HomeMy WebLinkAbout0217 ANSEL HOWLAND ROAD - Health V17Ansel Howland Road, Centerville
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i
IN
UPC 12534
No.2153LOR
NASYING D.UN
COMMONWEALTH OF MASSACHUSETTS f
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
_ DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, NIA 02108 617.292 SS00
u ILL1.,01 F u ELD TR;_D1 C(
Go�cmor 4l/r, /7 Sc.
ARGEO PALL CELLLICCI �' 11CS/ CP.. VID 3 STR
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 16 Comm ss
PART A Ga 91v, 1_V
CERTIFICATION j �TyQv r,qe�
Pro perry Address: 21 7 Ansel Howland Road Cent. Address of Owne hn Welles
Date of Inspection: o/8 (If different) 1 1 1
Name of Inspector: �OS@� '7 P•Macomber Jr. Ce ig , ass .
I am a DEP approved system inspector pursuant to Section 15,340 of Title 5 (310 CMR 15.000) 02632
Company Name: J.P.Macomber &Son Inc.
Mailing Address: Box 66 Centerville,Mass 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
I cenify that I have personally inspected the sewage disposal system at this address and that the information reponed below is uue accura
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper iunct,on anc
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails 7
Inspector's Signature: �� Date:
The System Inspector s all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing inns
inspection if the system is a shared system or has a design flow of 10,000 glad or greater, the inspector and the system owner shall subm
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the sys7em owr
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, Or D:
A) SYSTEM PASSES:
1 have not found any information which indicates that the system violates any of the failure criteria as deiined in 310 CMR 1 i 30
Any failure criteria not evaluated are indicated below.
COMMENTS:
6] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired The system. uC
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain Wny not
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cenificaie of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection.
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or ex-filtration. or to
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming seoc,c an.
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 217 Ansel Howlad Road Centerville,Mass .
Owner: Estate Of Herbert & Josephine Welles
Date of Inspection: 1 0/8/97
BJ SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to bro',en or oos:r.,c.ec
pipets) or due to a broken, settled or uneven distribution box. The system will pass inspec110n f (with approvai of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than (our times a year due to broken or obstructed pipe(s) The system wiu pass
inspeci,on if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
�A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is falling to prolecc (ne
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A ,titA.�NER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DEZER:tisINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface eater supp,,, 0
tributary to a surface water supply.
4jj The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds no,cates tna:
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
A4
(r•�18*d 04/25/37) Y4fl• 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:21 7 Ansel Howland Road Centerville
Owner: Estate Of Herbert & Josephine Welles
Date of Inspection: 1 0/8/9 7
D) SYSTEM FAILS:
You must indicate e: er "Yes" or "No" as to each of the following:
,V0 I have determined that the system violates one or more of the following failure criteria as defined in 310 C,,R 15 303 ne
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cone
the failure
Yes NO
Y Backup of sewage into facility or. system component due to an overloaded or clogged SAS or cesspool
Discharge or pond,ng of effluent to the surface of the ground or surface waters due to an overloaded or cioggec 5`.S o-
cesspool.
Static liquid level in the stributron box above outlet inven due to an overloaded or clogged SAS or cesspoo'
luo," j4rL a? ,X
Liquid depth in.G44+pQG4 is less than 6" below invent or available volume is less than 112 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(0
Number of times pumped _.
Any ponion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation
Any ponion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface . a!er
Any portion of a cesspool or privy is within a Zone I of a public well.
Any ponion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well —:n n
acceptable water quality analysis. If the well has been analyzed to be acceptable, anach copy of well water anal�s,s !o,
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen
E) LARGE SYSTEM FAILS:
You must indicate ether "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above.
The system serves a facility with a design flow of 10,000 god or greater (Large System) and the system is a signlf,can; tnrea! !e
public health and safety and the environment because one or more of the following conditions exist
Yes No
yi& the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone Ii o; a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment oro,3 aT
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information
l r.vl„d 0�/15/971 ➢.9. 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:21 7 Ansel Howland Road Centerville Ma
owner: Estate Of Herbert & Josephine Welles
Date of Inspection: 1 0/8/97
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No ,
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
now rates during that period. Large volumes of water have not been introduced into the system recemh.v 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 system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components.•ecluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance w
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(evicted 04/25/97) ?&q. 4 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:21 7 Ansel Howland Road Centerville Ma
Owner: Estate Of Herbert & Josephine Welles
Date of Inspection: 1 0/8/9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ')Wl p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:Q
Garbage grinder (yes or no):C�—
Laundry connected to system (yes or no): i°
Seasonal use (yes or no):,(/P _ q��tr>., (} n
Water meter readings, if available (last two (2) year usage lgpd): tQa� 'L✓s �)�/� ly : ���y
Sump Pump (yes or no): AV p 6-- 1 ilou'+ Q, x✓�/ it oo
Last date of occupancy: Gl/L
COMMERCIAUINDUSTRIAL:
Type of establishment: ti/¢
Design flow: N/� Rallons/day
Grease trap present: (yes or no)A��
Industrial Waste Holding Tank present: (yes or no)-&J,
Non-sanitary waste discharged to the Title S system: (yes or no)/t//;
Water meter readings, if available: All.
4
Last date of occupancy: I
OTHER: (Describe) 4
Las( date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and sou f information:
System pumped as part of inspection: (yes or no)y0
If yes, volume pumped: gallons
Reason for pumping �� �/��,�✓
TYPE OF STEM
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)
I/A Te hnology etc. Copy of up to date contract?
Other 4
APPROXI X AGE of II components, date installed (if known) and source of information: r��1J4
F�-16
Sewage odors detected when arriving at the site: (yes or no) df
(r•vlssd 04/25/97) 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addre5s:21 7 Ansel Howland Road Centerville Ma
owner:Estate Of Herbert & Josephine Welles
Date of lnspection: 1 0/8/9 7
BUILDING SEWER:
;locate on site plan)
Depth below grade.
3
Material of const uction Zast it 40 PVC _ other (explain)
[.
D,stance from private w ter supply well or suction line 141W_
Diameter i
Comments: (condition of joints, venting, evidence of leakage, etc.
SEPTIC TANK:ZG_'W�P_IU JC�
I locale On site plan)
Depth below grade:��
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age,1�4 Is age confirmed by Certificate of ComplianceoVA(Yes/No)
D,mensions 4Q�0/( 7 egI1642 6
Sludge depth._S ale
Distance from tQg�yldf sludge to bonom of outlet tee or baffle� _
Scum thickness /�7"'<1
Distance from top of scum to top of outlet tee or baffle: '�A 'rl
D,stance from bonom of scum to bonom of outlet tee o baHleZ;�/141'c
now dimensions were determined:i'%uYJ��'
Comments
(recommendation for pumping, condo n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struclura:
,ntegriry, evidence f leakage, etc,J rfZ�i /.�2T�-l!/T
/Q
a �
GREASE TRAP: ?J�
(locate on site plan)
Depth below grader
Material of construct,on;/Aconcretei�/Ametal V#iberglass V)O-Polyethylene.!/L4other(explain)
D'menslons: �iST
Scum thickness.:
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bonom of outlet tee or baffle:ltl4
Date of last pumping.
Comments
trecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, wuclura
.ntegriry. evidence of leakage, etc.)
(r.v1..d P.y. 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:21 7 Ansel Howland Road Centerville Ma
Owner: Estae Of Herbert & Jospehine Welles
Date of Inspection: 1 0/8/9 7
TIGHT OR HOLDING TANK;V;2&L7ank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade: XJ4
Material of con strua Ion V,#concretey/knetal&Wiberglass4)&PoI yet hylene4'&ther(explain)
Dimensions: X"A
Capacity: 4J 4 gallons
Design flow: -,V gallons/day
Alarm level:__ Alarm in working order44 YesX/4 No
Date of previous pumping: U/g-
Comments.
(condition of inlet tee, condition of alarm and float sw,tches, etc )
,4 �i
DISTRIBUTION BOX:�t`i'f�'
(locate on site plan)
Depth o liquid level above outlet inven: _
Comments:
(not if le I and d stribution is equal, vidence of solids carryover, evidence of leakag into or out of box, etc.)
PUMP CHANIBER:&) {/�.
(locate on site plan)
Pumps in working order: (Yes or No) cl4i
Alarms in working order (Yes or No) --fW
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(r•vi••G 0�/25/97) Pig• 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:21 7 Ansel Howland Road Centerville Ma
Owner: Estate Of herbert & Josephine Welles
Date of Inspection: 1 0/8/9 7
SOIL ABSORPTION SYSTEM (SAS):`1M'Q'4,�44,
AX
;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. I
leaching pits, number:_
leaching chambers, number:
leaching galleries, number: C
leaching trenches, number,length:--459
leaching fields, number, dime ions•. [/
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
T
CESSPOOLS: J,��VP_
(locate on site plan)
Number and configuration: �/ y
Depth-top of liquid to inlet invert:_If,),4
Depth of solids layer: /JJ�
Depth of scum layer: IVA
Dimensions of cesspool: ,UJ41
Materials of construction: 44
Indication of groundwater: /h
inflow (cesspil must be pumped as pan of inspection
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:�J(i
(locate on site plan)
Materials of construction: A"P Dimensions: IeW
Depth of solids:_
Comments:
Incite condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(rw1osd 04/25/97) P•g• 8 of 10
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ...
SYSTEM INFORMATION (continued)
Property Address: 217 Ansel Hoiwland Road Centerville Ma
Owner: Estate Of Herbert & Jospehine Welles
Date of Inspection: 1 O/8/9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locale all wells within 100' (Locate where public water supply comes into house)
66
r \
0
(rwl.•d Y.g• 9 of 10
SUBSURFACE SEWAGE DISPi: L SYSTEM INSPECTION FORM
I . C
SYSTEM INFO): . .!]ON (continued)
Property Address: 217 Ansel Howland Road Centervilel Ma
Owner: Estate Of Herbert & Jospehine Welles
Date of Inspection: 1 0/8/9 7
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater 0&ration:
Obtained from Design Plans on record
(/ Observation of Site (Abutting property, observation hole, basemtnt'sump etc.)
�etermine it from local conditions
_zCheck with local Board of health
/Check FEMA Maps
—Iecheck pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Ground xer-Elevation. Must be completed)
Used Cape Cod Commission MaP ~
September 1995
Water Contours
and
Public water supply
Wellhead Protection Ares .
(r.v1..d 04/25/97) PAS, - of 10
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Barnstable TOWN OF WARD OF HEALTH �
SIJIJSURFACF SFWAGF D1SJ'USAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
-TYPE OR PRINT CI.EARLY-
P/IOPERT Y INSPECTED
STREET ADDRESS 217 Ansel Howlad Road Centerville,Mass .
ASSESSORS MAP , DLOCK AND PARCEL #
OWNER' S NAME Estate Of -Herbert & Josephine Welles
PART D - CERTIFICATION J
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAME Joseph P . Macomber & ''ion, Inc .
COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066
Street Town or City 5t t9 CIP
COMPANY TELEPHONE (508 ) 775 -3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa-1 system at
this address and that the inrorination reported is true , accurate , and
complete as of the time ofeinspection . 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 :
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 fail(Ire
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 to
Protect the E)ublic health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEAL11I ,
• If the inspection FAILED , the owner or operator shall upgrade the eyoten
wic.hin one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CFIR 16 , 305 ,
partd . doc
w
y b
_ S
THE COMMONWEALTH OF MASSA.CHUSETTS
DEPARTMENT OF ENVI[RONMEE TAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTEFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15_340 and Section 13 of Chapter 21A of the
General Laws _ Issued by Tlie Department of Environmental Protection.
June 8, 1995
Acting Director of the 1 1011 W✓ Icl Pollution Control
TOWN OF BARNSSTABLE
LOCATION ��� �� W Vlp SEWAGE #
VILLAGE ASSESSOR'S MAP&LOT ��-4[
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ee ,,rr��
:I
LEACHING FACILITY: (type)X—Yd?2 / J (size)
NO.OF BEDROOMS �-
BUILDER OR OWNER n l2lrr 4) Oe,/-) ;
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 Faci ' (If any wetlands a 'st
within 300 feet leaching?faci ' ); Feet
Furnished by
r� -
�3 - c
�P
-j".
No.._1ee�
a:!.k Fxa......
APPfiOVED Barnstable Conservation DepartmentT
HE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOW
Sned Date N OF BARNSTABLE
ApV ira ivu for Di-ripi13tt1 Work,6 Tonotrurttnn 11rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
217 Ansel Howland Road Centerville
..............................•--............----•-------....------------------.._......-- ------•----•------------------•-•--------------•--------------------.........-----••-
Location-Address or Lot No.
Here r t_.We 11..s-------•-•••--•--•---•...-•------•-----•----•---------•---
Owner Address
W J.P .Macomber Jr.
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling-X No. of Bedrooms...........3---------------------_---------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons-_--_--_________----.-_---.- Showers ( ) — Cafeteria ( )
a' 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........................................
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-................... Depth to ground water........................
L% Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
-------------------------------------------•-•---•--------••--•-•-----------•--------------•....---.........................................................
0 Description of Soil.........................................Sand & Gravel
--------------------------•--•-------....--•--•-••-••------------•••-••-••••------••••--••------------
x
U ----••••-•--••••-•--•---•••...-••-----•-••-••-••••-•••-•-•-•-•----•------•----•--•-•----------------••-•--•-----••--•••••--•-------•-----•......----•-•---•••-----•---•--•-••••---...---•-•-------•--••.
UNature of Repairs or Alterations—Answer when applicable._-.-Add..-_one.._1-_1.OQO__.�_i;_J
p_z. .... yi_ t .11 ...sept c___s-- t c..system ----Existing.-__--1-1-000.._tanlz 1-1000 pit .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
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 hayb- n i sued by�te b and of health.
Signed ... v
- 1..2..1..1.3l93....:_....
Date g�
Application Approved By ------------ - -- ----- ... ��-."-/_5� F=7
Mte
Application Disapproved for the following reasons- -----------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- --------------------------------------
Permit No. ------- /...:...
l--� - !,lj. ... � .. Issued . ...................... . - --to --
Date
Ficic
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ! _� D
TOWN OF BARNSTABLE
Appliratiun for Biupuuttl Works Cnunutrnrtiun PPrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
217 Ansel Howland Road Centerville
--•-••.-•-•- •--------------------•-.............. . . _ ... . -- --------------------------------------------------------•-•...._
Location-Address or Lot No.
Herbert Welles
......................--.......................................................................... -------------------------------•------•--•------.................................................
W J.P.Macomber Jr. Address
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling-X No. of Bedrooms...........3_______________________________Expansion Attic ( ) Garbage Grinder ( )
a`L4 Other—Type of Building No. of ersons---------------------------- Showers
YP g -------------•-----..._..--- P ( ) — Cafeteria ( )
Otherfixtures ------------------------------ --------------------------------------------
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. I................minutes per inch Depth of Test Pit-.---..----_____-.__ Depth to ground water-.--_--_-._---__---__._.
frt Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:4 --------------------------------------------------------------------------------------------•-------.........................................................
0 Description of Soil.........................................Sand & Gravel
x -----------------------------------------------------------------------------------------------------------•------------_..
w
-----------------------------------------
U Nature of Repairs or Alterations Answer when applicable..----kid.d....One.__1.-1.900_.gallon---leaching,---.
_-u t...to.-an---ex sti-nq-..septic_-.septic_system.. .Existing 1-1000 tank i-1000 pit .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
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 bp en i sued by tt'e and of health.
Signed ....... .��.. .. .12/13 f-9 3---------
Date
Application Approved BY ...... ...... - -T_j
Date
Application Disapproved for the following reasons; Date
-- 9 Date
Permit No. -------I a L--- -�--- -----! ? ---------- Issued
Date
t
THE COMMONWEALTH OF MASSACHUSETTS"
BOARD OF HEALTH
r
TOWN OF BARNSTABLE
v Ertifi ate of 11 ampliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX)
by J.P.Macomber Jr.
----....._..---------------------------------------------------------------------
""'Iler
at - ............................................ow....17 Ansel Hland Road Centerville.
---------------------------------------- -----7----.----------------- --------...-- ---------- ----------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -----7.�3-------6f.-6-5------ dated ..................._ --------------------..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SAaTISFACTORY.
DATE....................
a. 7._'_ ---- ---------------------------------- Inspector ------------------ �--- -------------- ..------------------ -------
--------------------------------------------- ----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 30.00
No... ..........•----•- FEE....•-....-.............
�iu�usttl Turku �unutrttrtiaan �Prmit
Permission is hereby granted--------_-J.P.Macomber Jr.
- - -----------------------------------------------------------------------------------------------------••••----
to Construct ( 4 or Repair (XX) an Individual Sewage Disposal System
1 Ansel owlan6 Road Centerville
atNo. ..... -----------• --.....-----•--- --- ....... --------------..
Street /
as shown on the application for Disposal Works Construction Permit No._ ,j-hf8_ Dated...........................................
------------
••-.............
•�-----------.------------------------------------ ---------
.......................•._.... Board of Health
DATE.-------.._.�.�2Z-.------�--��----^-----�
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE
(..,.,-LOCATION tk/7 4,lsel- 1,dcG k'Id SEWAGE # 96
VILLAGE G e ASSESSOR'S MAP & LOT .
INSTALLER'S NAME & PHONE NO. J. 1 0 .e4,6
SEPTIC TANK CAPACITY b tp
LEACHING FACILITY:(type) )017— (size)_.o 0o
NO. OF BEDROOMS r PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE . COMPLIANCE ISSUED: ;. O " �
VARIANCE GRANTED: Yes No ��'�
y �
�� w
a
s►' No... 3�17Z` Fs$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
G--«.......... ......OF..... -.-.: .....
Appliration for Uhipvoal Works Ton,strnrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Location-Address orl o
........................... .......................... ........................................................
Owner Address
a ......... aA140 _-_-_••.................................... ------------------
-- .. . ... .................................................
Installer Address �..
U Type of Building Size Lot... ....Sq. feet
Dwelling—No. of Bedrooms................ .......................Expansion Attic (4.6 Garbage Grinder ( oVv
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Q' Othe fixtur
Design Flow___________ _ _.2.......................gallons per person per day. Total daily flow............................................gal
W Ions.
WSeptic Tank—Liquid capacity/V allons Length________________ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.__4*'a:'v_-. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•------------------------------------------------------•------------•--...........---._......_-----•.....=..................................................
0 Description of Soil........................................................................................................................................................................
W
U ----•••••-•-•-•---•-••------••••----••-------•--•-----------••----------••---------•------------••-•----•---•------•-----••---•-•-•-•-•--•--••----------.•..._-----•••••••-------------------•----•--•-
W .
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'TIT 5 of the State Sanitary Code—The undp7igned further agrees not t lace the system in
operation until a Certificate of Compliance has
Si d- b..e lth.e y P Z
-- -----------------------•------...............------
t
------
Application Approved BY--- ---- --------- ----•-------------.......----------------•--•-----------•------------------ d 31 ?
-•---- ----•-----------------
Date
Application Disapproved f or he following reasons----------------•------••-------•----------------------------•-------------------•••--••••-•-••-••.
••-------•-------------------•----------..._..--•---------------------•--.....-------------------------------•-•---------••-•-•-•--•----------•--•----•--••••---•----•--••-----••••.
PermitNo......................................................... Issued.................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application' is hereby -_-- for - Permit to Construct- ` ' or Repair- ` ' an Individual Sewage Disposal
................-................................................................................ --------'-----'--'------'---------------'-'------
� �=a�'Ae�� mL� m"
......................---....................------------------------' --------------------'--------------------'--'-'----
o°�� �a�"�
------------------------------------------------- -------------------------------------------------
Instal/er Address
Type cfBuilding Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Sbmvc,x ( ) -- Cafeteria ( )
^� Other fixtures ------------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Ix SepticIauk—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. b.
Seepage Pit No-'------. Diaozcter`--.----.- Dco/b below inlet.................... Total area..................sq. ft.
Z {}t6cr Distribution box ( ) Dosing tank ( )
~~ Percolation Test Results Performed br.......................................................................... Date........................................
Test Pit No. L---..-'odouteoyerincb Depth of Test Pit.................... Depth to ground water.........................
�Z4 Test Pb No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 .------------'''_-------'__---_-----'---_----------'----_----------__---
0 Description c6 Soil------..-------------------------------------------------_-'---.--------.------'-----
.......................................................................................................................................................................................................
.----------_----'_---_-----_'.--._--__------------_-_--__'-_'--''.'----_-'____._
U Nature of Repairs or Alterations--Answer when .--.---_-.-_--_-----'-_---.--''____-
---'-'----''—'--------------------------------'----------'---'---'----------------
' g -----' |
The undersigned agrees to install the aforedescribe6 Individual Sewage Disposal System in accordance with |
the provisions of TZTILE 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
---------' -' ------
� J��J�uboo Approved /y / ---------'----------------------'-'- -����~�� -----'- �
Application Disapprove grxoxonx:---_-----.--.--_-------.-------_-------------'--------
-------------'-------'--------'-------------'-------------------------------------------------
Date
PcrozitNo --------_'__. .......................................................
THE COMMONWEALTH or MASsAcHussrrs
BOARD OF HEALTH
..._......._� ....... OF.............._....._...................__..
of Tompliatta
IS TO CERTIFY, 1v cted (4-j-'®rRepaired
nstall
------------
nas been `osmucu in accordance with the pr"r`uioox of TI�6�� 5vf �
application for Disposal Works Construction Pomob DJo-' ...��r!/ ............ doted' .-��.--.-----
THE ISS�ANCE OF THIS CERTIFICATE SHALL NOT BE CO00���� GUARANTEE THAT THE
SYSTE�� K���� ��0'U�������«���y.
C��TIL-',�-L'�'����-----------_---------------' Inspector -'�----------.-----------------..
' �
THE COMMONWEALTH OrmAssAo*ussrrs
/ BOARD ��� HEX
|
-17:7
|
- ....................................OF.....................................................................................
~ ^
Permission is
& 0 CAT IO SEWAGE PERMIT NO.
` Lot 3 Ansel Howland.
VILLAGE
- _ Centerville,-Mass. - _ f
INSTALLER'S. NAME & ADDRESS
Robert B. Our Co. Tic=
Great Western Rd. North Harwich, Mass. 02645
B U I L D E R OR OWN ER
Alan Small
DATE PERMIT ISSUED 4/l/83
DATE COMPLIANCE ISSUED y/ ��
r
5� as
y a
St►.IGLG- FAMILY - :5 BEDROOM
uo
Q'WDEIZ+GAROAGE G / .
o�atb FLOW z I10A 3 =
i'SEPTIG TA►JK = 33ox15�'/• =�956.P. _ 1 _ ' _ _ _ _ --��
t.Js�• l000 GAL. - �- - - �°T ¢
0
ot5Po5A1- Pt•t- v6E IVo0 GL. k°
A 8�
j 1 pG WALL A2GA a 1 jo 15A
t5o 5.F X 2.5 e 3?r G.PD 2�-
50TTOM AR-EA:.. 20 iF•- I fwr �. I
S o S.t= x 1• o A �O G.
P,O '
'TaTA t v
_ RSI6N s .¢25 G0 D � 6,Aa AO�O
o•t�o„ R .11
-TOTAL DA 1 L.Y FUDW = 330 G.Po TaM>L T ss r
PER.COLATIo►J RATE] I''IN 2MIN DI-Lr=55 j io• FND �o I
r3 ca �I
4�',
P�SN m*;�-�!!o r. �.1N OF
RICHARD Cz) ALAN
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SANDY LEACtA PIT INV. INY.
GAVEL S7.Z rZ4
WITIA
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