}� �� #�'I�Fx�'� n ; �, i^ "� K�
fi depth,to 9roundwa'ter
M
.; k ,. �t ,, is..•A sa.F �s! kar- r�'.a� 7 R�.{p�,s,' ",�,'�- .f�� -.,�;
v. .,3• ti• - h�'rt
x�ti� fit +' > ✓. x{�, '.�,k 1 r x - - 1 '� � ,�q,<' x.�"'
41
methodof=determination =or approximation: ;
,3r7•1.::'Sga'd ��} �•gf.v.
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SUBSURFACE SEWAGE DISPOSAL BYSTZX INSPECTION FORM.
PART C ` wi.
FAILURE CRITERIA A r �, •
., aQ
� f <Indicate yes, no,' or' not determined (Y, N, or ND) . Describe fbasisof#' '
a: `determination in all instances. If "not .determined", explain'w2iy .iiot) 'll
' 7
Backup. of sewage into facility?
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 &
flow?
Required pumping. 4 times or more in the last year?
number of times pumped
ha4 Septic tank is metal? cracked? structurally unsound? substantial
t�
•infiltration? substantial exfiltration? tank failure imminent? y .
u ` Is any portion of the SAS, cesspool or privy: ' ai.
a below the high groundwater elevation?
within 50 feet of a surface water? ,
within 100 feet of a surface water supply or tributary o a surface
water supply? Y'?
r t
g t
within` a Zone .I of a public weld?
, Y
�•y�C,4 t .. ! "� t Tx F,t'yC�y}y 3j�.,
within 50 feet of a bordering vegetated wetland or 'salt marsh M 9
(cesspools and privies only, Z the SAS)?
41� t� 'Si k r 't r 1 x r ♦ A raa i s
°;within 50 ~feet of.;a,,private water 'supply well,?
,,.7 `v xc� t a r i A d xE:;tt 4oc d:'�� !` � t°•h .x'•:., 31,'x'.7 x x# �•xs,.•�'kY.7taY ��, t
lrt
s ff 3 P a r s f'' y .t?iLd 'j,.'Y+arr+t";'i'rAx'i o- s'r7ft'w°*Y.•,+„a3rF +, ,i +..+y'ry9r+''q' Y, fit" •; 'trc"a✓ ,''=1it n,da:,.Wex59er'iq :3, 7 Ls
wF ass` than 'ib0 kfeet :but' rester 4 �.
`l `` g than :50, Tfeet'y,fromK a Npriv�te�water y$.
xz( ^3 r supply weIl-,with-no-acceptable';.water;;qua lity:,*analysis? If Mahe dwell
has. been��anal zed- to be acce table, attach co of-we113�water.�ana1
� :for coliform. bacteria, volatile organic compounds,—ammonia nitrogen"
� »yy## and nitrate nitrogen. -s t,. kw1
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SUBSURFACE SEWAGE DISPOSAL SYBTEM INBPECTION FORM
PART D
CERTIFICATION
f `k Name of InspectorOR
r
ay Name
Company Address �W�Cj ecrT .
s x.c
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 ne: ;. .
have not found any information which indicates that; the' system• fails1
• to adequately protect public health or the environment as defined jnf,':
310 CMR 25.303, Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form. .
1` I have determined that the system fails to protect public health,`€acid
k the environment as defined in 310 CMR 15.303. The basis tor'.this k
determination is provided in the FAILURE CRITERIA section of this = k z
form. `
Inspector's Signature '€
.Vr tiY
• Date
F z
Original to system owner
r '
Copies to: �� L , �
C ,
i 4 , Buyer (if applicable)
Approving authority. �` f .
> �` ti '# 1:. • .. .. r .i�.1iS�' ' tom'
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