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HomeMy WebLinkAbout0042 CARRIE LEE'S WAY - Health 42 Carrie Lee's Way Centerville A = 168 008004 �I Sllll �Q��Y�� UPC 12543 N. No.553LL HoST+NGS MN Commonwealth of Massachusetts Title 5 Official Inspection Form ,,Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 42 Carrie Lees Way Property Address Thomas& Mary Joyce ; Owner Owner's Name information is : required for every Centerville Ma 02632 6/8;%2018 page. City/Town State Zip Code Date—of Inspection (,1•y Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, !! use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection r� Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification 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 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/8/2018 Inspector's Signature Date 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. ****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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ,�Td V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas& Mary Joyce Owner Owner's Name information is Centerville Ma 02632 6/8/2018 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: The dwelling located at 42 Carrie.Lees Way Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, 2 distribution boxes, a precast 1000 gallon leach pit and 4 HI Cap Infiltrators. The system was found to be in proper working condition at the time of inspection. 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas & Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas& Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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, 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 fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas& Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 42 Carrie Lees Way Property Address Thomas&Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. City/Town State Zip Code Date of Inspection C. Checklist 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: ® ❑ 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(5)] D. System Information Residential Flow Conditions: 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 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas& Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas& Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 42 Carrie Lees Way Property Address Thomas&Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System consists of Tank , d-box and leach pit installed 1978, d-box and 4 Hi Cap Infiltrators installed 3-4-04 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 10"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas&Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" 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 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc:): Tank needs to be pumped soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas & Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,a 42 Carrie Lees Way Property Address Thomas& Mary Joyce. Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" &0" 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.): System has 2 d-boxes. First inline is original and is functioning as intended. It has minor rot butis holding water at outlet inverts. Second box was installed 2004 and is in good condition. water level was even with 2 outlets. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: F t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 42 Carrie Lees Way Property Address Thomas& Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 4 Hi Cap Infiltrators ❑ leaching galleries number: ❑ 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.): Leach pit was found to have 1'of standing water with a stain line 1.5' higher. Hi Cap Infiltrators were found to have 2"standing water with no signs of past hydraulic overloading. Cesspools (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 ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 42 Carrie Lees Way Property Address Thomas& Mary Joyce Owner Owners Name information is required for every Centerville Ma 02632 6/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas&Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately o A2 2� 2 62 q2G A3 3 D ►33 q� 13Y y9"6 AS b9 f� - S3 6 t5ins•3/13 Title 5 Official won Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 42 Carrie Lees Way Property Address Thomas&Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 . 6/8/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Carrie Lees Way Property Address Thomas& Mary Joyce Owner Owner's Name information is required for every Centerville Ma 02632 6/8/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 }7 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates COST $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town 'r (WHICH YOU MUST DO BY M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1" FI., 367 Main St., Hyannis, MA 02601(Town Hall) and et the Business Certificate that is required by law, g Fill in please: DATE: J� ' APPLICANT'S YOUR NAME: I'10MaC, �• Sep C� BUSINESS YOUR HOME ADDRESS: �a 608.3(v7- 1173 TELEPHONE # Home Telephone Number: C�7? A- D2(o 2 NAME OF NEW BUSINESS — 51- I — 3 17 lOV�� P• TVe 'y TYPE OF BUSINESS E2 in4-,,,�q IS THIS A HOME OCCUPATION? YES NO Have you been given approval from the building division? YES NO ADDRESS OF BUSINESS y - p�32 WO-V Ceg4fy-�,nMAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you it) obtaining the information you may need. You MUST GO TO 200 Main St: — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual ha een info eTf o���ents that pertain to this type of business. Authorized ign0{SlRI COMMENTS: �. -•-• -- -' 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) fit! This individual has been informed of the licensing requirements that pert l0 to this type of business. Authorized Signature** COMMENTS: Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: C " 012 VENTORY MAILING ADDRESS:y a Car-ri e IPn_s (Ae�-x,,j. Ceti- -_r-V►I1-, /VhQ;�1o3,-,Z TOTAL AMOUNT: TELEPHONE NUMBER: 5D?' -310:7 CONTACT PERSON::Vy1 EMERGENCY CONTACT TELEPHONE NUMBER:��' 3�0"l-1 �7`� MSDS ON SITE? TYPE OF BUSINESS: P INFORMATION/RECOMME ATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive D NEW USED O Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) © Hydraulic fluid (including brake fluid) Refrigerants B Motor Oils 0 Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) © Diesel Fuel, kerosene, #2 heating oil NEW USED © Misc. petroleum products: grease, Photochemicals (Developer) © lubricants, gear oil O NEW USED Degreasers for engines and metal Printing ink © Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout 0 Swimming pool chlorine © Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible C9 Car wash detergents © Leather dyes © Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's © Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, O Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels © Paint &varnish removers, deglossers (including chloroform, formaldehyde, © Misc. Flammables 0 hydrochloric acid, other acids) © Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) © Spot removers & cleaning fluids (dry cleaners)o Other cleaning solvents D Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS No. go L) t v 3 3 Fee Y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for Oi6pool *pztem Cow5truction Permit Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No.w cCrr Owner's Name,Address and Tel.No. Assessor's Map/Parcel LPnI`� / M )Oyu—, O Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �)cJ lk� n- �--"--jX- Type of Building: �(j Dwelling No.of Bedrooms Lot SizeAsq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ,70 gallons per day. Calculated daily flow gallons. Plan Date 7 104 Number of sheets Revision Date Title Size of Septic Tank O 00• Type of S.A.S. _Qk C N C_rja Description of Soil ��� CC� Nature of Repairs or Alterations(Answer when applicable) Add � .1-S w• /i 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 _ied, by this oard ofHealth. Signed Date Application Approved by Date gI 122 01- Application Disapproved for the llowing reasons Permit No. Z2QQ -1 —8 ? Date Issued i 2 2 6 t, a ,No. o�do t/ Fee 7 t � r# - 'fHE�&dMMONWEALTH OF MASSY C10JIi'SETTS Entered in computer: Ye � r i PUBLIC HEALTH DIVVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS f Z(ppfication for Misspool *pztem Con!aruction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. ( Owner's Name,Address and Tel.No. Co.rrcCS �C 7 c Assessor's Map/Parcel ZPrt,�1_� 1�_ _ \O a `v V Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size rX,�J b sq.ft. Garbage Griner( ) Other Type of Building No.of Persons Showers( ) Cafeteria(' ) Other Fixtures Design Flow ?.30 gallons per day. Calculated daily flow gallons. Plan Date I 7_7 104 Number of sheets Revision Date Title Size of Septic Tank Q 00• Type of S.A.S. uZA-P N CC,Q Description of Soil Nature of Repairs or Alterations(Answer when applicable) Arl(/ Q «-cz-' �7)T C U J Date last inspected: tq- 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 issiled by this<oard o ealth. Signed `.• Date��.,?A) Application Approved by ,)A_ 41 Date G 1/ Application Disapproved for the o`llowing reasons Permit No. �70a LI/ —03 3 Date Issued l ?µ?A c"/ h THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Cnmpf.jauce THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(t/)Upgraded( ) Abandoned( )by (�M "�n V G-C at C, C G,r r t�CS pT�� �, �1� ��� has been constructed in acco dance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 uU 03 dated l �7- U t/ . Installer C ca fr C c� 2 r—vt L/- Designer _ S 1 / The issuance of this permit shall not be construed as a guarantee that the s ste will action as es ne ,CC Date �--/ y Inspector �vo .. ,1 —— No. '7�i 1 N t) 3 S _ _ .— — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEa MASSACHUSETTS W6po5al *pZtem ow5truction Permit Permission is hereby granted to Construct( )Repair([/ Upgrade( )Abandon( ) System located at t,4 C,.fr t`�S 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 pe it. Date: l ' - v�/ Approved by �� TOWN OF BARNSTABLE E . LOCATION � .!n�f\�C- � �` SEWAGE # do -01-?3 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Scots M• e SEPTIC TANK CAPACITY x G) LEACHING FACILITY: (ty LA I CCQO I& -G. (size) l 0-,(, J—X,,3g �. NO.OF BEDROOMS %A /0m`Deep / BUILDER OR OWNER \C 0 5n� :t� 6 N!C� PERMITDATE: sZ� COMPLIANCE DATE: '' ~�N 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) Nlci Feat j Edge,of Wetland aad.L.eaching Facility(If any wetlands exist j within 300 feet0f1eaching facility) A Feet Furnished by ;;;f-e . j IN *b eJCk;5A Vck = ® wx Q 0c3®x �� y TOWN OF BAP-NS(ABLE E f- F�. SSEPTIC A tN^`_�ri t��C IlX.�� �^��•�% SEWAGE # GE_ L'r� ASSESSOR'S MAP & LOT ./�9 ' TALLER'S NXA 3z PHONE NO. Sco M- C-«'�� _ TANK CAPACITY X1,& '�C:cc� Cf�L DX ~ LEACHING FACILITY: (type) r C64C) TA�,A (size) f X 3 Z t- h NO. OF BEDROOMS %A ao /0ps eep , BUILDER OR OWNER Cn h !C-9 PERMITDATE: [7-> COMPLIANCE DATE: 3-Y Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /I _ Feet Private Water Supply Well and Leaching Facility (If any wells exist f i on site or within 200 feet of leaching facility) /�' Feat Edge,of Wetland and Leaching Facility (If any wetlands exist within 300 feet'bf`leaching facility) Feet Furnished by �air f) pox FRI r eX 5 PCk y �.®..�� C3ox. to TOWN OF BARI STP.BLE 9 i Ie_ LOCATION Z W (LAt ta!6 VXUA SEWAGE # VU-LAGE QQh&-V-2 tN`.L- ASSESSOR'S MA.° & LOT_ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY i Qt$ S`� LEACHING FACILM: (type) aT (size) 16 0!!; NO.OF BEDROOMS f BUII_DER OR OWNER PER rwn:DATE: (e ( 61 COMPLIANCE DATE: Separation Distance Between the: 4 Z® Maximum Adjusted Groundwater Table to the B Private Water Supply Well and Leaching Facility (If any wells exist Gr" Fe on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist, within 300 feet of leaching facility) Furnished by -�t. C���� _ f - � c 8 � % � Z ® 3 Az- b2^ Li Ott f�3 -I'V 053- L(5' - COMNION\�TALTH OF NLkSSACHIISETTS MENTAL AFFAIRS, IVE OFFICE OF EN-VIRON EXECUT --- DEPARTMENT OF ENVIRONMENTAL PROTECTION ONEX%INTER STREET. BOSTON NL4 02108 (617) 292-5.)00 TRUDY Co\,i Secre-ar DAVID B. STR,H' ARGEO PAUL CELLUCCI Conurdss':nc Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION GoT-- ooWH Property Address: L Name of Owner oltll( V j Address Of Owner: 6% Date of Inspection:. EC-111/0 *&- d—.u a I-�/ _ 15 340 of Tirde 5(310 CMR 15.000) VAN Name of Inspector: P.Lkse�-P`11 inspector pursuant to Section - <11,91 1 am a DEP approved system Company Name: J!j&X.—A,-, I - -- Cl 4- Mailing Address: L:3:gL,— U&5:-HAtOi Telephone Number: 4 S:C2'2 Z. CERTIFICATION_STATEMENT ' and that the information reported below is true, accurate I certify that I have personally inspected the sewage disposal system at this address 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 ng Authority Needs Further Evaluation By the Local Approving Fails kapector's Signaturz1a IP�JN Date: _G The System Inspector shall 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 of Environmental Protection. The original should be sent to ttre system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS 40.. \j'._ 0 9t 0-It S"\ t, 130 'L 5N 4 0 RIO t-ak"' CA�& 34V V1 LAC�-IA kz:1 V-jb :qd revised 9/2/98 terii C.- prtaied on Rec'YcW PJPct i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM V PART A CERTIFICATION (continued) 'roperty Address: Owner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure —T— criteria not evaluated a e indicated below. COMMENTS: 4 ! 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. Indicate yes, no, or not determined(Y. N, or ND). 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 - _ The system required pumping more than four 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 revised 9/2/98 et`orii fit, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: 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 th 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 MR 15.303(1)(b)THAT.THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SA 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 m rsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WA SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH A D SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(S S)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ system nd the SAS is within a Zone I of s public water supply well. The system has a septic tank and soil absorption _ The system has a septic tank and soil absorption syste and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption syst and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water enalys for coliform bacteria and volatile organic compounds indicates that th well is free from pollution from that facility and the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation.not valid). 31 OTHER revised 9/2/.98 Pate 3ocll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM v PART A CERTIFICATION Icorrtirwedl Property Adoress: Owner: Date of InspecUn: D. SYSTEM FAILS` You must indicate eit}er "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination ii identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure Yes No Backup of ewage into facility or system component due to an overloaded or clogged SAS or cesspool. f the round or surface waters due to an overloaded or clogged SAS or _ Discharge or p nding of effluent to the surface o 9 cesspool. Static liquid level i the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspo I is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more t n 4 times in the last year NOT due to clogged or obstructed pipelsl. Number of times pumped Any portion of the Soil Absor\Systte cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or a Zone 1 of a public well. Any portion of a cesspool or 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less th n 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the we\nn,,analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compound nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must Indicate either "Yes" or "No" to each of the followin The following criteria apply to large systems in additioteria above: The system serves a facility with a design flow of 10, eater(Large Systeml and the system is a significant threat to put health and safety and the environment because one oe llowing conditions exist: Yes Nothe system is within 400 feet of a surface der supply the system is within 200 feet of a tributary to a surface drinking wa�gr 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) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regionz office of the Department for further Information. ` revised 9/2/98 Ppge4,of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: w?j Cr,n Owner: 1 Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ygs No may} Pumping information was provided by the owner, occupant, or Board of Health. Y _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NtA. 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, excluding 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: OiAExisting 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) 115.302(3)(b)) AThe facility owner(and occupants,if different from owner) were provided with information on the proper mainteraaca of SubSurface Disposal Systems. revised 9/2/98 $ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms (actual):i—s Total DESIGN flow Number of current residents:_ Garbage grinder(yes or no): R..s Laundry(separate system) As IV or not: ; It yes, separate inspection required Laundry system inspected 6yevor no) Seasonal use (yes or no);hr Water meter readings, if available (last two year's usage (gpd): Sump Pump(yes or no): Lest date of occupancy: � COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( 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 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of inform tion: System pum ed as part of spec ion:(yes or no)_ If yes,volume pumped: gallons 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.It any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date Installed(if known)and source of information: -- Sewage odors detected when arriving at the site:(yes or no) revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan)V �' Depth below grade: Material of construction:_cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:�.S (locate on site plan) p Depth below grade: Material of construction: ,concrete_metal_Fiberglass _Polyethylene_other explain) If tank is metal,list age,_ii Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: t t Distance from top of fudge to bottom of outlet tee or baffler Scum thickness' 611 tt Distance from top of scum to top of outlet tee or baffler_ t( Distance from bottom of scum to bottom of outlet tee or baffle: L How dimensions were determined: , J lomments: (recommendation for pumping, condition f' let and outlet tees or baffles, depth of liquid level in relation to utlet invert tructural in gray.Cl exidence of leakage,etc.1 �� t 4i GREASE TRAP• (locate on site plan) Depth below grade: Material of construction:_concrete_,metal_Fberglass _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: utlet tees or baffles,depth of Liquid level in relation to outlet invert,structural integrity. (recommendation for pumping, condition of Inlet and o evidence of leakage,etc.) revised 9/2/98 rege7 of.II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E PART C SYSTEM INFORMATION (continued) +roperty Address: 4 L CaK(w U- , Owner: Date of Inspection: TIGHT OR HOLDING TANK: 0.0 (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order:Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION SO o (locate on site plan) Depth of liquid level above outlet invert: IUL Comments: in if level and distribution is a at, v' en f solids carryover,,evid ce of lea age into or out9,fobo t e c.l _ CA PUMP CHAIVIBER:tz (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or Not Comments: (note condition of pump chamber,•condition of pumps and appurtenances,etc.) revised 9/2/98 Pyt�Ill orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) `roperty Address: yZ (tmelc U-c"i Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS1:11 (locate on site plan, if possible; excavat' n not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:—WO leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (�ote eondit'on of soil, signs of hydraulic failure, level of ponding damp s il, c dition of vegetation, etc.) t 44 CESSPOOLS:f (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: 9epth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PR(YY: (locate oh 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.) revised,,: 9/2/98 Pit 9eru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: L CAI&,lC j f f Jwner: Date of Inspection: 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) At �12 �z a� 3 '3PLAS y_46 revised 9/2/98 Page 10or11 r r X SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: 1t(gV1Aektfj Owner: Date of Inspection: NRCS Report name - — ---- ---- Soil Type_ --------- ----- Typical depth to groundwater—_ _ USGS Date website visited rv0 Observation Wells checked Groundwater depth: Shallow Moderate Deep —__-- SITE EXAM Slope yl� Surface water f.�u • Check Cellar :j>K.-1 Shallow wells Estimated Depth to Groundwater Zo Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) v. 1 C_� revised 9/2/98 PRceuarIt • D 1ATE• 1 /7/00_ -_ PROPERTY ADDRESS; 42 ,Carrie Lee_ s Way____ Centerville,Mass. ------------------------ __ 02632 On the above date, I Inspected the septic system at the above address. This system conslsts of the following; 1 . 1 -1000 gallon septic tank. 2 . 1 -Distribution box. 3 . 1 -1000 gallon pit. Based on my Inspection, I certify the following conditions; 4 . This is a title five septic system. ( 78 Code ) 5 . The septic system is in proper working order at the present time. 6 .The waste water is 52" below the invert pipe to the leaching pit. SIGNATURE;,/ Comp an Jose�h_P ;, Nacombsr_& Son , Inc . Address;_ Box-66 -- --------------- __Cencervi Ile L Na ,-02632-0066 Phone :... 508_775_3338_______ THIS CERTIFICATION ODES NOT CONSTITUTE A OVARANTY OR WARRANTY JOSEPH P. MAC OMBER & SON, INC. Tanks•Cesspools•LIachflIIds Pumped 4 Install#d Town Sewer CQnneotlons P,O. Box 66 CenterYlile, Mil 02632-0066 776.3338 776.6412 RIECFl�fE® O E G 0 7 2000 TOWN OF BARNSTABLE HEALTH DEPT. COMMONWEALTH OF MASSACHUSET'I'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600 TRUDY CORE 3ecreu.ry ARCEO PAUL CELLUCCI DAVM B STRnS Governor Comtnissiooer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Nwr►s of Ownw Thomas Joyce P,�,Aaar,s.,42 Carrie Lee s Way Adar.aa of owner: Centerville,Mass. 02632 Dee of kuPeC60n: N of yu�p.ctor: (pw&ye mnt)Joseph P .--Macomber Jr. I wn a DEP approved sYetem Inspector pursuant to Section 15.340 of T-rde 5(310 CMR 15.000) C,,,v&-ry N ..: Joseph P. Macomber & Son Inc. µ.&N Addrsss: BOx en ervi 11 e M 6 3 2-0 0 6 6 T sieptwne CER71RCATt0N STATEDAENT i cerdty 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 dme of inspection. The Inspection was performed based on my training and experience In the proper function and ms,ntsnsncs of on-site sewage disposal systems. The system: /Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority G� _ Fails Vupec-ta's Sigruture: f Darts: ZI- '10 The System Inspector all submit a copy of this Inspection report to the Approving Authority (Board of Heafth or DEP)wftNn thirty (30) days of compieunq this Inspection. 11 the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner fiall submit the report to the appropriate regional otflce of the Department cKnvironmentatl f ortectfon. The original should be sent to" system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND CONIMENTS revised 9/2/98 page Iorii Printed on R"14d Prper j ;T SV93VRFAC9 SEWAOC DISPOSAL SY97W 9N3r£CT10N FORM PART A .01 CFATV=,CA ON (owrtlrA-W4 ft„..,ry Ad,Jr*":42 Carrie Lee' s Way Centerville,Mass. Owrwr. Thomas Joyce Su►ECTtoN SVMMAAY, Ch ck A, 8, C, " of A. ,(SYsro`+ AASSes: /,qua 1 hove not band ►ny Informaton wNch In CC$$ that my of the fallure oor4tlonx dbicribed In 310 CMR 14,303 •x;4t. Any ra= crttorl+ not ovaluatod we Indlcatod below, {. SYSTEI,1 OokDITIONAUY rASSE3: A)• One w more system oornpononts w dosoribod In the 'Conal *" ►ass' soodon need to be roplsoe4 w ropalrod. The system, compiedon of the ropJ000mont w (•poll, " approvod by the gowd of HoWth, wW peas. V-4cote yse, no, or not detern-Mod(Y, N, of NO). DoocAbe baalo of doterminadon In all 4utwtooa. If 'not dotormined', expJoln why rwt. d1� The oopdc t" Is meal, unJese the owner w operator has prov{dpd the System 4upwor whh a oopy of o C•*-v Cate Comptlance (method) Indcadno thet the t" was Uutallod wlthln twenty (20)Yews prior to Ow date of Ow wpKt)c tho eepdc tank, whether or not motel, Is •rooked, svuewrally unsound, ohowo ►ubotandaJ In Nvadon w Oxlvv c or+� IaJlure Ir Imminent. The system wW pose IrupooUon If the exJsdnp oapde tank is (spitted with a eornp(Ytnp opproved by the ioard of HO&M. Sewage bockvp or breakout of Nph otado wator level observed In the dJevlbudon box Is duo to broken or obruvcuo p or dve to a broken, settled or vnevon dlevlbutJon box, The system wW pose InepeoUon if (whit approval of Vie Boars c HeoJth)• b(okon plpo(e) we roplaced obewcdon Is removed . devibudon box Is Iovell0d a ropl&cod • The syrtom racr,*od pumph17Tnon t}wn fpur dines yeardue t9 brollenvl vbrtrvclod Dlpe(el The vTeaTn InepoeUon If (with opprovaf of the to" of Haalth)l brokon pipe(;) are roplec•sd obewedon Is removed revised 9/2/98 n�eier►t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART A CFAT119CAT10N (con*--d) ,, , AdCreas: 42 Carrie Lee' s Way Centerville,Mass. Owrw: Thomas Joyce C. FURTHEA EVALUATION IS REOUIRED BY THE BOARD OF HEALTH: Condrdons exist which require further evaluation by the Board of Health In order to datern-Jno If th* system Is t&Mng to Protect 0► public health, slaty and the snvironment. 1) SYSTOA W1L1 PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303 (1)(b)THAT THP SYS7UW l3 NOT FUNCTIONING LN A WANNER WHICH WUl.ManCT THE PVSUC UVJ LMAND SAFETY kXD THE O3 OfUMBI L' / Cesspool or privy U within 60 fast of surface water jyl) Cesspool or privy Is within 60 last of a bordering vegetated wedand or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)DErEFUDiES THAT T*H2 SYSTB/ IS F;UNCT)ONWO IN A 6tANNEA THAT PROTECTS THE PUBUC HEAL'Ri AND SAFETY"0 THE EliWON"ANT: �) The system has a septic tank and soil absorption system (SAS1 end the SAS Is within 100 feet of a wrface water wPP+Y 01 trlbutary to a surface water wPPIY- /�!d The system has a septic tank and soil absorption system and the SAS Is wlWn a Zone I of a pubUc water wpplY wtu 17 The system has a septic lank and loll absorption system end the 3A3 Is wlthln 60 feet of a private water wPPrY w►u. The system has a septic tank and ►oil absorption system and the SAS la less titan 100 feet but 60 feet or mwe from The private water supply well, uNass a well water analysis for collform bacteria and voladle org"c compounds IndJcatss ttvt t/�a wall Is free hom polivUon from that facility and the presence of smmonls Ntrogen and nivete nlv"" Is equN to a less than 5 ppm• Method used to delsrmine distance (apWQzj udon not vaUd).- JI OTHER revised 9/2/98 relic 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM . PART A CER-nMATION (cortdnued) F-rOq*MAd&*":42 Carrie Lee' s Way Centerville,Mass. Ownw: Thomas Joyce D" of yapeodn 1 /7/0 0 0. SYSTEM FAILS: You must indicate either 'Yes' or No to each of the following: re ons exist as described �a I have determined that one or The the following Health lshouldnbe ticontacled to dotormine(what will+b• necesa� coma`'tf�e fa"' determintlon is Identified below. yes No oosnponertt•due%*an ovoeO0d*d o�94a'd Backup 0+"wage IrrrofsclNtYor•rT+•t� ed SAS or Discharge or ponding of stfluent to the surface of the ground or surface waters due to an overloaded or dop9 cesspool St+tic liquid level In t outlet Invert due to an overloaded or clopped SAS or Cesspool. I dlstrl � g"tlon box above Liquid depth In c+++P"1f lees then 6' below Invert or available volume Is lose than 1/2 day flow more than 4 times In the last Year ho due to clopped or obsuvoed pipel+l. Required p umDIn 9 Number of times pumped Q•, Any Donlon of the Sol] Absorption System. cae+pool or privy Is below the high groundwater elevation. 00 tent of a ourface water supply or tributary to a surface water wpWy Any portion of + cesspool or privy Is within 1 Any potion of a cesspool or privy riv Is•within a Zone I of a public well. Any portion of I cesspool or privy Is within 60 feet of I prlvato water supply well. privy Is tesa•than 100 feet but greater than 60 feet from I privet• water wpp►y weal wivN Any portion of a cosapool or p Y '— acceptable water quality analysis. II tho well u has been 9en`�denluate nluiopen ach copy of well water anvve�e ..colllorm bacteria, volatile orgenlo•compo E_ LARGE SYSTEM FAILS: you must Indicate either 'Yes' or iNoo leer eashstems In of the following: addition to the criterls above: The following criteria apply g y rjflcant vveat t and the The system serves a facility he with nment design flow .one .000 gpd the rloiltowlnprcondldon SYst9m)axial; system la • +i9 health and safety Yes No/ p" the system Is Within 400 feet of s surface drinking water supply / -to.0 w rrlew" c+ktw4-waswwu►fiy•..• the syetem•Irwlt 200 {++to4-+-V4"w Y of e the system Is located In a nitrogen sensitive area (Interim Wolthead Protection Arse•IWPA1 or I rr)+DD+d Zo^+ n water supply well) The owner or operator of any such well) system shall upgrade the system In accordance with 310 CMR 16.304121. Please cona ►t u a'+office of the Osperiment for further Infognstion. Psje4orit revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM . PART B ' CHECKLIST Property Agaro": 42 Carrie Lee' s Way Centerville,Mass. Own*(: Thomas Joyce Dev of 6n&poction:1 1 /7/0 0 Check If the following have been done: You must Indicate either 'Yes' or 'No' as to each of the following: Yes No Pumping Information was provided by the owner, occupant, or Board of Health. Nona of the systsm,c0R%0aa6ru.s erlaaq...sa+ A raise during that period. Large volume of weter have not been Introduced Into the system recently w as part of wa Inspection. As built plans have been obtained and exemined. Note if they are not available with N/A. The facility or dwelling was Inspected for signs of sewage backup. _ b The system does not receive non•enl%"or IndustrW waste flow. _ The she was Inspected for �*19ns of breakout. _ All system components, jwluding the 3oll Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the Intarlor of the septic tank was Inspected for condtion of osr or tees, material of conauuctlon, cilmenslons, depth of Uquld, depth of sludge, depth of scum. The site end location of the Soil Absorption System orrthe site has been determined based on:- E+Isting Information. For example, Plan at B.O.H. _ Determined In the Aeld (If any of the f►llure criteria related to Part C Is at Issue, approximation of dietance Is unacceptao 115.302(3)(b)l The faclUty owrw (.and.o.srp•nt Jf dlflerant pza-1 ed wUh lafau„ =,on tti. Ptni—m..nj. r SubSvrface Disposal Systems. revised 9/2/98 hilt Sof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION P,ay..sy Ad&*"A 2 Carrie Lee ' s Way Centerville,Mass. Owr+w: Thomas Joyce 11 /7/00 ROW CONDITIONS RESIDF?ITIAL: Drrs.Jgn now: AOU _9•p-d•lbedro m, Number of bedrooms (design):�p3 n mber of bedrooms(actual):,, Total DESIGN now. 16 _j6e* Number of current residents: Garbage grinder(yes or no): _ Laundry(sopusts system) •s or&:—: If yes, sspswi�lrup+ctlon nqulr�d Laundry system Inspected ('09 or no) Sessonsi use lye# or no): 1 .gyp Wote( motor reading#,If available (last two year's usage NO): w�T Sump Pump lye► or no). D �dl(�,lJ, Lost date of occupancy, p�M_I.IER tAVwPVSTRIA Type of establishment: Design flow: 4J d I Ba#.d on 16.203) Basis of design flow ff Onose trip present: (Yes or no) Industrial Waste Molding Tank present: (yes or no) Non•$"WY waste discharged to the Title 6 system: (yes or no)�jf Water meta( readings, If available: Lost date of occupancy:_ OTHER:tOescribeI f List date of occupancy: GENERAL INFORMATION PUMPING RECORDS and a r��ce o Information: IF System pumped as part of Inspection: (yes or no)_ If yes, volume pumped: --iJ gallons Reason for pumping: /n TYPE SYSTEM OF SYST ��Septc tank/distrlbudon box/soil absorptJon system Single cesspool If./& Overflow cesspool Privy Shand system(yes or no) (If yes, ortach previous Inspection records,If any) I/A Technology etc. Attach copy of up to date operation and malnionance contract Tight Tank �.._Copy of DEP Approval Other APPROXIMATE AGE of all components, date Inotagediif known)-end aourw o 4wforrnadon: Swage odors detected when arriving at the site: (yes or no) 10 revised 9/2/98 Pitt 6ofII SUBSURFACE SEWAGE DMPOSACSYSTEM INSPECTION FORM .r PART C SYSTEM INFORMATION (contirxsed) P„p.rty Ad&*":42 Carrie Lee' s Way Centerville,Mass. oWT+«: Thomas Joyce 0" of k%sPect o":1 1 /7/0 0 BUILDING SEWER: Ilocato on site plan) f/ Depth below grade: Material of construction: acest Iron_L/40 PVC.L4 other II lain) Dis _-ttance from Private water supply wall or suction line fj- Oismetor — Comments: (condition of)oints, venting, evidence of)sakage,-etc.) Joints a2peag t j- No evidence of en e r SEPTIC TANK:AM ilocete on she plan) Depth "low gred4 al bor Ias$A,) Polyethylene_other(explaln) Material of construction: Concfete�,met � 9 1 If tank Is fnetd, li//st age 1a.&gs.conArmed�yby Certificate of Compllance (Yes/No) Dimensions: O Gf A�tiIQ �' //��/l�� Sludge depth: . '4 Distance from top o ludge to bottom of outlet tee or bet Scum thlcknoss: Distance hom top of scum to top of outlet tee or botfla:/�- Distance hom bottom of scum to botto of outlet t or batflo:;� - Mow dimensions were determined: 1 Comments: Uecommandation for pumping, condition o}Inlet and outlet tees or•batfll$, depth of liquidGarbagerelation to outlet invert, etivctvrer K+te9rrty. gvidonci of leakage, etc.) is present. Inlet i Ui s. GREASE TRAP: goullds ows no evidence of leakage. tiocato on site plan) Depth below grade. Aa Motorial of constructlon:AiRconcrete �tal�jJ�Flbergiass&!APolyethyioneN)other(explain) Dimensions: Scum tivcknoss: ::�;,F Distance from top of scum to top of outlet too or baffle: / /r r„ Distance hom bottom of s um to bottom of outlet toe or.baffle: Dote of lost pumping: Comments: (recommendation for pumping, condition of inlot and outlet tee$ or bofflos, depth of UQuid level In relation to outlet Invert, srtructural IntepmY. evidence of leakage, etc,) rease r revised 9/2/98 hgtIof11 SUBSURJ'AC.i SEWAOL DISt•OSAL SYST'EJd W1rfCT10N FO.RJa PRAT C SYSTDA WFORMAT)ON (Con %Jo"d) P,,q..A6&,e,: 42 Carrie Lee ' s Way Centerville,Mass. O-WTW: Thomas Joyce Dvu of `&P , :1 1 /7/0 0 MHT Oil MOLMHO TANK: (Tank mv►t be pumped prior to, or •1 time of, inapeadonl 11941t• on ►Ike plan) Depth below grada: A�f MatarlaJ of comVVI;Von:41,concfeteA1144metaJNA Fib arpl•aO—APolysthylan44&oth6f(9XPI&In) plmanalonl: Cspaclry: 9►Ilona Of►ign Ilow: g►llonslday Alarm pre6ent Alarm lerel: Alarm In orking order:Yea/ No Oete of prevlovs pvmpin0: � Comment: lfonoloon of Iniet tee, eond)tion of alarm and float awlichee, eto•) '140t oruliiy t anKS are 17nf rccn 094TRIBUTION BOX:d� Iiocfte on site plan) Oepth of Iicivld level above ovdel Invfrt: 1� Comments: tnoae II level and oUvlbvtion it eov&j. evldenw of solids curyov•(, ovld.na• of leakage into or out •I boa, eta. Di o ev o ev nr n»+ ri PVMp CMMISEA ZZde II9411e on Ilia plan) ►vmps In working orde(:(Yef or No) NO Alerm►In working order (Yes of No)2:9 Comments: mote condlt)on of pump chamber, condld urt on of pumps end eDp •n•naee, eta.) n • • ►e{flofII revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTUA INSPECTION FORM � PART C SYSTEW INFORMATION (con*vjed) Ptopw y Ad&ess.42 Carrie Lee' Way Centerville,Mass Owrw: Thomas Joyce Deu of kuPoction:1 1 /7/0 0 SOIL ASS 0RPTVN 3Y5TEI.1(SAS): lDd—It (locate on sit• plan, if possible;excavation not required, location may be approximated by nondnVuslve methods) If not located, explain: Type: leaching pits, number: leeching chambers, number: Li leaching galleries, number:—= leaching trenches, number, length; leaching fields, number, dime on overflow cesspool, number: [ Alternative system; Name of Technology: i Comments: ( to condition of s I, signs of by rsulic failure, level of ponding, damp soil, condition of vegetation, etc.) �°oamy sand to medium fine s n ai ure or pond i nci Sni 1 G Are dry.Vo9etat}eR is eeFinal CESSPOOLS:-wt (locate on site plan) Number and configuration: Oepth•top of liquid to Inlet Invert: Depth of solids layer; A J14 •/7 Depth of scum layer: Dimenslons of cesspool: Materials of construction: indication of groundwater: Inflow (cesspool must be pumped as part of Inspection) esspoo s are not rpSPnt- ' Comments: incts condition of soil, signs of hydravllc fallurs, level of ponding,condition of•vegetadon, etc.) esspoo s are not nres nt PRM:jlz.Cr', (locate on site plan) Materials of construe• qn: ,e(,/� Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) rivy is not nresent revised 9/2/98 Pses9or11 SU93URFACt SE!WA09 OLS►OSAL SYSTVA LN""T'ON FOPM ►AAT C ' SYSTE7d WFOrt"TION(oon*-od) r,op.-yAd&—: 42 Carrie Lee' s Way Centerville,Mass. Own.: Thomas Joyce 1 1 /7/0 0 SKETCH Of SEWAGE OtSPOSAI SYSTEM: InGJVd1 tot to it Ioait two permanent►9rorence I.ndmukt or benchmmks locate NI well► wlWn 100' (locate whM public wets► supply comes Into house) y2 C��r�c L te 't l."d enA wl� Ca( e� CpUS{ NI \ i SD revised 9/2/98 nj�l0ortt 3U93URFACE SEWAGE Df3I93A.I SY3TE3d WSIECTION FOR1.1 PART C SY3TFAi pFORIAATION fcondnwd) ' 42 Carrie Lee' s Way Centerville Mass op.rsY y ownw: Thomas Joyce Dau of k,apa.cdon: 1 1 /7/0 0 NRCS Report nsm• SoU Type_ Typlcal depth to groundwater VSOS Oate websf o visited Observatlon W1Us checked Oroundweter depth: ShallowModerete Deep — SITE EXAM Slope Su(lace waler Check Cellar Shallow wells Est,msted Depth to Orovndwstorxis Feet Itesse Indlcale all the methods used to determine High Groundwater Fievadon: _ Oolalned from Design(lane on record v/0 served She fAbvT%1n9 poporty.,lifisservadon hole, basement Bump W.) Oetermined from local condltlons Checked with loc►1 {oard of health Checked FEMA Maps /hocked_pumping records Checked local e+cavators, Installers Used V503 Oslo Dotcribe how yov established the High Oroundwslor Elevation. 1MY0 be completed) Used; Water Contours Map. Gahrety & Miller Model 12/16/94 revised 9/2/98 hN11olII rn•rrr-r.—r-.-. ._... �-••r.n r,r_rt rr—rr- rnr 1rr.•nnrrrnr•ar.r.tr.r.:•.r+:+err:•nr.•snrn nrr:tu r.a�snr.rts F 'I'OHN OF Barnstable BOARD OF HEALTH SUBSURFACE SF.HAQF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION �. -T••.•...r-�.t t I-.�.T.T.T."1t•ri.'rTr TT.lTt11'l'Tt'.T-t•T"'{ITf'R7\relOT1••�R f!T•911�Y1A'Rf7 i'RTf IITRI"nTiSPtTT'I'�nT.•.�.r••''r 1'.•... .�..A -TYPE OR PRINT CI.EARL1'- PIlOPERTY INSPECTED STREET ADDRESS42 Carrie Lee' s Way Centerville,Mass. ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Thomas Joyce PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Ind:• ' COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State 1IP COMPANY TELEPHONE (508 1 775 - 3338 FAX ( 508 790 -1578 n q CERTIFICATION STATEMENT 0r 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 ecomrnendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Ch( one ; System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have conalcted has found that the system fails to Protect the j-)ublic health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature v Date 1� ne copy of this ce ification must be provided to the OWNER, the BUYER he applicable ) and the 130ARD OF HEAL711. * If the inspection FAILED , the owner or.'.op operator shall u P pgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 ChIR 16 . 305 . partd . doc TOWN OF BAMSTABLE LOCHiiON J SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILM: (type) a � (size) NO.OF BEDROOMS BUILDER OR OWNER �O' PERMITDATE: COMPLIANCE DATE: �� w 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 o le)' hin ility) Feet Furnished by YZ Cirri c L to's !.i a ----f�-----t77�1--l-�,—,-------�—�------- - ----------------- - --­----------- I --_-_ - I ____, ------____________.,__ — ,___,.______��___ ",.--- __ — —_ _ ____­ -----7----- —________' I ,1, , , I —------,----_ ______ ------- , ---,----,------- _________,_______. ,___,_ — - — , _ __ —____________,_--- _____— -_ _ — ________­___ ____________­__­_______ - -----,— , , 11 I I I I I I I I I � , -------.— ——— ---—---- --- _____ " , 7 . .1 I I �', I I .� I 11 I I I , I '11�1 I I I'� I " I� I � I I 11 11 I I ,rl —------- ��,, , I I I . 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