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Home My WebLink About1116 CRAIGVILLE BEACH ROAD - Health l l l 5 Craigville Beach Centerville A=206-090 oYuu° //7/I� ®' UPC 10259 No.H� HASTINGS.YN o , i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1116 Craigville Beach Rd Property Address Kerry,Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. City/Town State Zip Code Date of Inspection 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: A. General Information When filling out �J forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name reb P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)477-8877 S14454 Telephone Number License Number B: Certification tr_1 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 maihtenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to_Section 1.5:340 0. Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails; ,l i� ❑ Needs Further Evaluation by the Local Approving Authority `,� rn ` 2/10/2011 Ins ctor'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. C/ t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 0 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. CitylTown 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 septic system is in porper working order at the present time. 13) . 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I e R Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 FIND (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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ° M 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every 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 1/2 day flow t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma., 02632 2/10/2011 every 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— IW PA) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. Cityrrown 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d NA g ( Y 9 (gP ))� Detail: Sump pump? 0 Yes ® No Last date of occupancy: NA 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title .5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma., 02632 2/10/2011 every page. City/Town 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'w 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: f 6t Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): 10, Distance from private water supply well or suction line: fe eee t Comments (on condition of joints, venting, evidence of,leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 1.5 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 gallon •311 Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ° M 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. City/Town 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 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every 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•11/10 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 ,M 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. Citylfown 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 No 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.): Box is Ievel.Box AS ONE OUTLET LATERAL.No evidence of solids carryover.No evidence of leakage. 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.): Pump chamber appears structurally sound.Pump,floats and alarm in proper working order. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 Flowdiffusors ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Leaching was dry at time of inspection. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 • • t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 'Map _ . Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® zoom Out f f]IE B n IV U In yv, Ra � r R 11 y ',•.�3 j 1 d� 3 q1 F V� , ry� "v ..T.010 1 10% In Set Scale 1" = 20 j r I iAerial Photos I MAP DISCLAIMER (`-nnvrinhf 9nOC;_9n1f)Trnern of Pnrnetnhlo INAA All rinhfe roconr; http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=206090&mapparback= 9/19/2003 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. City/Town 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: Bottom of leaching 1' 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: As-built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 y . . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1116 Craigville Beach Rd Property Address Kerry Bulawka Owner Owner's Name information is required for Centerville Ma. 02632 2/10/2011 every page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 DATE : 9/6/02 PROPERTY ADDRESS: 1116-Craigville Beach-Road RECEIVE® Centerville,Mass. -- enter ille,M s -------- SEP 2 5 2002 02632 ------------------------ TOWN OF BARNSTABLE HEALTH DEPT. On the above date, I inspected the septic system at the above address. This system consists of the following: � � 1 . 1 -1000 gallon septic tank. 2 . 1 -Pump chamber. 3- 1 -Distribution box. 4 . 3-F6°asedlon my Inspecttio n I certify the following conditions: 6. This is a title five septic system. ( 78 Code ) 7 . The septic system is in proper working order at the present time. 8. Pumped the septic tank at time of inspection. 9 • Installed by drawn engineered plans. ( On file Barnstable Health Dept) 10 . Engineer; Peter Sullivan. ( Formerly with Baxter & Nye) Osterville,MaSS. ! ! . All variancesand conservation releases were approved in 198.9 SIGNATUR Name : J . P . Macomber Jr . ---------------------- Corripany : Joseeh P._ Macomber & Son, Inc , MAP Address :__Box ..... PARCEL LOT Q2632-0066 -- - Phone:--508-775-3338 ------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 a -\ COMMONWEALTH OF MASSACHUSETTS x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property' Address: 1 1 1 6 Craivi1le Beach Road Centerville,Mass. 02632 Owner's Name: Owner's Address:P ,Box 922 Centervill_e,14ass. 02632 Date of Inspection: q/g.In2 Name of Inspector: (please print)Joseph P.Macomber Jr, Company Name: J,P,Macomber & Son Inca Mailing Address: Box 66 rPnt-arvi 1 1 P,Ma s--;_ 02632 Telephone Number:508-775--13. 8 CERTIFICATION STATEMENT I certify that 1 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. 1 am a DEP approved system inspector pursuant to Se tion 15.340 of Title 5 (310 CMR 15.000). The system: Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: The system inspector shall mit 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 authoriry. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1116 Craigville Beach Road Centervi e,Mass. Owner: Mary Balsamo Date of Inspection:9 6 02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Cys=temPass�e) X0 1 have not found any infor�Ayy hich indicates that any of the failure criteria described in 310 CMR 15.303 or to exisfailure criteria not evaluated are indicated below. Comments: I The septic system is in proper working order at the prt-spnt time, B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined" please explain. 426 The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 14 � The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 ' Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:1 1 1 6 Craigvi1le Beach Road Centerville,Mass. 02632 Owner:Mary Balsamo Date of Inspection: 9/6/0 2 C. Further Evaluation is Required by the Board of Health: ,9/0 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: VoCesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if 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 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 I 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. /)e)The system has a septic tank and SAS and the SAS is less than 100 feet but 5 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Paoe 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Pro ertv Address:l 1 1 6 Crai ville Beach Road P I Centerville ass. Owner: Mary Ba 1 s;amn Date of Inspection: 9/6/Q2 D. System Failure Criteria applicable to all systems: You must indicate "yes" or"no" to each of the following for all inspections: Yes No �8ackup 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 distributeRRn box above outlet invert due to an overloaded or clogged SAS or xWsspool �� .✓ iquid depth in cesspee�ess than 6" below invert or available volume is less than ''A day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number f times pumped I . y portion of the SAS, cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ater supply. _ of a cesspool or privy is within a Zone I of a public well. Xr' y portion of a cesspool or privy is within 50 feet of a private water supply well. l0 Anyportion of a cesspool or privy is less than 100 feet but eater than 50 feet [Tom v P P p �y greater fi a private water supply well with no acceptable water qualiry analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma (Yes.'No) The system fails. 1 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. You must indicate either"yes"or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no / _ the system is within 400 feet of a surface drinking water supply ;/the system is within 200 feet of a tributary to a surface drinking water supply l' the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered ..yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 1 1 6 Craiqville Beach Road Centerville,Mass. 02632 Owner: ark Bal samo Date of lospectioo:9 jr' 4n? 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 11kere 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 pan 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? 'Alas the site inspected for signs of break out ? 47 Were all system components, -"luding the SAS, located on site ? V _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page 6 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 1 1 6 Craigville Beach Road CentervillefMass_ Owner: Mary RaI samo Date of Inspection: 9/6/0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): � Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):�w'o —9pely Number of current residents:_ 6 Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system or no):/JJlJ[if yes separate inspection required) Laundry system inspected ky s or no): Seasonal use: (yes or no): 2 Water meter readings, if available (last 2 years usage (gpd))�000=29, 000 gallons=79 . 46 GPD Sump pump (yes or no): 2 = , gallons=95. 89 GPD Last date of occupancy: ,lz COMM ERCIALANDUSTRIAL ` � Type of establishment: V'W Design flow(based on 3I0 CMR 15.203): _gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): dV Industrial waste holding tank present (yes or no):.,VO Non-sanitary waste discharged to the Title 5 s stem (yes or no):.�� Water meter readings, if available: .lJ Last date of occupancy/use: �l OTHER(describe): GENERAL INFORMATION Pumping Records SourceofinformationTank Only Maint. 6/19/96 6/27/97, 6/25/98 & 6/23/99 Was system pumped as part of the inspection (yes or no): S If yes, volume pumped: le+O gallons -- How was quan ity pumped determined? ��✓�a/��y"r Reason for pumping: Scum & solids layers were present. Also the ked for water intrusion. ( None) TY 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 'o pined from system owner) Tight tank �Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed (if known)and source of information: System was installed 6/22/89 By; J P Macomber & Son Inc. Were sewage odors detected when arriving at the site (yes or no): .1/4 6 Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 1 1 6 Craigville Beach Road C'enterville ,Mas Owner: Mary Balsamo Date of Inspection: 9/h/02 BUILDING SEWER(locate on site plan) Depth below grade: 14 Materials of construction: ast iron Y40 PVCA/dother(explain): 144114 Distance from private water supply well or suction line: /c#'A- Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight No evidence of leakage The system is vented through the house vents. SEPTIC TANK: Zlocate on site plan) id44 j� Depth below grade: JUG' fad�% Material of construction: _�oncreteA*metaWd fiberglass4kpolyethylene 4U other(explain) �7 If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no):.0(attach a copy of certificate) l i1 j Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: _ 0 Distance from top of scum to top of outlet tee or baffle:_(!I Distance from bottom of scum to bottom of outlet tee or baffle: How-were dimensions determined: Pumped tank at time of inspect on. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump the septic tank annually. Pump chamber is present.Do not want Solids to pass to the pump chamber Inlet & outlet tees are in place.The tank is structurally sound and shows no evidence of leakage. GREASE TRAP locate on site plan) Depth below grade:X,,j Material of construction:,fjQconcrete AO metal fiberglass.�.Jp polyethylene4O other (explain): AX Dimensions: lelw Scum thickness: 10.4 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: A4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present. 7 Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1 1 16 Craigville Beach Road Cg_nterville,Mass. Owner:Mary Baisamo Date of lospectioo:9 6 02 TIGHT or HOLDING TAN i/rL(taitk must be pumped at time of inspect ion)(locate on site plan) Depth below grade: -0- Material of construction: Xqconcrete metal A14 fiberglass P�polyethylene 4�k7 other(explain): Dimensions Capacity: gallons Desien Flow gallons/day Alarm present (yes or no): Alarm level: " Alarm in working order(yes or no): Date of last pumping: tW Comments (condition of alarm and float switches, etc.): Tight or holding tanks are not present DISTRIBUTION BOX: Zof present must be opened)(locate on site plan) Depth of liquid level above outlet invert: yy 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.): Distribution box has one lateral.No evidence of solids carry nvPr_No evidence of leakage into or out of t e ox PUMP CHAMBER�� (locate on site plan) Pumps in working order(yes or no): L Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): P ,im anrl Tn„rn rhamhr- are in working Light & alarm are in L y�order. r. 8 Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1 1 1 6 Craigville Beach Road C'ant-ervi 1 1 a�Ma�s _ Owner: Mary Balsamo Date of lnspection:9/6/02 SOIL ABSORPTION SYSTEM (SAS): locate on site plan, excavation not required) 3_-Flow diffussors in sereies. g'X8 'X14" If SAS not located explain why: Located: See page 10 Type ,� D leaching pits, number: 2TE5 leaching chambers, number: j/o d'W, A,Q leaching galleries, number: D leaching trenches,number, length: D leaching fields, number, dimensions: Q overflow cesspool, number: /UQ innovative/alternative system Type/name of technology:%f/tj Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamv sand to beach sand.No signs of hydraulic failure or ponding. Soils are dry Vegetation is normal CESSPOOLS4(?(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: f� Depth—top of liquid to inlet invert: �J Depth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspools are not present PRIVY/LLdf,�e(locate on site plan) Materials of construction: Dimensions: /W Depth of solids: x Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy i G nc)t- DrP-,F+nt 9 Pagc 100r11 O17FICLA-L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWACE DISPOSAL, SYSTEM INSPECTION FORD PART C SYSTEM INFORMATION (coniinvcd) P,oPcrr� .,oaf(,,: 1 1 1 6 Craicfville Beach Road t�prvilla.,MaSS. 02632 Orocr; Mary Ba samo Dlic o11n,PIclioo: 9/6/02 SKETCH OF SEWACC DISPOSAL SYSTEM Pion o1 1 Ix11cl of 11 11w1�1 0"Polll ly)lcm inclvd(ng llct !0 11 Icail two perminint rcrcrcncc lanCmux, OanlrrnVk, LOc1,< III w011 within 100 (111. Locm whm pvblic wcicr lvpply cnlcrl (hc bviloing. to 1_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH QQ Q� .........Taw.n...................OF...............Har.ns.t~ab 1 e..........................-.......... No...(J.. ../lu.. FEE.... ....2�}..-Q�- DioVooal Workii Tonatruxam "nmit Permission is hereby granted.......J...P-.....Macomb tex...Zx.............................. ... . ...... ........................................ to Construct . ) or Repair (X)� an Individual Sewage Disposal System at No......./.%l,.......C-r-ad-gvi-}.1e•--$ea-c-h....Roa-d....fie tre v }.}e.............. .. Street Qy as showq on the application for Disposal Works Construction Permit No..P.........1. Dated.-- .............� Y�.. l- ! .. .� .� ......................................... IIoard of Healt DATE....- . •-�.--•-- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................Town.............OF..............B.3.r.ns. . .}J� ....................................... GnI f iratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal Syste constructed ( ) or Repair x ) by•-•-J•-P.-..Macomber....J r.............................................................................. .. .... Installer' at....... . . ..Cr.ai. viLLe...Beach...goad...Cen_terv.iile........... .. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s described in th� application for Disposal Works Construction Permit No......................................... dated .......................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C011STRUEI) S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE:,4 ....?'' - ................................... Inspector............ --- . t . Page I I of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11 16 Craiavi1le Beach Road Centerville,Mass. 02632 Owner: Mary Bal samo Date of Inspection: 9/6/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: YES Obtained from system design plans on record - If checked, date of design plan reviewed: 9 5 0 2 yFS Observed site (abutting property/observation hole within 150 feet of SAS) N.0_— Checked with local Board of Health-explain:Installed YES Checked with local excavators, installers- (anach documentation) yRS Accessed USGSdatabase-explain: http: //town. barnstable.ma.us. You must describe how you established the high ground water elevation: Jsed: Gahrety & Miller Model. 12/16/94 Ground water elevations above sea level. Jsed: USED: USGS: Observation well data. June 1992 Jsed: USGS-: Technical bulletin 92-000-1 Plate #2 Janiary 1992 Annual ranges of r un 1 v ions 3-Flow Diffussor �eet �7 Groundwater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is d feet. ll f 9 ".T.�T^rtf'TT�.'fT tTlT.-Sii.•'RiZT+r.iSTT.TTt'.T•'r'TRr:TT'i't'I'ITfTITRT'L.i 1'iyQ:TLT..Ji1 TOWN OF Barnstable BOARD OF HEALTH � -_SUI1SUItFACR 9ENA(;F DISPOSAL ,SY�STF;M IN�9I�'ECTION FORM - PART D^- CEfZTfF1CATIONr � —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS _1116 Craiqville Beach Road Centerville,Mass. ASSESSORS MAP , BLOCK AND PARCEL #206-090 OWNER' s NAME Mary Balsamo PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr. , COMPANY NAME J.P.Macomber & Son Inc:""' COMPANY ADDRESS Box 66 Centerville Mass.02632 street Town or City S t a t 0 LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX P08 ) 790 _ 1578 n CERTIFICATION STATEMENT R I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and omplete as of the time ofiinspection . 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 . Ch/ec}y one ; Y System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healt)t or the environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection wlliclt I have conducted has found that the system fails to Protect the Pttblic health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspecteo f m . I Inspector Signature Date copy of this" rt.ification must be provided to the OWNER, the BUYER One Where applicable ) and the 130ARD OF IIEAL7'Ii. * If the inspection FAILED, the owner or" _P.erator shall upgrade ' the system within one ,year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CPIR 16 , 305 . partd - doc /� 4- _2 TOn OF Ai�N LE {� LC�ATION SEWAGE # VILLAGE SSESSOR'S MAP & LOT D 'INSTALLER'S NAME& PHONE N . i SEPTIC TANK CAPACITY 777 LEACHING FACILITY: (type) f�� C�GL�IGC� (size)a4n > NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 f t of leac 'ng facility) Feet Edge of Wetland d hin tlity(If any etl s exist within 3 et f ac ility) Feet Furnishe y i r' � ii � � � � � i � '�� 1� � t r / \ yr� �' � �.i DATE. 3/3/00CID _ PROPERTY ADDRESS: 111,6-Crai ville Beach Road Centervi 11e,,Mass L,______ 02632 ---------------- On the above date, I Inspected the septic system at the above address. This .system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 1 -Pump chamber 3. 3-flow diffussors. 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- -tank has been pumped annually since 1989 , Tank was pumped for maintenance purposes only. 7 . Pumped and maintained by J.P.Macomber & Son Inc. SIGNATURE:,f Name: Company: Jose2h_P` Macomber & Son , Inc . Address:_ Box_6 6 ------- --Centerville L Ma__02632-0066 Phone:...508 775_3338_______ THIS CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY r7— SEPH P. MACOMBER & SON, INC. Tanks•Cesspool:•Leach!folds Pumped L Installed Town sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.33138 775.6412 t COMMONWEALTH OF MASSACHUSET M EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292.6600 Vj TRU'Dy C Seer ARGEO PAUL CELLUCCI DAVID B. M. Governor CoIILRS:.J� SUBSURFACE SEWAGE DISPOSAL SYSTEM•WSPECT)ON FORM PART A CERTUWATION Property Address: 1116 Craigvillebeach Rd. uaffw of Owrw Phyllis R. Dubinsky Centervill M 02632 AddressofOwnw: 741 ary an AVE Dsu of inspection: .3%3 7 8 S t. Louis,MO. 63130 M&'M of�UW: (Ptease P� Joseph P.Macomber Jr. I art+a DEP approved systern Inspector pursuant to Section 15.340 of TMe 6(310 CUR 15.000) compwry Nafrw: J P Macomber & Son T_nc_ M&TurgAddrass: Rnx 66—rr �tc� 11p7Mass. 02532 Teiaphona Nurtsber: CER'nRCATlON STATEMENT 1 cartity 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 tnspectlon. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site St age disposal systems. The system: '1pp PPasses Cond(tJon all j-Pisaaa _ Needs Further Evaluation By the Local Approving Authority _ Fails Iru.pectoes SJgnature: L X Data: The System Inspecto all submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wIWn thirty (30) days completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater,the kupettor and the system ow shall submit the sport to the appropriate regional oMcti of the Department oKmY1ronmsrMM Protection. The original shouidU.sent tomw system owner and copies sent to the buys(. If applicable, and the approving authority. NOTES AND COMMENTS ,!EU MAR 6 2000 1 of 11 .r TOWN OF W'SIA3LE Pees revised 9/2/98 H .t Pi. �, ►Mted on a•cvCW/spar `� f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA PART A i CERMCATiON(con vjed) PropertyAd& ..: 1116 Craigvillebeach Road Centerville,Mass. Owner: Phyllis R. Dubinsky DawOf WaP--I°n:3/3/00 INSPECTION SUMMARY: Chock A. B, C, or D: A. SYSTEM PASSES_ 5 1 have not found any Information which Indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any fsawe criteria not evaluated are Indicated below. COiAMENTS: S. SYSTEM CONDITIONALLY PASSES: X116 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,wW 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 exfiluation, 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 pips(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 pipes)are replaced obstruction Is removed distribution box is levelled or replaced The system fsquired pumphtg-more than-four-times-a-yeardus to broken or obstructed pipe(sl. The iystsm wAt7zxr— Inspection If(with approval of the Board of Health): _..._. broken pips(s) are replaced obstruction Is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Add,eu: 1 1 1 6 Craigvillebeach Road Centerville,Mass. Owner: Phyllis R. Dubinsky Date of lnspection: 3/3/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 1,7+ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 16.303(1D)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.l AUPRQTECT THE PUBLIC IIiFJ1LTILAND SAFETY AND THE ENVIRONMENT. Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC.HEALTH AND SAFETY AND THE ENVIRONMENT: 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. AZ n The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less then 100 feet but SO feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance 44e (approximation not valid)•- 3) OTHER .k) 44 revised 9/2/98 Page 3orIi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ProWtyAddress:1116 Craigvillebeach Road Centerville,Mass. Owner: Phyllis R. Dubinsky Date of Inspection: 3/3/0 0 D. SYSTEM FAILS: You must Indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No/ s Backup of.**wage irrtofecih " --system component•due%to an overloaded orclegged•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. t/ Static liquid level'n the di tribution box ab out et invert due to an overloaded or clogged SAS or cesspool. Liquid depth in caeepeoFIs less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped I. Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public well. J/ 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. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: Ah 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/ l the system is within 400 feet of a surface drinking water supply the system is-wltWn 200 feet of•w-*Abutary49.0 aurfaoa•drinkiwg•watar•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 regional office of the Department for further infognation. revised 9/2/98 Page 4of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM c PART B CHECKLIST PropartyAddress: 1116 Craigville Beach Raod Centerville,Mass. Owner: Phyllis R. Dubinsky Data of Inspection: 3/3/0 0 Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the systemcompoaaants Iw►ss:bwn pumpedAwaRJeasttwoaweakeand-siae"tystem hasbaeagscalaiwgwsasai flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. fL _ 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, e"kcluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on-the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / 115.302(3)(b)) Y _ _ The facility owner(and.occupants.if dlfferant fforn-o wnw), wa prauklad,Iwlth Infnrmati oapn tha proper rnaintaaan......f Subsurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ProWtyAddress: 1116 Craigville Beach Road Centerville,Mass. Owner: Phyllis R. Dubinsky Date of lnapection:3/3/0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: I//) g.p.d./bedr om. Number of bedrooms( esi Number of bedrooms(actual): Total DESIGN flow Number of current residents: } Garbage grinder(yes or no): Laundry(separate system) (yes o o : If yes,separauJimpection.required Laundry system Inspected` Y so n Seasonal use lyes or no): Water meter readings,if available(last two year's usage(gpd): 9i7f� �� Sump Pump(yes or no): e�' �1�,(,�'� �� Last date of occupancy:= ` CO M M ER CIA L/INDUSTRIAL Type of establishment: Design flow: �4 A cad ( Based on 16.203) Basis of design flow /UJF Grease trap present: (yes or no) ^ Industrial Waste Holding Tank present: (yes or no)" Non-sanitary waste discharged to the Title 6�xstem: (yes or no)I ? Water meter readings,if available: Jy/f Last date of occupancy:AA— OTHER:(Describe) Last date of occupancy: NIf GENERAL INFORMATION PUMPING RECORDS and source of information: Main er & Son Inc. System pumped as part of inspection: yes or no) It yes, volume pumped: 0 ga llons Reason for pumping: TYPEO AV— SYSTEM Septic tank/distribution box/soil absorption system ,, _ Single cesspool Overflow cesspool ,4,b_ Privy tir Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract TF Tight Tank Copy of DEP Approval Other 4 APPROXIMATE AGE of all qornp nts, Asts injta8ed4if own • nd source iwf lion: - �y SewsW odors detected when arriving at the site: (yes or no) 4" revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION(continued) Property Address: 1116 Craigville Beach Road Centerville,Mass. Owner: Phyllis R. Dubinski Date of Inspection: 3/3/0 0 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:Zast iron/0 PVC40other(explain) Distance from private water supply well or suction line Diameter_Yr Comments: (condition of joints, venting, evidence of leakage,-etc.) — - Joints appear tight - Na elzi denne—cif leakage. SEPTIC TANK: (locate on site plan Depth below grade: Material of construction: concret.429 metaI43 Fiberglass 44Polyethylen"ti other(explain) If tank is Enetal, list age is.age.confirmed by Certificate of Compliance (Yes/No) Dimensions: '! Sludge depth:2z4& -- Distance from top�ludge to bottom of outlet tee orbaffie-,�Q� —' Scum thickness: -'L.� Distance from top of scum to top of outlet tee or baffle: r[ -- Distance from bottom of scum to bow of o t et t e or baffle: How dimensions were determined:, Ay Comments: (recommendation for pumping,condition of Inlet and outlet tees or-baffles,depth of.liquid level in relation to outlet Invert,,structurei-integrity, avid nce of leakage,etc.) LoaIT1 inlet .& outlet tees are in place L d 16ina of_f-hA=1 otititlet fQ xQr-t is 51 he tank ; g gtr„e- -„ga1 sol3ad aRel she;s ne evidence GREASE TRAP: i (locate on site plan) Depth below grade:�� Material of construction:�f/�concretatlmetal��Fiberglass4/_tPolyethylen-JNother(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffie:.AIW Distance from bottom of,scum to bottom of outlet tee or baffler Date of last pumping: err Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert, structural integrity, evidence of leakage,etc.) Grease traD is not present revised 9/2/98 Page 7of11 �. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO N FORM _ PART C SYSTEM INFORMATION(continued) Property Address: 1 1 1 6 Craigville Beach Road Centerville,Mass. Owner: Phyllis Dubinsky Data of Inspection:3/3/0 0 TIGHT OR HOLDING TANK:A&&(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction:.aconcreted4metal44 Fiberglass VfPolyethylene //other(explain) AM Dimensions: .e/d Capacity:_gallons Design flow: 4,1A gallons/day Alarm present_ Alarm level: Aq Alarm in working order:Yes No_4/4 Date of previous pumping: 414 Comments: (condition of inlet tee, condition of alarm and float switches,etc.) Tight or holding tanks art- nnt��eUj- DISTRIBUTION BOX:-4/ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.).Distribution box hag nne lateral No euidence of solids--rar-rrover. No Pvi dPnnP of leakage ; Qtr on o it of the bee PUMP CHAMBER: t (locate on site plan) Pumps in working order:(Yes or No)-)6c Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) Pump chamber is gtrtntttra l l U gnitnr3 211ro and f l nctc ri crest i nn rn=t-rlr� Chamber hag ht-t-n rkecked and maintainer, anntiaiiT■ revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM 11iSPECTION FORM ' PART C SYSTEM INFORMATION(continuad) PropertyAddvess:1116 Craigville Beach Road Centerville,Mass. Owner: Phyllis Dubinsky Data of lnspectlon: 3/3/0 0 SOIL ABSORPTION SYSTEM(SAS) (locate on sita plan,If possible:excavation not required,location may be approximated by nondntrusive methods) If not located, explain: Type: _ leaching pits,number: leaching chambers,number: �/ J71OA! NI r0'tl��ars leaching galleries,number. leaching trenches,number, length: leaching flelds, number, dimAsions: overflow cesspool,numb�(( Alternative system: A);.` Name of Technology:1Tltr2 give 78 Code Per Engineer Drawn Comments: plans. Peter Sullivan. ( Baxter & Nye ) (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) o sl ns Pon0ing. Solis is nnrmaj CESSPOOLS: (locate on site plan) Number and configuration: 4 Depth-top of liquid to Inlet Invert: Depth of solids layer: Depth of scum layer: Dimenslons of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of Inspection) esspools are not nrpRenf- Commenu: (note condition of soil, signs of hydraulic failure,level of ponding,,condition of-vegetation, etc.) esspoo s are not present (locate on site plan) Materjals of constr c qn: �� Dimensions:_�� Depth of sot :A, Commenu: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy is not p rpcpni- - revised 9/2/98 Page 9ofII l ` i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(con*vued) PrWw%yAd&&": 1116 Craigville Beach Road Centerville,Mass. Owrw: Phyllis Dubinsky Date of Insp.cdon: 3/3/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include tie to at least two permanent reference landmarks or benchmark& locate all wells within 100' (Locate where public water supply comes Into house) revised 9/2/98 Page to or,) t e • ' TOWN OF BARNSTABLE LOCATION 11/` C itq 4 e A & " VILLAGE �,� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) did Q;�uSS (size) . NO. OF BEDROOMS 2_PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER_ '\ _A DATE PERMIT ISSUED: a, DA11; COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ` All SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) P.opertyAddre": 1116 Craigville Beach Road Centerville,Mass. Owner: Phyllis Dubinsky Date of Inspection: 3/3/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicateall the methods used to determine High Groundwater Elevation: /Obtained from Design Plans on record Observed.Site(Abutting propertyJobservation hole, basement sump etc.) Determined from local conditions --y-1/checked with local Board of health Checked FEMA Maps -hocked pumping records —'z/Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water Contours Map. Gahrety & Miller Model 1 2/1 6/94 Engineers drawn plan on file at the Barnstable Board Of Health revised 9/2/98 page norn ...nnr.-n•rr—.�-rr.rnrmr•nmr.�rn a�.rrr..r:•.T+srnr�nrr+rinn nereZ++sntrees�s rn-r,-r-�r--r-:..-..r-... ,I'ONN OF Barnstable BOARD OF HEALTH SOBSURFACF SF.HACF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ...rr�•r•..-•.+.--...a.--.rnmr-�-rr.•rr.rs+r+eerrrnnn-r-.s�.�v+.r�srw�•`•+w+w� ran n .-,rr+••••r-„-..J -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 1116 Craigville Beach Road Centerville,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # 206-090 OWNER' s NAME Phyllis Dubinsky PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sell 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 ra 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at 0ecoinmendations his address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any 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 ne : . 1 Systeui 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 con Ucted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . "r - Inspector Signature Date copy of this crtification must be provided to the OWNER, the BUYER Ong ere applicable ) and the I30ARD OF HEALTH. * If the inspection FAILED, the owner or•#'o` pgrade ' the system wi orator shall u Pthin one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .doc No.--- y' Fims.....$.....2 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town......................O F.........b.amns t.ab l.e..---------------.............................. Appliration for Disposal Works Tontrnrtiun Famit Application is hereby made for a Permit to Construct ( ) or Repair kX) an Individual Sewage Disposal System at: ........ ._.Q eju t e r,.vjIIe----------------------------------•---------•------------------------------------- Location-Address or Lot No. ..........AU.b-b1&1r i----------------------------•--•-------........................... .................................................................................................. Owner Address a ..........J.-2._MaQ0MbP_r...Zr.............................................. -•--•-•----------------------.......-•---.............-•-•-------..................._.....-------- Installer Address dType of Building 'Size Lot............................Sq. feet U Dwellingx-No. of Bedrooms...............3....................--....Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ............................................ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.----.--------.--...__. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.---------. -.--.----- a -------•--•.............•-------------••--•--••--••-•--•--•--•--•-------•---.-•-••---........................................................................ 0 Description of Soil..............................•------•---------------....-------•-------------------------------------------------------------------------------------------------••-•- U -•••----------••---•---•-----•-------•-------------•----•-•-•••-•-••--••••--•--•-•-- Sand.----.....--------•--••--•----------------------•-------------•---------------•-------•--•-------•---- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•----------•----•-•. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..................1-_IQQO...ga1.1,o-n-- tank----3----f tow-d-i.f:-f-us-s.0bs----------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 1 T TIE p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issu b t oard o' e h. Signe -• •--- s ...4/-2- /8�--------- Date Application Approved By........... --- ---------- ---- - ---•. •--•-•---•-•---•••••.............. Z-7. ��---- Da Application Disapproved for the following reasons---------------------•-----------•----------------------------------------------•-------------------....._....-- ..............•-------------------..........--------•----------------------------•-•------...------=-----......---....--•--•----------------------------------------------------------------•-•••-------- Date Permit No.... .//. ------------------------------- Issued------.... --Z 7 .� i�stz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............�-..OF........... ----------_-_------------.................... Apphratiou for Bhqpoiial Works Towitrurtion u" mit V Application is hereby made for a Permit to Construct or Repair (KX) an Individual Sewage Disposal System at: Cnai(tville Beac_q road Centervilla -----------------------------------*"*-------*-- ------------ Location-Address or Lot No. I.............................0..................................... ...........................................................................................—----- .......... Owner Address .............................................. .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet U DwellingX-No. of Bedrooms----------------3..........................Expansion Attic Garbage Grinder a Other—Type of Building ------------------------ No. of persons............................ Showers CafeteriaOther fixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width...___..___._... Diameter__._--_..._____. Depth.............__. Disposal Trench--No..................... Width.....____....__..... Total Length......_.-__......... Total leaching area--------------------sq. f t. Seepage Pit No_____________________ Diameter--_-----_-__-_______ Depth below inlet_._..._........_.... Total leaching area.........0........sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.________........... Depth to ground water_.___.___________.._:__. Gi, Test Pit No. 2................minutes per inch Depth of Test Pit--.___----______.__. Depth to ground water---_------------------ 04 -------I..................................................................................................................................................... 0 Description of Soil...................................................... .................... �4 95�1'_dl-----------------------------------------------------------------------------I------- U ----------------------------------------------------------.............................................................................................................................................. ---------------------------------------------------------------------------------------------.......................................................................................................... U Nature of Repairs or Alterations—Answer when applicable._............................................................................................. .................. "ii 2,lan....ta U1.010JAff u-s-aata................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'IE of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bden issu,- �b Vt oard of"-he h. 141 1 �Si.g.ne&"- Signe . .......... Date ApplicationApproved By..........;(h.... ........ ........ .................................................. ......... Da Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date Aj�k.................................Permit No._41 Issued----------e-1112_74-7------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town narnstable ....................................OF.................................................................................. dle Qwrfifiratr of Tompliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired rX) J.P.Macombvr Jr. ------------I—-------- ------------------- -------"--------------------------------------------------------1------------------------------------------------ Installer, at-- ----'---""-'-.. ..Cnaigville Beach Road Canterv , ................................................................................................................................................................................ has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_--.._.____..____......___..__.__._._...._.__.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.., .................................. Inspector................... ................................................. ------------ THE COMMONWEALTH OF MASSACHUSETTS 4. BOARD OF HEALTH Town....................OF...............Barnstable ..................... ........................................................................ NFEE........................... Bispoiial Works Tonstrudiou,pirrutit Permission is hereby granted........J...j_..__.Ma.c.ofnber....Jr' ............................................................0.................... .................... ..... . to Construct or Repair (X� an Individual Sewage Disposal S stem CraVivillo �Deach Poa-4 rer vil i's at No..................................J............................................�ft...::..................................................................................................... Street as shown on the application for Disposal Works Construction Permit No.4121--le..- Dated.... . ...... ............................... .... ............. ...................... F44 Board of Heal DATE.. . ------------------------------------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS L TOWN OF BARNSTABLE LOI ATI N11 J� i2A JG V144 e 13 e A eH QD SEWAGE # VILLAGE ,tc,sc/� ASSESSOR'S MAP & LOT r INSTALLER'S NAME & PHONE NO. y,0 y/ 4 eoloeW L Sam 77S-�rygF V 1 SEPTIC TANK CAPACITY LEACHING FACILITY-(type) ' (size) NO. OF BEDROOMS �J PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED: VARIANCE GRANTED: Yes No I � a