HomeMy WebLinkAbout0065 CAP'N JAC'S ROAD - Health 65 Cap'n Jac's Road
Centerville P
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COMPLETE •N COMPLETE THIS SECTIONDELIVERY
■ Comp')te itemse_1,2,and 3.Also complete A. Sig re
item 4 if Restricted Delivery is desired. Agent
■ Print your name and address on the reverse Addressee
so that we can return the card to you. g iv ed rr am) C. Date of Duel%
■ Attach this card to the back of the mailpiece,X, 1
or on the front if space permits.
1. Article Addressed to: *;f Is el' ery address different from item 19 ❑Yes
If YE ,enter delivery address below: ❑No
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bZa ZtQ 3. Service Type I
❑Certified Mail ❑Express Mail
❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number 7007 0 710 0 0 0 5;,5 818 ,8 5 7 3;(transfer from se►vice label) �a _ —r: _ i i f
PS Form 3811,February 2004' ` Domestic Return Receipt 10259502-M-1540
UNITED STATE '
y up A.0.,�
Dili I
• Sender. Please print your name, address, and Zl' +4 in this box • I
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"O Town lBarnstable
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ealtli�ivision
1V— 200IUn Street
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Hyannis,MA 02601
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Town of Barnstable
VETp Regulatory Services Department
M1 BARN STABLE, Public Health Division
MASS. ,e� 200 Main Street, Hyannis MA 02601
TfD MAC
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
October 30, 2007
Michael & Mary Gordon
60 Birch Street CC
Dedham, MA 02026
As of October 1, 2006 a new rental registration ordinance was put into affect
requiring all property owners of rental units to register their rental units with the Town of
Barnstable Health Division. According to our records, you own the rental property at 65
Cap'n Jac's Road.
Enclosed is an application and a copy of the ordinance. Please use a separate
application for each rental unit you own. Should you need more applications, they are
available online at www.town.barnstable.ma.us. Go to the Health Division page by
looking in the Department Menu. There is a link to the Rental Registration information
on the Health Division page. You may print out as many as you need, and return them to
the Health Division with the appropriate 2008 fees included.
Failure to comply with this ordinance will result in the issuance of a non-criminal
ticket citation in the amount of$100. Each day of non-compliance is considered a
separate offense.
Should you have any questions,please feel free to call 508-862-4644. Thank you
in advance for your cooperation.
Sincerely,
-Caitie Barrett
Health Division Assistant
-Thomas McKean
Health Director
CERTIFIED MAIL# 7007 0710 0005 5818 8573
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENT
REC�1VE®
MAY 1 9 2004
TOWN Ur HAW STABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 65 Captain Jac's Road MAP 1 T
Centerville, MA 02632
Owner's Name: Gerry DiPalma PARCEL
Owner's Address: LOT
Date of Inspection: May 8, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osteryft MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Condi Tonally Passes
Need her Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: May 12, 2004
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not.address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 65 Captain Jac's Road
Centerville, MA
Owner: Gerry DiPalma
Date of Inspection: May 8. 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 65 Captain Jac's Road
Centerville, MA
Owner: Gerry DiPalma
Date of Inspection: May 8. 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,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 fad unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that 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,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 65 Captain Jac's Road
Centerville, MA
Owner: Gerry DiPalma
Date of Inspection: May 8, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped—
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well,
✓ Any portion 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 with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that 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,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
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 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
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Page 5 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 65 Captain Jac's Road
Centerville, MA
Owner: Gerry DiPalma
Date of Inspection: May 8. 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any"of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
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Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 65 Captain Jac's Road
Centerville, MA
Owner: Gerry DiPalma
Date of Inspection: May 8, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never pumped(newsystem)_per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
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)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 318100-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
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Page 7 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 65 Captain Jac's Road
Centerville, MA
Owner: Gerry DiPalma
Date of Inspection: May 8, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 16"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
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:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 65 Captain Jac's Road
Centerville, MA
Owner: Gerry DiPalma
Date of Inspection: May 8, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was clean. No solids were present. The cover was 20"below grade.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
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Page 9 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 65 Captain Jac's Road
Centerville, MA
Owner: Gerry DiPalma
Date of Inspection: May 8, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 gal.)
leaching chambers,number:
✓ leaching galleries,number: 2-500 gal. drywells 25'x 13'-per as built card
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
There did not appear to be any signs of failure in the galleys The old pit had 6"of water on the bottom and the bottom to grade
was 9'.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(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(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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,etc.):
9
• Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 65 Captain Jac's Road
Centerville, MA
Owner: Gerry DiPalma
Date of Inspection: May 8, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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10
Page 11 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4 Kenneth Street
East Sandwich, MA
Owner: Estate o Steve Quigley
Date of Inspection: May 6, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 50+ feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using a Barnstable topographic map and water contours map, the maps were showing approximately 50'+ to ground water at
this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
No. Y Fee ;� a 00-
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for �Die;poq;af 6pgtem Cougtruction Permit
Application for a Permit to Construct(6_--rI'tepair( )Upgrade( )Abandon( • ) El Complete System ❑Individual Components
Location Address or Lot-N.. (; �+� J�4's' .149"1 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address and Tel No. Z!7'7— Designer's Name,Address and el.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer w en applicable)
[li 71 'V"S;na,,7L.: 12i:
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until ayCertifi-
cate of Compliance has been issued by this Board of Health.
Signed _ i Date
Application Approved by F Date 3 A2 Z'`0
Application Disapproved for the following reasons
Permit No. 70-yo aI 2s Date Issued
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No. Fee,4-y,
j THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
T - Yes
PUBLIC HEALTH DIVISION - TOWN"OF BARNSTABLE, MASSACHUSETTS
Application for Migpogar *p$tem Congtruction Permit
Application for a Permit to Construct(1_ ' epair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. J,44'S Owner's Name,Address and Tel.No.
/2vss1 u/ �
Assessor's Map/Parcel Ce_arez-!-✓1111,.
9 d�D and
Installer's Name,Address,and Tel.No. N 7-7'a-'5gy Designer's Name,Address and el.No.
✓dSGpl'! Qi �jwy„"O.S ✓OSC ' � �•G- ia/^r'<1,$
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title :
Size of Septic Tank Type of S.A.S.
Description of Soil Sibh
Nature of/Repairs or Alterations(Answer w en applicable)
Date last inspected:
r
i
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions oPTitle 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate'of Compliance has been issued by this Board of Health.
Signed Date
i Application Approved by Date ,3 ? zc'm
Application Disapproved for the following reasons
Permit No. Z"O ' Zr Date Issued 3 3 Z67-O
THE COMMONWEALTH OF MASSACHUSETTS
`I y o7v-w6" BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(-c--)-Repaired( )Upgraded( )
Abandoned( )by jcls
at J,a-j S 121 has been construct d in accordance
with the provisions of Title 5 d e for Disposal System Construction Permit Noff>" ZS� dated
Installer Designer .v o
The iss nce o this pe t not b onstrued as a guarantee that the 1 unction si °
Date Inspector v�
i
---------------------------------------
D 11 d
No. �d- Z 9�/ Fee
THE COMMONWEALTH OF MASSACHUSETTS
ley�76-t.)o0 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
M 5pogal *pgtem Congtruction Permit
Permission is hereby granted to Cons ct(Z--j Repair( )Upgrade( )Abandon( )
System located at S f ww i ,j,�c's /97
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
a�
Date: 3/3/ Z� Approved by a
1/6/99
NOTICE: 'This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTMCAT ION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUMON PERMIT (WITHOUT DESIGNED PLANS)
I, ,/os�6;a�o5' , hereby certify that the application for disposal works
construction permit signed by me dated 3 ^2 -- l o , concerning the
property located at or r,Ioc 'S A/ (2i;,orzfe 1/ll= meets all of the
following criteria:
The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
,ef,�ere are no wetlands within 100 feet of the proposed septic system
4---T—here are no private wells within 150 feet of the proposed septic system
&�ere is no increase.in flow and/or change in use proposed
er, ere are no variances requested or needed
ottom of'the proposed leaching facility will 42Lbe located less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable]
•- If the S.A.S. Mll be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching faciE:ry will Iz be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
r 4
E) G•W. Elevation ^3_f+the MAX. ugh G.W. Adjustment. _
D�ERI.N E BETWEEN A and 13 �—
It
SIGNED :
[Sketch Propose*'Plan of DATE:
q: u jo,� arc system on back].
d
s
'��
�vi�w °L S'
e a
O
TOWN OF BARNSTABLE (�
LOCATION C ;/f�T �l9G�.5' / SEWAGE # 00— 12j"
VILLAG ASSESSOR'S MAP & LOT l9 0?0
INSTALLER'S NAME&PHONE NO. c/as
SEPTIC TANK CAPACITY 400
LEACHING FACILITY: (type) WS115 (size) )S.X/3
NO.OF BEDROOMS 3
BUILDER;OR OWNER
PERMIT DATE: 3— --4 O COMPLIANCE DATE: — 00,
Separation"Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist ,
on site or within 200 feet of leaching facility) Feet
Edge otWetland and Leaching Facility(If any wetlands exist
within'3mo f et of leaching facility) Feet
Furnished by
r ,
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_ c^
h' CIO
J �19f9r �/!9G'S' Rc�
TOW'N OF BARNSFf
LE
-- C�J CA .�ALS SEWAGE #.
LOCATION
VILLAGENA
ME �1�. ASSESSOR'S MAP& LOT�I y— 01 O
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY UW '
�. LEACHING FACILITY: (type) PT La-Sod g•►!. (Sii)
NO.OF BEDROOMS 3
T
BUILDER OR OWNER J�rr`�t L�oD.41Ma
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachi�g facility / Feet
Furnished by Tit soGc�
n�
C3
' 3a�
3 1
J
3 3$ 3�
Russi Wadia
65 Capt Jac ' s Road
Centerville ,Mass .
02632
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DATE: 1/3/00
PROPERTY ADDRESS: 65._Capt Jac _s Road
---Centerville
02632
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon septic tank. l a 70 U) 60
2 . 1-Distribution box.
3. 1-1000 gallon precast laeching pit .
Based on my Inspection, 1 certify the.following conditions:
4 . This is a title five septic system. ( 78 Code )
5. The leaching pit is in hydraulic failure . 1
6. A new leaching area should be installed .
7. Pumped system as part of inspection .
SIGNATURE:_f
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a
Company: Jose.Rh_P_ Macomber & Son, Inc. �
Ir V f0
Address:_ BLx_66_____________ JAN 4
Centerville Ma . 02632-0066
TO�OF 1DOO
------------L------- Wo 4
Phone:___508 775_3338_------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
46
JOSEPH P. MACOMBER & SON, INC.
Tan ks•Cesspools•Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE.WINTER STREET, BOSTON MA 02108 (617) 292-6600
TRUDY Cc
Secre
ARGEO PAUL CELLUCCI DAVM B. STRI
Governor Commiuic
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART A
CERTIFICATION
Property Address: 65 C a p t Jac ' s Road Name of Own«R u s s i Wadi a
Centerville,� 0 Address of Owner
Darts of Inspection. Joseph P.Macomber J r .
Nan»of lrup.ctor:(Pleas.PrirrU P
I wn a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CHAR 15.000)
company Name: J. P.Macomber & Son T n r _
µaangAddress: Rnx 66 rent®rv4lJe-,Naa8-02632
Telephone Number: ;nth'7 9998
CERTIFICATION STATEMENT
I certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below Is true, accurate
and complete es of the time of Inspection. The Inspection was performed based on my training and experience In the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
4u4ectoes Signature: /, Date:
The System Inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days c
completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system own
shall submit the report to the appropriate regional office of the Department ohf nvlronmental Protection. The original shouldbe.sent ioV a
system owner and copies sent to the buyer, if applicable, and the approving authority. .
NOTES AND COMMENTS
revised 9/2/98 Page IofII
C�Printed on Ucycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION(FORM
PART A
CERTIFICATION(contirwed)
ProPertyAddr.: 65 Capt Jac ' s Road Centerville ,Mass .
owner: Russi Wadia
Date of k►sPecd—: 1/3/0 0
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
1 I have not found any information which indicates that any of the failure conditions described in 310 CMR 1.6.303 exist. Any failure
criteria not evaluated are Indicated below.
COMMENTS-.Waste water was ahnvp i nprt pipes to the tan _ hnx and
the 3-oaching pit
B. SYSTEM CONDITIONALLY PASSES:
Nd One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate yes,no,or not determined(Y,N,or NO). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the Inspection;or
the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial Infiltration or exfiltration, or tank
failure is imminent. The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
NO - The system required pumping-mom than`fourtimes a yeardue to broken or obstructed pipe(s). The system wi(tpeas-
Inspection if(with approval of the Board of Health): - --
broken pdpe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2ofIt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 65 Capt Jac ' s Road Centerville ,Mass .
Ownw: Russi Wadia
Dace of Inape`6`1/3/0 0
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CUR 16.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH.lMLLPRQ=THE PUBLIC HEALTHAND SAFETY AND.THE BYMONMENT:
Cesspool or privy is within 50 feet of 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 ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
10 The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a tone 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.
it 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 col)form bacteria and volatile organic compounds Indicates that 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
J
revised 9/2/98 Page 3orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
P,op.TyAdfeu: 65 Capt Jac ' s Road Centerville ,Mass .
Owner: Russi Wadia
Date of Irtspection: 1/3/0 0
D. SYSTEM FAILS:
Y04 indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
AAZ determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of-eewage into feciH "er•tyetem component do*%to an overloaded orciegged-GAS-*r-eeespool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
_ Static liquid level in;he dlstrl¢ution box above outlet invert due to an overloaded or clogged SAS or cesspool.
.�, r
Liquid depth in eeeapeoFis less than 6 below Invert or available volume is less than 1/2 day flow.
jell, Required pumping more than 4 limes In the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
41 Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy Is-within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
L Any portion of a cesspool or privy is less-than 100 feet but greater than 60 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 analysis for
coliform bacteria,volatile organio•compounds, ammonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
You must Indicate either"Yes" or"No" 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 gpd or greater(Large System)and the system is a significant threat to publi(
health and safety and the environment because one or more of the following conditions exist:
Yes No
d the system is within 400 feet of a surface drinking water supply
the system•iswiWn 200 f"tof-a-tsilwtaW-to++urteoedrinklwg+µaio►wPf�Y
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further Information.
revised 9/2/98 Page 4of11
i
.i
. i .
j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prope<tyAddress: 65 Capt Jac ' s Road.-Centerville ,Mass .
Owner: Russi Wadia
Date of Inspection:1/3/0 0
Check if the following have been done:You must Indicate either"Yes" or"No" as to each of the following:
Yes No ,
]I/ Pumping information was provided by the owner,occupant,or Board of Health.
_ None of the system•components.hawbaan pumped►Ewst-Jaast twoawe"s awd4he-irystem hasbaeaascetaiwg"maw sow
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.
4 _ The facility or dwelling was inspected for signs of sewage back-up.
4Z The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system componenta,A41uding 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:
Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable)
(15.302(3)(b)1
_ The facility owaar.(and.n^. anj,_jf diiferaW frnn' mmarj war&4)rzu d&d WW)WorALoaDn thApr par rn 10ja QC ^f
SubSurface Disposal Systems.
{ "
l
i
I
revised 9/2/98 Page sof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropwtyAdd,s,ss- 65 Capt Jac ' s Road ,Centerville ,Mass .
Owner: Russi Wadia
Date of ln�:1/3/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: JA g.p.d./bedro
Number of bedrooms(desig Number of bedrooms(actual)l
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no): 4
Laundry(separate system) (yes or®:_, If yes,separata3nspection,required
Laundry system inspected IeVor no)
Seasonal use(yes or no): /
Water meter readings,if available(last two year's usage(gpd): AAAa11.ljfirJS
Sump Pump(yes or no): c Q�
Last date of occupancy:-ito� ;.,g" }yam)'XVOZ2/
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: .Z'//2'9� aad ( Based on 15.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no),
Non-sanitary waste discharged to the Title 6 system(yes or no)9
Water meter readings,if available:
Last date of occupancy:_
OTHER:(Describe)
Last date of occupancy: 1"
,1
GENERAL INFORMATION
PUMPING REC RDS and sour e o i formation:
AI&Ar Ad s .�_ '
System pumped as part of ins action: (yes or no)
If yes, volume pumped- gallons
Reason for pumping: /10
TYPE OF �YSTEM
_Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
_F Privy
Shared system(yes or no) (if yes,attach previous inspection records,If any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
__Y,Z Tight Tank �� Copy of DEP Approval
Other p
APPROXIMATE AGE of all components,date Installed4if known)-and source.of4eformation:
Sewage odors detected when arriving at the site:(yes or no)
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress:65 Capt Jac ' s Road Centerville ,Mass .
owner: Russi Wadia
Date of Inspection: 1/3/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade:��
Material of construction:wAcast iron 20 PVC�ther(explain)
Distance from,private water supply well or suction line e
Diameter
Comments:(condition of joints,venting,evidence of leakage,-etc.)
Joints appear tight No Pyidp.nr.p of 1Pa)ra9P
SE11TICTANK. M fM
(locate on site plan)
Depth below grade:
Material of construction: concretAliametal,eQFlberglaS3,VAPolyethylene,lAother(explaln)
If tank Is Instal,list age 13.age.confumed bfy Certificate of Compliance (Yes/No)
Dimensions: �1AAA1
Sludge depth:
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:
Distance from bottom of scum to bottgm of outi t tee or baffle:_
How dimensions were determined: JUM
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,etc.) Pump tank P v P r y-2—3 y e a r s T n 1 Pt 9 o 11 t 1 Pt- t P P c
GREASE TRAP: e,
(locate on site plan)
Depth below grade:
Material of constructionlil�4concrete metal/1AFiberglas&4//&Polyethylenq,4other(explain)
Dimensions: AN
Scum thickness: NV
Distance from top of scum to top of outlet tee or baffie:_X
Distance from bottom of scum to bottom of outlet tee or baffie:_9
Date of last pumping: l/J
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, etc.)
rease trap is not present -
revised 9/2/98 Page 7of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contirwed)
Property Address: 65 Capt Jac ' s Road . Centerville ,Mass .
Owner: Russi Wadia
Date of Inspection: 1/3/0 0
TIGHT OR HOLDING TANK;&J&(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:JV4
Material of construction WAconcrete4�A) metaW41Fiberglass_Polyethylene_other(explain)
Dimensions: A40
Capacity:_ eW19 gallons
Design flow: gallonanon
s/day
Alarm present
Alarm level: Alarm In working order:Yes,!!�4 No.ViJ?
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
Tight or holding tanks are not present .
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Alw
Comments:
(note-if level and distribution is equal, evidence of solids carryover, evidence of leakage Into or out of box, etc.) — -Distribution box has one lateral . There is evidence of solids
rnrry near No ad rience of lankaae into or, Out of the box.
PUMP CHAMBERA,�tve—
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No),�
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
ump chamber is not present .
revised 9/2/98 Page 8of11
r
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 Capt Jac ' s Road Centerville ,Mass .
Owner: Russi Wadia
Date of 4upection: 1/3/0 0
SOIL ABSORPTION SYSTEM(SAS)-._z
(locate on site plan, if possible;excavation not required,location may be approximated by non intrusive methods)
If not located, explain:
Type:
leaching pits,number:
leaching chambers,number:
leeching galleries,number:
leaching trenches,number,length:
leaching fields,number, dime Ions.
overflow cesspool,number:
Alternative system:
Name of Technology: 7`
Comments:
!note condition of soil, signs of hydraulic failure,level of ponding, damp soli,condition of vegetation, etc.)
Loamy sand to medium coarse t
ailur A nPw 1 Parhin_area ghet}ld be fk9t-eslle
CESSPOOLS•
(locate on site plan)
Number and configuration:
Depth-top of liquid to Inlet Invert:
Depth of soiids layer:
Depth of scum layer:
Dimensiohs of cesspool:
Materials of construction:
Indication of groundwater:
Inflow(cesspool must be pumped as part of Inspection)
esspoo s are not present
Comments:
(note condition of soil, signs of hydraulic failure..level of pending,condition of.vegetation,etc.)
essDools are not =rPePnt
PRIVY: �o11�e
(locate on site plan)
Mater*s of construction: Dimensions:
Depth of solids:�l�
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
Privy
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddresa: 65 Capt Jac ' s Road Centerville ,Mass .
Owrw: Russi Wadia
Data of Imspectk m: 1/3/0 0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes Into house)
3(r���% ice
o ,
I
revised 9/2/98 Page 10 of11
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` SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPEC110N FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 Capt Jac ' s Road Centerville ,Mass . 02632
owner: Russi Wadia
Date of Inspection: 1/3/0 0
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
—:
0Det.rmIn.d
ite(Abuperty, bservation hole,basement sump etc.)from local conditions
Checked with local Board of health
Checked FEMA Maps
�hecked pumping records
_,6.,�/Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map .
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page 11of11
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TOWN OF Barnstable WARD OF HEALTH
9lJf)SUIiFACF 9EWAGF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION I
•T!1-T'•.••:1—�.IIT.�.�T1'M11ST:'RI'II.'fTITT1r.RT1fTTT1T•frV}T.'711TIrT�RR�►ItI-A�lt�Tr7 � Yn!`I'T'TT•1)—r.A
-TYPO OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 65 Capt Jacs Road Centerville ,Mass . 02632
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Russi Wadi&
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P.Macomber� & SoiTll Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 ,
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578
R
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
omplete 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: '
Systeoi PASSED j
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
.zSystem FAILED*
The inspection which I have con cted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature - � l Date
ne copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEAL1'rl.
* If the inspection FAILED, the owner or operator shall upgrade ' the ayatem.
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 , 305 .
partd.doc