HomeMy WebLinkAbout0087 CONNERS ROAD - Health 87 CONNORS ROAD, CENTERVILLE
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HASTINGS,MN
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617.292.5500
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I'ILLIANI F �%ELD TRL'Dl'CO T
Go�cmor 4 / �r'rrtir
ARGEO PAh'L CELLLCCI T`
'9�Q E D:4\.D B STR�'HS
Lt Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `�/ � Com^tiSs..nc
PART A
CERTIFICATION
Property Address: 87 Conners Road Centerville Address of owner.,, r'Aq�(F `98
Date of Inspection:4/20/98 Mass . (If different) N': �
Name of Inspector: `lJ °
I am a DEP approv system inspectors pursuant
d to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J.P.Macomber & Son Inc. — -
Mailing Address: BOX 66 CEnterville,Mass . 02632
Telephone Number: 508_775-1338
CERTIFICATION STATEMENT
I certify, that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accura,e
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function anc
maintenance of on-si(e sewage disposal systems. The system:
asses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: �G� ' Date: ,
Tne System Inspector all submit a copy of this inspection report to the Approving Authority within thirty (30) days of comp4eting th,s
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 summ,i
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the sysiem owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, Or D.
A) SYSTEM PASSES:
1 I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR I i 303
Any failure criteria not evaluated are indicated below.
COMMENTS:
BJ SYSTEM CONDITIONALLY PASSES:
u- = 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 wh,, 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 tan:
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tani,
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http Itwww,magnet state ma usrdep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR•*'�
PART A
CERTIFICATION (continued)
P,o;en, Aocress: 87 Conners Road Centerville,Mass.
O»nC' Estate Of Anthony DeCrosta
Ditc of Inipc(l,on: 4/20/98
?; SYSTE.tis CONDITIONALLY PASSES )continued)
/� Sewage backup or breakout or high Static water level observed In the d,slrlbct,on oo= Is _-e _ =
ptpels) or due to a broken. senled or uneven distribution box. The system will pass
Board of Health) Describe observations:
broken pipe(s) are replaced
obstruction Is removed
distribution box Is levelled or replaced
40 The system required pumping more than four times a year due to broken or obstr;;Jec o•,e
,nipecl,on it (with approval of the Board of Healthl
broken pipe(s) are replaced
obstruction is removed
C! Ft-,RTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require funher evaluation by the Board of Health In order to deters. nz :i :r.e
health, safety and the environment .
SYSTE.1,s WILL PASS UNLESS BOARD OF HEALTH DE-TER-MINES THAT THE SYSTEM IS NOT
~'HIGH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT
1s
i1d Cesspool or prwy ,s wnh,n 50 feet of a surface water
,iP> Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt m.a�sn
:t SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPR`
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAlF
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS ,s w th n )J0
tributary to a surface water supply.
( s The system has a septic tank and soil absorption system and the SAS is within a Zone , o a
j The system has a septic tank and soil absorption system and the SAS is within 50 ice: v a ,
The system has a septic tank and soil absorption system and the SAS is less than !0C ee'. -
private water supply well. unless a well water analysis for col,form bacteria anc o,g;'
the well ,s free from pollution from that (acuity and the presence of ammon,a nnroge, a-• -
less than S ppm method used to determine distance .y34 (approximaiipn no:
3) OTHER
7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 87 Conners Road Centerville,Mass .
O�,ner: Estate Of Anthony DeCrosta
Date of Inspection: 4/2 0/9 8
DJ SYSTEM FAILS:
You must indicate e,: er "Yes' or "No" as to each of the following:
,tl4e, i have determined that the system violates one or more of the following failure criteria as defined in 310 Cn1R 15.303 The bass
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to conrec
the failure.
Yes No /
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or pondrng 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 di tribution box above
ove outlet invert due to an overloaded or clogged SAS or cesspool
4A - -r c y
Liquid depth in is less than 6" below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped Q
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 suppls
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
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 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
,Lg 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
N� 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 bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(raviaad 04/25/97) Pag• 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 87 Conners Road Centervi1 le,Mass .
Owner: Estate Of Anthony DeCrosta
Date of Inspection: 4/2 0/9 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health,
None of the system components have been pumped for at least two weeks and the system has been receiving normal
now rates during that period. Large volumes of water have not been introduced into the system recenti� 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,4V,-luding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum
— The size and location of the Soil Absorption System on the site has been determined based on
The facility owner (and occupants, if d}fferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
i/ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) O5.302(3)(b))
(revised 04/25/97) Peg• 4 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 87 Conners Road Centerville,Mass .
O..ner: Estate Of Anthony DeCrosta
Date of Inspection: 4/2O/98
FLOW CONDITIONS
RESIDENTIAL:
Design fiow ji�7D g p d./bedroom for S.A.S
~umber of bedrooms.
lumber of current residents
Caroage grinder lees or no) -$
:auncry connected to system (ye5 or no)
Seasonal use (yes or no) ti0
�':ater meter readings, if available (last two (2) year usage lgpd: /y 6 = �)�Cr 44�--�� ,-�r�E31�0/�
Sump Pump (yes or no):� �9`f�= r tiPa�b' _ /G/,Cry (�•_�Z6/
_asi Cate of occupancy
COMMERCIAUIN'DUSTRIAL:
Type of establishment z"A
Design flow A)A Sallons/day
Crease trap present (yes or no)&1-4
nousinal Waste Holding Tank present (yes or no)�/L
Non-saniiar, waste discharged to the Tale 5 system (yes or no;LZ
%a:er meter reaCings, if available
_as: Cale of occupancy. N
OTHER: ,Describe. AJ,I,
.as't care o' occupancy,
CENERAL INFORMATION
PUMPINC RECORDS and source of information
System pumped as pan of inspection: Ives or no),"
It yes, volume pumped / gallons
Reason for pumping JL
TYPE OF SYSTEM
- Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
A 1l) Priw
A)/ Shared system (yes or not (if yes, anach previous ins;�ection records, if any)
I/A Technology etc. Copy of up to date contract?
tither ./'%"
,�PPROXI T A E of all com nents, date installed (if knov,n) and source of information:
-�-�'� ,�y �ry/��n���
Sewage odors detected when arriving at the site: (yes or no) "
l:•v:••C 0�/15/57) F.9. 5 of 10
SUBSURFACE SBs AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTENA INFORMATION (continued)
Prooerl� Address:87 Conners Road Centerville,Mass .
o'ner: Estate Of Anthony DeCrosta
Date of Inspection: 4/20/98
BUILDING SEWER:
ocaie on site plan;
�4
Dep '
tn below grade �L
•,tiatenal of construction: _ Cast iron �iAO PVC _ other (expla plain)
Distance from private water supply well or suction line /*0 t
Diameter ,r
Comments (condition of joints, ve ting, evidence of leakage, etc.l �• _ , _ � �¢
s 4. �e
r
SEPTIC TANK: /Cr0Oyj¢4G��cir�
.,ocate on site plan,
N
Depm t>elo,, grade
aa,er aI of construction. oncrete _metal _Fiberglass _Polyethylene _other(expla;n)
;an, is meta, list aged.—Id Is age confirmed by Cenikate of Cumplhance/Z�4_ (Yes/No)
Stuoge depth%!
Distance from top of sludge to bonom of outlet tee or bailie
Scum thickness
D,s;ance from top of scum to top of outlet tee or bafite: �r
Distance from bonom of scum to bonom of outlet tee baffle:_'
now dimensions were determined:,—TC
Comments
trecommendat,on for pumping, Condit In of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structura
n;egriry, evi 'ence of leaka e, etc.)
GREASE TRAP:Z-&e'
locate on site plan)
Deptn Delov grade
:•.atenal of construct;on/L-Loconcreteggmetal,, ,be(g!;ns� Pulyethylenerti4other(expla n)
Dimensions. A1,4
Scum thickness.
Distance from top of scum to top of outlet tee or barfle.lf�
Distance from bottom of scum to bonom of outlet tee or baffle:2644
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, structure
ntegnry, evidence of leakage, etc.)
;r�r,��C 04/35/97) Pig• 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 87 Conners Road Centerville,Mass .
Omer: Estate Of Anthony DeCrosta
Date of inspection:4/20/98
TIGHT OR HOLDING TANK:,V( /t'_(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:/✓�
Material of con struction;&concretewAmetaXAFiberglasytAPoi�,ethylene—V other(explain)
Nres'
Dimensions: J"•
Capacin: .114 gallons
Design ilo ZJ !g gallons/day
Alarm level. / Alarm in working order,,l'es;.!/�l1 Nu
Date of previous pumping. —41W
Comments
(condition of inlet tee, condition of alarm and float switches, etc.)
B X:DISTRIBUTION O -)-�
(locate on site plan)
Depth of ijc ,d level above outlet invert:
Comme-s
(note if level and distribution is equal, evidence of solid carryover, evidence of leaka into or out of box, etc.)
is-
,l v-
PUMP CHAMBER:Z'L
(locate on site plan)
Pumps in working order: (Yes or No) 4�
Alarms in v:orking order (Yes or No) ,d,//
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revia.d 04/25/97) Page 7 of 10
SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FOR.'s
PART C
SYSTEM INFORMATION (continued)
Property Address: 87 Conners Road Centerville,Mass .
Owner: Estate Of Anthony DeCrosta
Date of Inspection:4/20/98
17
SOIL ABSORPTION SYSTEM
OC.aie on site plan, if possible; excavation not required, but mad be approx,mated by non-,n;resive
If not determined to be present, explain
leaching pits, number. D
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:---�
leaching fields. number, dimensions. L1
overflow cesspool, number
Alternative system.
Name of Technology: r
Comments
r. to con Gt On of soil, signs of hydraulic Jute. level of pondin ondtt.on of vegetation, etc )
COP �q I^ ,- Q i—
CESSPOOLS: iC'�
ioc.�te on s'te plan)
"vmG2r and configuration:
Deptn-(op of liquid to inlet invert
Depth of solids layer: AM
Depth of scum layer: AW
Dimensions of cesspool.
.mzenals of construction:
tnc,cation of groundwater: ANY
inflow (cesspool must be pumped as pan of inspect'on)IV
— - /
Comments
Note cononion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PR IVY:'±Zpp
;locate on site plan)
Materials of construction: D ,rnens.o-, --
Dep;n of solids
Comments.
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc )
Ir.v:..d Cc/1s/97) 7.9. 111 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 87 Conners Road Centerville,Mass .
OKner: Anthony DeCrosta Estate Of
Date of Inspection: 4/20/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
ir.cude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
7
) i
t'
Q
(revifed 04/25/97) Pag• 9 of 10
SUBSURFACE SEWAGE DISK SYSTEM INSPECTION FORM
SYSTEM IN'FOI. ON (continued)
Property Address: 87 Conners Road Centerville,Mass.
Owner: Estate Of Anthony DeCrosta
Date of inspection: 4/20/98
/
Depth to Croundwater:�C Feet
Please indicate all the methods used to determine High Croundwaie'r N .a.ion:
Obtained from Design Plans on record
Observation of Site (Abutting property observation hole, baseintfv-simp etc.)
// Determine it from local conditions
Check with local Board of health
Check FEMA Maps
_ 4"/Check pumping records
Check local excavators, installers
lase ',ISCS Data
Describe in your own words how you established the High Grounck,/atzr;levation. (Must be completed)
1 . Installed system. No water encountered at 12 ' .
2 . Used Water contours mao.
3 . Gahrety & Miller Model .
4 . 12/16/94
(revis.d 04/25/97) Psc. MQ ! 10
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TOWN OF Barnstable BOARD OF HEALTH
SWISIIRFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CH'fIFICATION
�...._....r.._...__.n r.---+.r-n•r..T:—er.--r.-re•r�-r—•.�—.Ts—rtnrr-•,�.-s�n�rr*-nrrr�m�.nr�mrv+ssm rr.mrrzr rm.r.r —r r r
-TYPO OR PRINT CI.EARL)'- r
PROPERTY INSPECTED
STREET ADDRESS 87 Conners Road Centerville,Mass .
ASSESSORS MAP , BLOCK AND PARCEL # Act
OWNER' s NAME Estate Of Anthon y DeCrosta
PA11T' D - CEIITIFICATION f
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J•P.Macomber & Seyl 'Inc .
COMPANY ADDRESS Box 66 Centerville,Mass . 02632
Street Town or City Stat• i1P
COMPANY TELEPHONE (508 1 775 - 3338 FAX ( 508 ) 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 :
�y s t e m' PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED* \
The inspection which I have conducted has found that the system fails to
protect the public health and the environment in accordance with 'Title
5 , 3tO CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
„r 1
Inspector Signature r Date � J';
One copy of this certification must be provided to the OWNER , the BUYER
( where applicable ) and the BOARD OF HErAL1'll ,
IC the inspection FAILED, the owner or "operator shall upgrade the aystem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CmR 15 . 305 .
partd . doc
w
y Y
rr7
b
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15 . 340 and Section 13 of Chapter 21 A of the
General Laws. Issued by The Department of Environmental Protection.
June S. 1995
Acting Director of the 6on of Water Pollution Control
TOWN OF BARNSTABLE
, i SEWAGE #
i ���/�
LOCATION `
VILLAGE` ASSESSOR'S MAP & LOT�J`V�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) I� a (size)
NO.OF BEDROOMS
BUILDER OR OWNERS�,/f-
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: P
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well 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 leaching)aci ' � Feet
Furnished b
LU
�� sr'3
30.00
II' No.- _4;A •_ Fizz.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
OWN OF BARNSTABLE
Appl cation is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
67 Conners Road Centerville
...----•----......................•--•-•I-•---------....----•-•--•--••-••-••----......_..._.._.... _...._..._..._..•-•••-••-.....-•-•••-••-••-•-----••--••----•••----........................-----•--
Anthony DeCrosLoation-Address or Lot No.
...........................•---............__ .----•------------------•-----•-----...-•--•-
Owner Address
W J.P.Macomber Jr.
-------- ....... •--•----
Installer Address
d Type of Buildin Size Lot............................Sq. feet 2
V Dwelling—No. of Bedrooms______________________________ __ _Expansion Attic ( ) Garbage Grinder ( )U
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures __________________________________
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No.____________________ Width.................... Total Length.................... Total leaching area___________.________sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
GTq Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
M •-•••-•-•••••-••...._____•-•----•-•••••-•••-•-••••••--••--•-----•--•-•••-•---•-•••--•--•-•-••--•••••-••-•--••----------••...•••............................•-
O Description of Soil S
xar7d---&- G- `av-e l--------------------------------------------------------------------------------------
w
--------------------------------------------------------------------------------------------------••-- •-••-••------••-••--------••--••---•-•--••--••-----•-•••••••••-•••-
1 1C0'J gallon tanl Y•=---•----•---•�-•••------
UNature of Repairs or Alterations—Answer when applicable.___________________ ________________________________________________________________________
distribution box 1-..00Callon _ eachin .-•Pit,-------------------------•---- ...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee is ed b the boar of alth.
igned.............. . .. .-- - ..... ........... ......................... ..-----5/2-1/92-----
Date
Application Approved By .. ..- ..... ......... ................ ........ . .... ... ...... .. ..:......
--- -- ------------------------------ --'-.-.....----- -----------------
Dace
Application Disapproved for the following reasons- ---------- ----'----........-......-------'---...--------...---.......----------- - -- ----------.-....--------...-------------
-..
........... .... ---------------------
y � Date
PermitNo. - - -- ---------------------------------------------- - Issued --....................................................----............ ,..�
Date
.� 0� _»
No.....ti< -------- ... F�s.. ....a!J..J2...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD/O-F HEALTH
TOWN OF BARNSTABLE
Vpfiratiou for Di"aoal arks Ton,itrnritun Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
R7 Conners Road Centerville
................_................................................................................ ---...---------•...-•---•-•-.......--•---•••--•--•------------.....-----••-------........_--------
Location-Address or Lot No.
Anthony D _Cr.g,9.ta.._... ---.....----
Owner Address
WJ.P.Macomber• Jr....................................................... -------------------------------------•----.....-•------•-•------•-•---•-----------•••---•--•--•---
Installer Address
PQ
Q Type of Building Size Lot............................Sq. feet
U Dwelling-Z No. of Bedrooms............... __________ ______ _______Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
P4Other fixtures .------•---------•---------•-•---------•--------------•-----------------------_._.---------------•-----------•-----•------------...._•---•------------
W Design Flow............................................gallons per person per day. Total daily flow.........................._........__.......gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-________._-__ Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area_._.................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' -•...........................•-• •-•---------------------•-••••--------•-•........----._._...--••••........................................................
Descriptionof Soil---------------------------------------------S•--an-h'd-- ..._..... ....... ----------•----------•-----•-------•...-•------•--------------•---•-------------------
x d & Gravel
v ..............................................--------------•----------------••-•••--------------•---------•-•-••--------------------••••..............................................................
W
---•---------- ............................................................................---------------------------................................................................................
V Nature of Repairs or Alterations—Answer when applicable------------1---1_Q9!?... 1.
...di_s,t_r_h).zta-an---hnX...1- 0!)!)...gallon----le—a hi-n�P:---P-i-t-9-----•--------------------------------------------------------------•---•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of ealth.
i ned
g G - --------- --- ..-....----- ----------`./21L-U2-----. --
Date
Application Approved By ....... ..... ...... _ f!L- L---- l'!
Date
Application Disapproved for the following reasons- -------------------------------------------------------------......................................................-----------------
................... --------------------------------------------------------------------------------------------............
----------
..�• Dae
PermitNo. ---- - -------.......---------------- -- -- ------------ Issued -- ............................................................ �I
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
tEer#tftrate of Tompliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or RepairedxXX
by ...J..P-.-Macomber Jr.......................................................................•...................------ ---- -. --...............--- --...--..--..--..........-------------- X)
:
Installer
at ---F7---Connors Road Centerville
-------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------....-.-.--...::---------------
has been installed in accordance with the provisions of TITLE 5 ofrThe StateTrivironmental 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 FUNCTION SATISFACTORY.
DATE-------------- .................. - Inspector ............................�j't� / ; ��' W.................. .. -------.....................
f f J A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH/�
� TOWN OF BARNSTABLE
No........................ FEE........................
Dispasal Workii Tnnir ion "permit
J P-Macomber Jr.
Permission is hereby granted ---------------•---------------------------•------..•------------------.-.----------•••------.._.....__--_-•---
to Construct ( ) or Repair ( X) an Individual Sewage Disposal System
at No..t_ Connors -Roa Centerville /
------ ------------•--. ..----- A
Street
i
as shown on the applicati 41 for isposal Works Construction Permit o.�._ ___. .I/_ ated__ ________________ /f� ) ,__...,
�� 9 Board of Health
DATE.................... 7---��-. "`
FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS
L� TOWN OF BARNSTABLE
LOCATION 7 6 D -Y ,Qa . SEWAGE
VILLAGE C'e klree4V1I- ASSESSOR'S MAP & LOT '®/l �
INSTALLER'S NAME & PHONE NO. ,/�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ,Q�T (size) /• oez)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: 51, dqa
DATE COMPLIANCE ISSUED:
qj-
VARIANCE GRANTED: Yes No
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i
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