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HomeMy WebLinkAbout0032 DONEGAL CIRCLE - Health i 32 DONEgAL CIRCLE, CEN7ERVILLE _ A= 169-071 L u No. 42101/3 ORA ESSELTE 10% ® O Q O i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments —?Cz Olar Property Address Owner Owner's Name information is Ce 0 1 ✓ / 7 eV! //z 2 9' /O required for every page. City/Town State Zip Code Date f Ins 4 coon Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the and of the form. important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your cursor-do not Name of Inspector use the return C T key. O / C— G Company Name Q / ' q � � Company Address LL'cr5 f�Q w► �.� Doi 6�oC ICI City/Town State Zip Code Lro-s,) ') Telephone Num er License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of T-t Title 5 (310 CMR 15.000). The system: `s z i a cc Passes ❑ Conditionally Passes ❑ Fails co c` � r--,r ❑ Needs Further Evaluation by the Local Approving Authority o ram:. z �o Va,4 tj F- a N Inspecto 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. �A t5ins•09/08 Tine 5 Official inspection Form:Subsurface Sewag isposai System•Page f of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 0 Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date o Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: al have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•09r08 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form • Not for Voluntary Assessments J � o���►� a vas /ti o< Property Address Owner Owner's Name �j� -T information is / `le/ doZ d required for ;r^'1'e✓yr every page. City/Town State Zip Code Date of Ins ection 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 DMR 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 15m3•09/08 Title 5 ofrical Inspection Form:Subsurface Sewage oisposal system•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments UU. - Property Address / y ��Q Owner Owner's Name information is �4,4. p required for every page. Cityfrown State Zip Code Date ol 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 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 ❑ U�/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Q/ 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 i5ms•o9ro8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page a of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L o/1a,,- 000V,S �d Property Address Owner Owner's Name �6, /� information is rem ���Ile, �a z /�g/Ifl required for every page. City/Town State Zip Code Da 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. ❑ Q/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•09108 Title 5 ofriciai Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2c� so ✓,jr, led Property Address Owner Owner's Name information is / O� 4, `l �,¢ a)6� �//,p required for lW �_1� every page. Cityfrown State Zip Code Date olKnspectidn C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): t5ins•09/08 Title 5 Official Inspection Form:Subsurface sewage Oisposai System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewaagel Disposal System Form - Not for Voluntary Assessments h Property Address Comer Owner's Name information is required for eve page. CityfTown State Zip Code Date f Ins ection every 9 P D. System Information Description: �I�n bH 7�ic� .ts6Jl Number of current residents: Does residence have a garbage grinder? ❑ Yes E No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ❑No Laundry system inspected? ❑ Yes [. —96 Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes o Last date of occupancy: 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: i5ins•og/os Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 't 3c;� rL0 6//a Property Address Owner Owner's Name A information is P� � � �6�� /C� �.o required for / every page. City/Town State Zip Code DO of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: �� f b Source of information: �fd� Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of/System: Ly' 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•09i08 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sys em Form • Not for Voluntary Assessments Property Address Owner Owner's Name in information is J required for every page. Cityrrown State Zip Code Date df Ins ection D. System Information (cont.) Approximate age of all components, date installed known) and source of information: f-51- 6e 17L Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet C; Material of onstruction: ast iron 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: / 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: S->( Sludge depth: 2// l5lns•09/08 Title 5 Of9aat Inspection Form;Subsurface Sewage Disposal system•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 1/0 Owner owner's Name information is Ce v,�ep-n �- required for every page. City/Town State Zip Code Date o Inspe tion D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): A<L" r h IS 40 *0 Le f 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 'Sins•ostoe Title 5 OKicial Inspection Form:Subsurface sewage Disposal System•Page 10 or'7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • �pZ �0Ila✓ Ora Yd Property Address / yo �i Owner Owner's Name J / information is ce'm required fory2✓t/�6 t° /� 0046 q' �( q every page. Cityfrown State Zip Code Dat6 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 ts.ns-09r08 Title 5 offcai Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c2)o/lezy- &,-2 It Property Address Owner Owner's Name / information is //� / Qd 6.7� 7 �p required for Cam% L every page. City/Town State Zip Code Date 6f Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert G 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.): �b Sol 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins-09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments O ar �G✓/S Property Address y 0 / Owner owner's Name / information is Pvti y yi l/{ �016� required for every page. City/Town State Zip Code Dat of Inspection D. System Information (cont.) 6X Type: [f leaching pits number: ❑ leaching chambers number: ❑ 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.): d� din 'S L e�oi.✓ t Pi vex 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 OW08 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C( )o la il- Property Address Owner Owner's Name �y information is required for Cpv, ✓t/i Ile- �J V6 3� / g 10 every page. Cityrrown State Zip Code Date 6f Inspedbon 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.): tslns•09/09 Tille 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 14 of 17 ICommonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form • Not for Voluntary Assessments :.�2 �ol/o✓ &I"o) I'd 01 Property Address Owner O `/ Owner's Name / information is /„ �0� /9' /0 required for c6po_ ✓yi /'�� every page. City/Town State Zip Code Date Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately A a 3 '3_7 (0 rsins.ogros Tiue 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S ste//m Form - Not for Voluntary Assessments D d 1'ar 1,21 Pal Property Address Owner Owner's Name CC ,� �q,information Is required for H �,yj Ile- /'A�//W CtLG 3� p, every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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) l� Checked with local Board of Health - explain: /0/GAS 7415A let ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J;� Property Address / Owner Owner's Name ) information is ,,� .{e�v�/� /�� ���, �� /j g•/gyp required for every page. CitylTown 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 stem Information — Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•09/08 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f No. Fee $ 40. 00 r.•t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for MigosmY *pgtem Cunotructiun Permit Application is hereby made for a Permit to Construct( )or Repair(XX)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 32 Donegal Circle Centerville Gerald Dowling Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. J.P.Macomber Jr. Box 66 Centerville ,Mass . 02632 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(N ) Other Type of Building Re s No. of Persons 6 Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily flow gallons. Plan Date Number pf sheets Revision Date Title Description of Soil Medium sand to fine sand Nature of Repairs or Alterations(Answer when applicable) R—I n f-i l t r a_t o r s a d(e d to @-.n existing 1000 gallon tank Pj�stri 'h1iti on box and two-1000- gallon leaching Pits Date last inspected: Agreement: The undersigned-Agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this Bo' d prynea Signed a Date 1 /1 7 Z 9 6 Application Approved by_. Application Disapproved for the following reasons Permit No. Date Issued / No. Fee $ '+J 0.00 ""'NE COMMONWEALTH OF MASSACHUSETTS" PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS x p1 pYtration for Migpogaf *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair(XX)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. F 32 Donegal Circle Centerville Gerald Dowling Installer's Name,Address,and Tel.No. 508-775-333 8 Designer's Name,Address and Tel.No. J.P.Macomber Jr. Box 66 Centerville,Mass. 02632 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(H ) Other Type of Building Res No.of Persons 6 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title . Description of Soil Medium sand to fine sand Nature of Repairs or Alterations(Answer when applicable) R=i n f j 1 t,rr t n r S a d d e d to an existing 1000 gallon tsnlc, Distri huts �n I►nx anci two 1000 gallon leaching nits. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this Bo d Hea h. J. Signed Date 1/17/96 A/I . 9 Application Approved by Application Disapproved for the following reasons Permit No.. —'�_ Date Issued / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(xx)on 1 1 7/96 by J.P.Macomber Jr. for as 32 Donegal Circle Centerville Mass has been constructed i accor ance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: loge �,.. No. g�/ r�z— Fee� 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wigpont *pgtem Congtruction Permit Permission is hereby granted to J.P.Macomber Jr. to construct( )repairYXX)an On-site Sewage System located at 32 Donegal Circle Centerville,Mass. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction ust be completed within two years of the date below. Date: ,�/�� Approved by r' .� v ,.- CERTIFICATION OF SKETCH AND AP PLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) a I, J.P.Macomber Jr. , hereby certify that the application for disposal works construction permit signed by me dated 1 /17/9 6 , concerning the property located at Donegal Circle Cen ervi ll P meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is ,.A feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances.requested or needed. SIGNED : DATE: 1 LICEN SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER i [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I 4 � TOWN OF BARNSTABLE `LOCATION C 4,41 C TL SEWAGE # 10r�- VILLAGE C P CARVI I I ASSESSOR'S MAP &LOT��9-0'7/ INSTALLER'S NAME&PHONE NO. IM�iCOWI��� Sam �vr SEPTIC TANK CAPACITY 10 Q U LEACHING FACILr Y: (type) t+ '/ (size) NO.OF BEDROOMS . BUILDER OR OWNER a�d4o -7---,7,& 4i1,4.,, v`it PERMTTDATE: f"'•1-7— ,COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Z � � �� , �/ � �� 1 � i ����� � \ � ��� y, mac. 1 i `O,f; \� � � i �(' 1 y/ � `� a�� i i .. . o��. �Y f 32 Donegal Circle 1 /17/96 Centerville ,Mass . 02632 It le m TOWN OF BARNSTABLE (,C. LOCATION �' ! � (.s� �, SEWAGE VILLAGE C�� ///� �_ ASSESSOR'S MAP LOT/ _ INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type)c;x_/040_ ��S (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER lzBUILDER OR OWNER DATE PERMIT ISSUED: DATE . COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No l_ Tcl7- , 1 1 L0•CATI0N SEWAGE PERMIT NO. VILLAGE CF f�' ✓i �'I�ss � �' INS A LLER'S NAME & ADDRESS V BUILDER OR OWNER GJ /�i9id y`1 r3'l/arYN/.3' DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ,J � I QQ� P ti �es� IRCFL NO, FEs.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H ..--- eal .........._0F....... ..... 1�.:�� .. --L---_--.-_----------------- Apptiration for Uhipaiia1 lVarkii Tonstrnrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( kj"an Individual Sewage Disposal System aVeep --- ... &Yl_14�......0,-1:,_ az--b.--------._&AJ77 ----------------------------------------------•-------------.....-----------............------ Locatio Address r or Lot No: --------------- 17 caner Address Installer Address Type of Buildinv Size Lot............................Sq. feet V Dwelling No. of Bedrooms...----g...............................Expansion Attic ( ) Garbage,Grinder ( ) aOther—Type of Building ____-_•---•________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................:................................................................................................. W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. P4 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....................................... Test 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........................ ............... ODescription of Soil..........__ ------------------- --- ---------------•-------------------------------------------- x V ---------------------------------------------------------------------•----------------------------------.------•------••---•----------------------- W •--••---•------- -----------------------•---------------••-•-•-•-•-••--••--•-•------•--•--------•••-•-• --------------------• ➢7� U Nature of Repairs or Alterations—Answer when applicable.___.. __.I.rjA........__t................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T T;., p of the State Sanitary Code—The dersi ned further agrees not to place the system in operation until a Certificate of Compliance has be issued by e o •�th Signed.... .... -•-• ../._. .... . . ............... ..... Application Approved ............... ------• - =---- ........ ......... ------------- ............. --- -- G Date Application Disapproved for the following reasons:-----•----------------•---------------------------------------------•-----------------------------•-•........._. ---------------------------------------••-•-----•-•----------...----••--•----•----------....-•------•-•-.........................s...................................................................... ...��—.�, Date Permit No..............._ _._.__i 1 1 - Issued... Date • ,'i S� 7I THE COMMONWEALTH OF MASSACHUSETTS J r BOAR® PF HEAL H .......,�2C.��f� o F.......A4�fl/.4SrAVl ........................... Alipftration for Biiipoii al Works Tontrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (Wan Individual Sewage Disposal System at,/) ...... ......OuLaie,.......... r............................................................................................... L Locatio /Aldd'resss/ or Lot No. !►�� �, .......... wr�4T�ha.<�C ------•------- ----------------------------------------------------- -------- •----------------------- --....--^ W Wner Address .�... ............�_..... � -�•- ...... ........-•---------...........---......----•--•-•--.............---------•-•--.•.....--------... Installer Address UType of Buildinsr Size Lot............................Sq. feet Dwelling NO. of Bedrooms....... ................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures ------------------------------------•-••-•-•---•--•--. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length.............•.. Width................ Diameter___--__..___-.._ Depth................ x 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 '"...`------------••-• . • ..................................................--•••••••---•------•----•----------...............----... Descriptionof Soil-----•--•-w5 ./ ------•--•-•-•--------------------•-•-----------------------•---------------------•-•-•----------•••-•-------••-•----........ x ----------------------- •-----------------------------------------------------------•••.....-----•-•---••-•----- ----- ••-- /' __.. —Answer when applicable----- =____1_ 011...................... ..................................... U Nature of Repairs or Alterations ...............................................................-........................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i t: : of the State Sanitary Code—The ndersi. ned further agrees not to puce the system in operation until a Certificate of Compliance has b issued b e bo�o Ith. Signed_. .. �_.. .... _ 1 Application ApproveY --- - ---•-•--- ....---••-------------1�' -' - -------------•---" ------..._.... Date Application Disapproved for the following reasons:-•---••-•••-----••••-••--•-••••----•--•••---•-•--•••----•-••--------------------•-•......•-••-••-•-••-----•---- ...----•--•••-•-•--•-••----•••----•----••••---••....-•-•--•---•-••-•--•-------••...-•--------------------.-•••---------•-------•-•-•--••----•----•--•••------------•------•---•-••-------•--•-------•---- Date Permit No-`.... fir'-------• 1 Issued ----------------•-----•-•------------ -----•----------------. .------•---•------Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA .....................��-;2 ..........................................i ��L OF.. �. Tntif irFa#r of TonapfiFanrr TW TO. RTI� Tl the I livid 1 Sewage Disposal System constructed ( ) or Repaired by...__1.�d��� ... ��'. ---------- •-- - staller ----------------•---•-------•------------------------ has been installed in accordance with the provisions T 4 5 of The State Sanitary Code as de' 'b_ed in the application for Disposal Works Construction Permit �_.1-' '�"'l•-••-------- d-ated---� �� Z`7 ��� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE_...... -�f & . ------------•........... Inspector._. - -...... ---------••---•----------•-----•................•-•-.•--•- THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE:V/;- , L 70 ........ ..-OF....!� �1--: a....................... Noy ._..` FE •-•- to�rax al o `,o� Ton tr ion antic Permission is hereby grante�IU4 /��►! _ ! to Constr t ),,of Repair (, Indiv' al Sewlia e DispoA_ S em at No...-- !�.�' `�---�----, `�✓ -.....-c ' .' Street�� JJ.� as shown on the application for Disposal Works Construction .Permit I`10- .11 �. ated.._.�.. J-...�..._��.._....... 6 Boar7. d of Health SATE. _ 1, •. Zti FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ^•,.:� �! e..