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HomeMy WebLinkAbout0112 CAP'N JAC'S ROAD - Health 112 CAP'N JAC'S ROAD, CENTERVILLE A= 194 076 i r ,R y/}��Ir��� J40.6CYCCFpCo UPC 12543 No. pkftrcoc�'a� HASTINGS,MN No. 1/ Fee 50. 00 9 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for MigOai *p5tem Cow5tructiou permit Application for a Permit to Construct( )Repair(X)o Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 1 1 2 C a p n Jac ' s Road Owner's Name,Address and Tel.No. T h e r e s a F i n n Centerville ,Mass . 02632 112 Capn Jac ' s Road Assessor's Map/Parcel Centerville ,Mass . 02632 Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8-7 7 5-3 3 3 8 J.P.Macomber & Son Inc . J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 Box 66 Centerville ,Mass . 02632 Type of Building: Dwelling X X XNo.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons 5 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3 x 110 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank E.x i G t-i n g 1000 Type of S.A.S. 2—S n n gal I a p ch4m be r s Description of Soil Loamy sand to tight sand to fine sand ; Nature of Repairs or Alterations(Answer when applicable) 2—5 0 0 gallon chambers p a c k e d in 4 ' of stone . 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 a Certifi- cate of Compliance has been iss ed by th' and f Healt Signe Date 12/16/9 8 Application Approved bn.— 0 . Date Application Disapproved for the following reast6 Permit No. Date Issued No. ee { THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ' . PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS Zippricatiou for Migoml *psAem Construction Permit Application for a Permit to Construct( )Repair(X X)Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. 112 Capn Jac ' s Road Owner's Name,Address and Tel.No. T h e r e s a F i n n Centerville ,Mass. 02632 112 Capn Jac ' s Road Assessor's Map/Parcel Centerville ,Mass. 02632 Installer's Name,Address,and Tel.No. — 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0,9—7 7 5—3 3 3 8 J.P.Macomber & Son Inc . J.P.Macomber & Son Inc . Box 66. Centerville,Mass. 02632 Box 66 Centerville ,Mass . 02632 Type of Building: Dwelling X X 4lo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons 5 Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily flow 3 x 1 10 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1000 Type of S.A.S. 2-500 g 11 nn rhamhPre Description of Soil Loamy sand to tight sand to -fine sand ; � f Nature of Repairs or Alterations(Answer when applicable) 2—5 0 0 gallon chambers packed id 4 ' of stone. Date last inspected: Agreement: The undersigned agrees to ensure-the construction and maintenance ofthe 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 a Certifi- cate of.Compliance has been iss ed by Zbaz f Healthv/It Signe ! Date 12/16/9 8 Application Approved by Zj Date Application Disapproved for the following reas r Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS w-- Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired 4 X )Upgraded( ) Abandoned( )by J.P.Macomber & Son INc . at 112 Capn Jac ' s Road Centerville ,Mass. hkbaen constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. D dated Installer J.P.Macomber & Son Inc. Designer J. P. acomber & Son Inc . The issuance of this)p iesf ap no construed as a guarantee that the system m�ll fdVction as designed. Date Inspector ` No. / 77F--------------- ----------Fee $ 50. 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS XMi5po5ar *p! tem Construction Permit i Permission is hereby granted to Construct( )Repair(X X)Upgrade( )Abandon( ) System located at 112 Capn Jac ' s Road Centerville ,Mass . 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 co pleteqld three years of the date of t sperm t. iDate: LQ Approved by !A ., 10/9/9) NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) 1, Joseph P. Macomber Jr,.hereby certify that the application for disposal works construction permit signed by me dated 12/16/98 , concerning the property located at 112 Capn Jac ' s Road Centerville MA meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. 0 If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will!14!be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: po A)Top of Ground Elevation (according to the Engineering Division G.I.S. map) B) Observed Groundwater Table Elevation (according to Health Division well map) GD LI F DATE: SI NE CE SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER I7 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). q:hcalth roldcr:ccn r tin 1000lon c system ibution box . 2-500 gallon chambe 'Packed in 4 ' of stone . TO -7 TOWN OF BARNSTABLE + OCATION 1!p Cp SAe-L SEWAGE# - t S C `VILLAGEs �t.2, ��j «E� ASSESSOR'S MAP & LOT 1 1`i INSTALLER'S NAME&PHONE NO. 004,&mAkA, SEPTIC TANK CAPACITY 4;Al. LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER �.rtA.e�- t1n�►-. .PERMI TDATE: �. - t lv - ct'Sf COMPLIANCE DATE: /X-- f "g� ;"Separation Distance Between the: Yh Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Fazility (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 ` . �a� 1iGtc FAM�►.Y - Bf.oczooM .t a GA¢gA&E G2�NDE2 17 '2Z °To i 1 oV = 3oGP � EX�97 p ;.SPT1GK33ox15c> A USic t000 C�►L• �15Pas A1- P 1T ' t 1 S F AL 2L-a 5 1 G N . z G.P.D. ti r -rcrr PEtZ.to�AT1oN RA?6 � � V �t��c \` PETER Mr-HARD /0 Top Ft�u= ►�L. o •Nai Tom-- �����F� ��-/Z� ,� 'j4" � tl-� t'.t`r• /Z 3 �L-Iz� ��• t,o� ��►. DUST. iNJ. 56p?IG sdt� '�► 13�x /Z2,40 •r kw K 3 lavo iW� t a M&D S � LC-A. INV. ( $ p rr /ZZ z �Zz..., 51.1 t73A �� v,1a�uco {,Tv N fa Sows �t�� —�t'�-- C�1zT1+�tcta Pt_wr Pt_p•tJ ,40AVa. PROtrIL� � LocA-c1cN CC-1.1T•�-Uij-{� Q= 3 p o -- ', N° / -ov►��a-��o�-1 SNoVlN 1 t GE�'t1t=Y 'cNAT THE LO�C ( A tA1c.R E0 G µ� DMP�-`�5 Y+ItTN-[H� S t D6tlt�1 p;tiJn sE-ra�G zQ A ANC YZ T p�AW �n2 �� QT-AL'L W[U-1w II) �� t_ocp•TEfl WtTNt1, TNT 1%000 PLD►tN �� _ �,. w ♦1 t c� widT a�s�p oa p N Town of Barnstable Department of Health, Safety, and Environmental Services • BAMSPABM ' MA SS. Public Health Division P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A McKean,RS,CHO FAX: 508-790-6304 Director of Public Health December 21, 1998 Mrs. Theresa Finn 112 Captain Jack's Rd. Centerville, MA 02632 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 112 Captain Jack's, Centerville was inspected on December 14, 1998, by Joseph P. Macomber, Jr. a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged leaching pit You are ordered to bring the septic system into compliance within two (2) years of the date of discovery. Therefore, the construction of replacement septic system component(s) must be completed on or before December 14, 2000. However, if any raw sewage overflows onto the ground, you are required to upgrade the system within fourteen (14) days of discovery. First, you must hire licensed Town of Barnstable septic system installer to submit a sketch diagram of proposed replacement septic system component(s)to the Town of Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code,Title 5. In the meantime, you shell ensure that no raw sewage discharged onto the surface of the ground or into any surface waters. You must maintain the system by hiring a licensed septage hauler to pump the septic system whenever it is necessary. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. ZcKea&masA 0T! BOARD OF HEALTH . M n,, R.S., C.H.O. Town of Barnstable Department of Health, Safety, and Environmental Services SAMSTABM Public Health Division �0"A0�p P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health December 21, 1998 Mrs. Theresa Finn 112 Captain Jack's Rd. Centerville, MA 02632 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 112 Captain Jack's, Centerville was inspected on December 14, 1998, by Joseph P. Macomber, Jr. a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged leaching pit You are ordered to bring the septic system into compliance within two (2) years of the date of discovery. Therefore, the construction of replacement septic system component(s) must be completed on or before December 14, 2000. However, if an r sewage overflows onto the ground, you are required to upgrade the system withi orte (14) days of discovery. First, you must hire licensed Town of Barnstable septic system installer to submit a sketch diagram of proposed replacement septic system component(s) to the Town of Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code,Title 5. In the meantime, you shell ensure that no raw sewage discharged onto the surface of the ground or into any surface waters. You must maintain the system by hiring a licensed septage hauler to pump the septic system whenever it is necessary. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. ER,�OF THE BOARD OF HEALTH o as �McK, R.S., C.H.O. �tNE i Town of Barnstable Department of Health, Safety, and Environmental Services &%RNSTABM *` ,0� Public Health Division ED N1AY 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health TO: I I Z COA-, ARCS Lzo DATE: 2 1jrf v,!/c Nift J21�3z— ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 112 /7 L64 i.l was inspected on O,C&, - l`G 11'6' , by i o a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: C' 0 ,,4, L,,(,�, -c'r s7l-'t�- -� an 61tfla its You are ordered to bring the septic system into compliance within two (2) years of the date of discovery. Therefore, the struction of replacement septic system component(s) must be completed on or before 14P ? D-0'- oo-" T1" ,W, �4��i� ram- „-d-oJ: e�..c( .s "rA 0 First, you must hire a licensed Town o Barnstable septic system installer to submit a sketch diagram of proposed replacement septic system component(s) to the Town of Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5. In the meantime, you shall ensure that no raw sewage discharges onto the surface of the ground or into any surface waters. You must maintain the system by hiring a licensed septage hauler to pump the septic system whenever it is necessary. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health g4=]di brila\tille3i.doc 0a DATE: 12/.1'4./98 , PROPERTY ADDRESS: 112' Capn Jac ' s• Road Centerville ,Mass . r 02632 On the above dale, I Inspected the septic system at the above address. This system conslats of the following: 1 . 1-1000 gallon septic tank. ' 2. 1—Dist•rib•ution box . / 3. 1-1000 gallon precast leaching pit. , Based bn my InPc-ectlon, I cerlify the following conditions: 4. This is a title five septic system. '( ��7Z Code ) ' 5. The system is in failure,. 6. The leaching pit is in hydraulic fail.ure . 7. New leaching area must be installed , SIGNATUM7 / Name: J P.M�acomber Jr i ' .' Company; J, P.Macomber• & �on* lrtc ., •; ----------- -------- ' �f Address 8•oac_65- •`0 'r __C e n t ear v�1 L e �,�(,�,�,�_Q 2 b 3 2 •' '�' 9q Phone:---SQB..•J_7..5..3338_______ •. l 1! � THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER *& SON; INC. T+nks-Css.spools-Lsachfleids .Pump+d 4 Instilled ' Town Sewer Connections P.O. Box 66' Centerville, MA 02632.0066 77.5-3338 776-6412 { 4 - COMMONWEALTH OF'MA,SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION yA�eu; 112 Capn Jac ' s Road N �OMr Theresa Finn Centerville ,Mass . 02632 Address of Owner: Same Date of Inspection: 12/14/9 8 Name of Inspector:(Please Print) Joseph P.Macomber J r. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) company Name:J.P.Macomber & Son Inc . MailingAddress:Box 66 CPntPrvi 11 P ,Mass _ n2632 Telephone Number: 5 C)B—u 3 3 g 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 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 eads Further Evaluation By the Local Approving Authority ie Fails ,.�J Inspectors Signature: Date: The System Inspector all submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department cKinvironmental Protection. The original should,be sent tovin system owner and copies sent to the buyer,If applicable,and the approving authority. . NOTES AND COMMENTS Rt 4 v 7 1g9q A 1 revised 9/2/98 Page Iof11 i1 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAI,SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 112 Capn Jac ' s Road Centerville ,Mass . Owner: Theresa Finn Date of motion' 12/14/9 8 INSPECTION SUMMARY: Check A, B, C, of A A. SYSTEM PASSES: I have not found any Information which Indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: : �t�l-���, L- FiN&A, k14W �d 'liiil tYlL/�P' taus 4 e-- B. SYSTEM CONDITIONALLY PASSES: NO 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 ND). Describe basis of determination In all instances. If "not determined", explain why not. &IP 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. A* 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 - The system required pumping-more than four-times•a yeardue to broken or vtrstructed pipe(s). The system wilhmw-- Inspection if(with approval of the Board of Health): - broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 \.rn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 112 Capn Jacs Road Centerville ,Mass . Owrw: Theresa Finn Date of Inspection: 12/14/9 8 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _Affi_ 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 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICHWILL.PROIECT THE PUBLIC HEALTILAND SAFETY AND THE ENVIRONMENT: 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 IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: AJ 1 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 Zone I of a public water supply well. 40 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 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 -A A (approximation not valid). 3) OTHER d& Ail* u revised 9/2/98 Page 3or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 112 Capn Jac ' s Road Centerville ,Mass . Owner Theresa Finn Data of Inspection: 12/14/9 8 D. SYSTEM FAILS: Yo must 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 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-sewage iwloiaciRty-er-sYatem component due tto an overloaded orckgged"SAS-or-cesapod. •�-- �� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 4' _ Static liquid level in the distri ution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ r Liquid depth in ceaspaolls leas than 6" below invert or available volume is less than 1/2 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 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. V 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. 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for rcoliform bacteria,volatile organic.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 public health and safety and the environment because one or more of the following conditions exist: Yes No a the system is within 400 feet of a surface drinking water supply the system•is•witWn 200 feetofa-tfibutary4oa4urfaoo4rwbkingw ator-supply.do _ . . .__... _ ._ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area:IWPA)or a mapped Zone 11 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 Infor,(nation. revised 9/2/98 Page 4of11 1 } SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 112 Capn Jac ' s Road Centerville ,Mass . Owner: Theresa Finn Date of Inspection: 12/14/9 8 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-cornpoaents.hawbaen puaiped4w.atJeast two•awealm and-tba'aystem hasbeeovscaiaiwga nsmal flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ 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,'Acluding 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 orrthe site has been determined based on: _ Existing information. For example, Plan at B.O.H. V _ 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)l The facility owner.(and.ocrupaais.if differaW from-owner)awaraprmrided wlth Infnrmatioacn tha pto er maintanaaae of Subsurface Disposal Systems. I revised 9/2/98 Page 5of11 l l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 112 Capn Jac ' s Road Centerville ,Mass . owner: Theresa Finn Dace of Inspecdon:12/14/98 FLOW CONDITIONS RESIDENTIAL: Design flow: //0_g.p.d.lbedro m. Number of bedrooms(design): Number of bedrooms(actual) Total DESIGN flow 196 Number of current residents: gf Garbage grinder(yes or no): ND Laundry(separate system) (yes or no): If yes,separa s impection.required Laundry system inspected (yes ore Seasonal use(yes or no):/I,- Water meter readings,if available(last two year's usage(gpd): ..S Sump Pump ( es ornc): Ni s , _� S ' ��Last date of o p y�� !v— — 'y, 611d oaf, e COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: f)17 sad (Based on 15.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or nouA li Non-sanitary waste discharged to the Title 5 system:(yes or no)/ Water meter readings,if available: Last date of occupancy: 414 OTHER:(Describe) A10 Last date of occupancy: ilJrSf GENERAL INFORMATION PUMPING REFQRpS a d sourSV of information: F,+ System pumped as part of inspection:(yes or no) f If yes,volume pumped: ,00 gallons ✓� Reason for pumping: 444$ tlh4Tc ,01 d44ZP1 AVztr^T,O�' TYPE OF SYSTEM __i-`4 Septic tank/distribution box/soil absorption system _Weg Single cesspool A,V_ Overflow cesspool 4.)Q 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 �fZ Tight Tank V,4 Copy of DEP Approval Other .f/0 APPROXIMATE AGE of all components, date installediif known)-and source 44nformation: - ---•• S !e � ion Sewage odors detected when arriving at the site:(yes or no)�yJ I revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 Capn Jac ' s Road Centerville ,Mass . Owner: Theresa Finn Dace of Inspection: 12/14/9 8 BUILDING SEWER: (Locate on site plan) i Depth below grade: Material of construction:Zast iron/40 PVC_other(explain) Distance from Private water supply well or suction line OJT_ Diameter 'I ` _ Comments:(condition of Joints,venting,evidence of leakage,-etc.) - Joints anpPar tight ,NO__Qicideuse of leakage . ti-F-91-10 bite hottse vent . - SEPTIC TANK.100 9 5 (locate on site plan) � Depth below grade:S jG��b1,,, w� Material of construction:�crete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list a/geAjA Js.age.confirmed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee orftaffle —' Scum thickness:_ Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to botto of DUD tee or baffle: How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, structural4ntegrity, evidence of leakage,etc.) Pump septic tank Pvery 2-1 3�aarc 'Tnl Pr & G�titlAt tees are in pl ace The tank is structurally—SoUnd The t��vws Ito GREASE TRAP: (locate on site plan) Depth below grade: Material of construction/✓IQconcreteNfinetaL4fFiberglass ,�Polyethylena•(/jQother(explain) Dimensions Scum thickness: Distance from top of scum to top of outlet tee or baffle:IV4 Distance from bottom of sc m to bottom of outlet tee or baffler Date of last pumping: 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:112 Capn Jac ' s Road Centerville ,Mass . Ownw: Theresa Finn Data 01 Inspection: 12/14/9 8 TIGHT OR HOLDING TANK;& (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:IVA/ Material of construction�V�concreteAmetali✓ berglasaPolysthyleno,lEiPother(explain) 1V --- -- — Dimensions: Capacity: VA gallons Design flow: .�r— gallons/day Alarm present Alarm level: Alarm in working order:YesV,4 NoA1e Date of previous pumping: IV.* _ Comments: (condition of inlet tee, condition of alarm and float switches,etc.) iQ t or holding tanks are not present - DISTRIBUTION BOX:Z (locate on site plan) Depth of liquid level above outlet Invert: t�s Comments: (note-if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.) — — Di stri hnti nn hnx hac nne I t-orn1 Ther® l8 auida r.Q of 13Aj_j_d8 Garr` ,,,,, -There is no evidence of laaksga into nr niit of tha hnx PUMP CHAMBER:ti��1M1?C (locate on site plan) Pumps in working order:(Yes or No) )04 Alarms in working order(Yes or No) A14 Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) ump chamber is not present . I revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 Capn Jac ' s Road Centerville ,Mass . Owner: Theresa Finn Date of Inspection: 12/14/9 8 SOIL ABSORPTION SYSTEM(SAS)-"#Z&,v �f+ .k- (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: leaching galleries,number:_ leaching trenches,number,length: leaching fields, number,dime pions: overflow cesspool,number: Alternative system: Ai Name of Technology: 1 Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) i.oamy sand to tight- -,oil to mark iim fi na canri T.Parhi ng pit- i c in h3 rlrniiI i r fat 1 iirc Wasto .seta.^ ra wer6 the Inve t pipe . Sol! Is damp Vegetation is also damp . New tedulitirg aren Lausl: be timCatted . CESSPOOLS �X e, (locate on site plan) Number and configuration: C Depth-top of liquid to inlet invert: AJA Depth of solids layer: Depth of scum layer: Dimensions of cesspool: AJA Materials of construction: /Ulf Indication of groundwater: M inflow(cesspool must be pumped as part of inspection) 4 Cesspools are not present _ Comments: (note condition of soil,signs of hydraulic failure,.level of.pending,condition of,vegetation, etc.) Cessvools are not present . PRIVY:Albve— (locate on site plan) Materjals of construction_ : Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) Privy is not present . revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(eontirwed) Property Address:112 Capn Jac ' s . Road Centerville ,Mass . owner: Theresa Finn Data of Inspection 12/14/9 8 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) ign I revised 9/2/98 Page 10of11 L0CAT10N xc, SEWA E PERMIT,:_.-144 L O T VILLAGE C=,ft-� c i �— ��'-` I N S T A LLER'S NAME i ADDRESS Vic, 7?,oie1 e Aw3, R U I L D E R OR OWNER ��- 5�,-r pry DATE PERMIT ISSUED � 7_T ,' r DAT E COMPLIANCE ISSUED 7'. < ,,. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 Capn Jac ' s Road Centerville ,Mass . owner: Theresa Finn Date of Inspection: 12/14/9 8 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 t� served.Site �Iocal g property bservation hol basement ump etc.) Determined froconditions Checked with local Board of health Checked FEMA Maps <Checked pumping records y Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used Gahrety & Miller Model 12/16/94 revised 9/2/98 Page iiofit •mnr+T-nr�>—•r7� rnrmr•nsRres'Tn+VYA1e*1frle+lsrr/TA*7*An ers*w7f Tls'vfertreT .. TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION `� F.•••T}91••. ::.—T.III.�TTTISR RIl1'R.7lIT`JRlf�1/!R•fR.:T—{1�T.'t RRf�TwR��iR1�11�11�9tt7 �.f1 •.+'tl•'rT"•1"'1r+r•� -TYPE OR PRINT CI.EARtI'- PROPERTY INSPECTED STREET ADDRESS 112 Capn Jac ' s Road Cenllt>>ervillle ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # _ ZZL_ 6_1A OWNER' s NAME Theresa Frnn PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J. P.Macomber�& SovreInc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 . Street Town or City State LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 1 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of.inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: Systeui PASSED The inspection i+hich 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 his form. System FAILED* The inspection which I have con Lcted has found that the system fails to Protect the jiublic 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. r , , Inspector Signatur Date �y One copy of this certification must be provided to the OWNER the BUYER ( where applicable) and the BOARD OF HEALTH. ' * If the inspection FAILED, the owner or.r.operator shall u within o'ne year of the dateo re system of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 15 . 306 . partd.doc f h No....... .... , ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Dispaoal Works Tontrurtion ramit , Application is hereby made for a Permit to Construct (I or Repair ( ) an Individual Sewage Disposal System at ocation• ss r No. .� O n r A ess a ..........S'•.. eg.v.---.. .*C-:F.tft� ._r__ � . .......................S-:...?` emi.aa..-rH--------------•- Installer Address Type of Building Size Lot_____ aX/Sq. feet U Dwelling—No. of Bedrooms_____________3______.___________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building _PAW No. of persons.......jG-----••••--•--__ Showers �) — Cafeteria ( ) Q' Other fix re r� .............•••-- W Design Flow........ ____ gallons per person pertd4y. Total daily Pow_________._s�__�__�__._.___________gallons.�/ WSeptic Tank—Liquid capacityIW-gallons Length...f_Q__4___ Width..... Diameter________________ Depth...6-W.- Disposal Trench—No_ ____________________ Width........t.......... Total Length.......... __. Total.leaching area.......... _._...sq. ft. Seepage Pit No.........I.......... Diameter........../0..... Depth below inlet........6........ Total leaching area.... ..sq. ft. z Other Distribution box (ti Dosing ank ) '-' Percolation Test Results Performed by.__ JLV6 Date._____l0_. l!_.. Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water.. f= Test Pit No. 2________________minutesper inch Depth of Test Pit__.__._______.______ Depth to ground water.... O Description of Soil.....................Me.:]L ,__Law....---•--t! lY J------•-------•----• ---------•--•-•-••---•--•---•---••••--. x 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 TITI E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the bo r f heal Signed•:- •• c ?._.. �7 to Application Approved By.................................________ Date Application Disapproved for the following reasons---------------••--••-•-•••-•................................................................................. --•--••....._..-•...............•-•----•-•-•-•--•--------•--•----•-•••--•--•----•-•.....-•---••••--•_•••-' Date PermitNo......................................................... Issued_....................................................... Date _ No....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL-11-l"A . . ........OF.._6...! .....�L� Appliration for Disposal Works Toustrurtion "rrmit V Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: eg ...LA/ ....... ocation-A 's" 'q '.' 0.1 ..............................1-------— _.t..Ae.A...C ................... . ... .............. W Address-'� ,..................... M.A.Lpl. . .......... ................ 1.4 Installer Address Type of Building Size Lot L�Sq. feet 1-1 Dwelling—No. of Bedrooms_-_...__.... Expansion Attic Garbage Grinder aOther—Type of Building Aw No. of persons.......(0--------_------- Showers Cafeteria Otherfi ur ................. ..................................................................... Design Flow.............. ... ..... gallons per person pet d al dail flow.......... .....................gal;ons,, J gallons Length-101... Width.... 6_3.. W #. Tot 9 Septic Tank—Liquid'capacity W." .......... Diameter________________ Depth.. Disposal Trench—No..................... Width.L.1........... Total Length.............. .... Total,leaching area ...sq ft Seepage Pit No t........... Diameter......... ...... Depth below inlet.._....6......... Total leaching ar;�.49..;2.sq.*ft. ' Dosing to Other Distribution box q, )V ) / by­­... ........() .7 Percolation Test Results Performed W... .. cn..)RUM4 Date..... .7 Test Pit No. 1................minutes per inch Depth of Test Pit._............___... Depth to ground water. �Xq Test Pit No. 2................minutes per inch Depth of Test Pit...__............... Depth to ground water ................... 9 .............0 .................. -----------------------------"------------------- ........:------ 0 Description of Soil..................... ............ ............................................................................ ------------------------------------*-----------------------------------------------------------------*----------------------------------------------------------------------------------------------- ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the bb Ord of heal Signed- .. . ... -------------------------- Date ApplicationApproved By.................................................................................................. ....................................... Date Application Disapproved for the following reasons:............................................................................................................. ....................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF .REAC4 . T ......... ......OF....j�.3.................. . .... .... . ............ THIS IS 50�, RTIFY, That the Ind* S.S w D System ystem constructed or Repaired - by............... ........&........0 ........ / ...................................................................................... Installer at A ..... ---------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_._.._____-_______----.__________---------.__.-. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F)JNCTION 5ATIS-FACTORY. —.7. r..... 3 .........................DATE---------------- ............. Inspecto ......f---------------------------------------------- .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �0 ......7���O.....OF....... 7 ....... .... No... .... ......... FEE........................ Works % lpstrudjon Vrrxit Permission is hereby granted '94-7 4kfj�!? 4,-L- e4_- t" ............................................................................ .................... ....... to Construct '4—__ f ............... T orz,,Repair an Individual Sewage Disposal Sys .........-----4:1 S! 'y" ....... at No.. ...... ....... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... .......................�L.L ................................................................... DATE.........................................../ ...... Board of Health . .... ...... ............. FORM 1255 A. M. SULKIN, INC., BOSTON h 1��,. l - L 0 C A T I ON � C l�i�'T Tr4C;S W A ( �.IJ'l-tA E PE T N Q. VILLAGE I N S T A LLER'S NAME i ADDRESS �o 16 AltILIO fAv Gk' B U I L D E R OR/OWN ER � ` pry DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 5 � � 3 37 _ __ i f � � ���iPIG� 3N�f' ��`s'� t� � .i r ���� 6 �� -. 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I RAYr OND (�� .� W 5T' �.1 C. i R c ,?E.4 G`/� !' _..• ti �'iB 3 � l:,'PTv�u P 7. ,p No.21583 r �/ I 4 [XAG"A(11A/C p li✓,0C,Ci ��sT1�F Q' t ._ .. �Yl) " " .Q.P P 1.r 9 G I Ail$J_r- �i..1 C..+ ` �� F�F2gPC.SWD LALFIING PIT i 00 % x FIA t l s 1 O►� 1 E t . t o> %kid YCXv ,r�. . ' ��1L.f�kr a����►r.J �.a`�I�O�z.�f s��' r - � r��!fi�,, r j"j•�; � d�+/-; ; �•��+,i-.fu,AG�Utr�� !�{A.� Cf 2:�� M { j J/Z)r"ALi. AREA = , x rix `i 'Ib 'I2 a 317 CUL, ,G't P Y�040 Co - x q`I'1 i•d .i c� D W no ��Ji 7.5 -9 SCALD• DATE: >�MItL'Y •=� G p 0 'AF• A 5 NO TE.P I'+ 1 OF! go, 3359 �'"r+J1A1, C�MAwN qY: CNKtiS OvaAPPt! ay: Kd►hl lst3