HomeMy WebLinkAbout0138 DONEGAL CIRCLE - Health 138 Donegal Circle
A= 169— 085
Centerville
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5 M E A D®
No.2453LOR
UPC 12534
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YOU WISH TO OPEN A► BUSINESS?
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For Your Information: Business certificates (cost$H0.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
xf �,.......�,;, :max DATE:"7 / Fill in please:
M; APPLICANT'S YOUR NAME/S: i
l'I'.•_�.. I r;fmi'"1'"7(t.�9r
`'''_'{{` J :FF BUSINESS YOUR HOME ADDRESS: e
i�:r'j?lF�ili' "'r'o al^"«
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TELEPHONE # Home Telephone Number 4, 1-7- P i -1
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NAME OF CORPORATION:
NAME OF NEW BUSINESS TYPE OF BUSINESS
IS THIS A HOME OCCUPATION? JZ YES NO G -
ADDRESS OF BUSINESS MAP/PARCEL NUMBER IW (Assessing)
CIZCo 3Z
When starting a new business there are several things you must do in order to be in compliance with the rules.and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rai. & Main Street) to make sure you have the appropriate permits and.licenses,required to.legally operate your business in this town.
t 1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of bN&WJsCOMPLY WITH HOME OCCUPATION -
�j RULES AND REGULATIONS. FAILURE TO
uthor' d igfature** COMPLY MAY H��
MENT WL$IN FIt�ES:
O
2. BOAR O EALIH
This individual has been nfefr ed oft p mit re irements that pertain to this type of business. MUST COMPLY WITH ALL
d., _HAZARDOUS MATERIALS REGULATIONS
A ized Signature
COMMENTS: I
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature.*
COMMENTS:
f . Date: 7 /( /
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: k,S OZ63 2-
BUSINESS LOCATION: ( ANVENTORY
MAILING ADDRESS: TOTAL AMOUNT-
TELEPHONE NUMBER- I —9R (�— 3
CONTACT PERSON: r: U
EMERGENCY CONTACT TELEPHONE NUMBER: (2(?-QV "fo C<P '? MSDS ON SITE?
TYPE OF BUSINESS: O s a ►` ,-til(1----
INFORMATION / RECOMMENDATIONS: Fire District:
.� /17
- L
Waste Transportation: > e_A, Last shipment of hazardous waste:
Name of Hauler: 6ArtxL Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach) /F A 16�
Spot removers&cleaning fluids
(dry cleaners) /",u
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
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:When filling out forms A. General Information
(J
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S.M.Jones Title V Septic Inspection
ICI Company Name
74 Beldan Ln.
Centerville Ma 02632
Cityrrown State Zip Code
774-248-4850 smjonestitle5@gmail.com SI4522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/9/2014
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
g1� I,N
t5ins•3/13 Title 5 Official Inspe ?.rm surface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 138 Donegal Circle Centerville is served by a Title V septic system consisting
of a 1000 gallon septic tank, distribution box and 2 1000 gallon precast leach pits. The system was
found to be in proper working condition at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5 138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. Cityrrown 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 'h day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 138 Donegal Circle
Property Address
HOUDE; GREGORYJ
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. CityrFown 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 y portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply'
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. Citylrown 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): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is Centerville Ma 02632 8/9/2014
required for every
page. Citylrown 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? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
2012= 0 2013 = 7,000 total = 19 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: vacant
Date
CommerciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 91.
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: at 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: 1000 gallons
Sludge depth:
6"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
3"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers, took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
Outlet tee has a filter that needs to be cleaned every 6 months to prevent clogging.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection 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
138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
11
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 was in good condition, no rot, water level was even with outlet inverts.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ 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.):
Both leach pits were found to be dry with no signs of past hydraulic overloading.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
L
i O
Ta^,--�f Z
A, 22
p
13.3 Nq C-�;- Z 1
&EACR Prr
A,y 30
R-LI H?
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is Centerville Ma 02632 8/9/2014
required for 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: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
138 Donegal Circle
Property Address
HOUDE, GREGORY J
Owner Owner's Name
information is required for every Centerville Ma 02632 8/9/2014
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
, , 7
DATE': /13/98 -'7
PROPERTY ADDRESS: 1 0 �Rr^24 1998
Centerville, �"�` '
Mass. 02632 ,\ t__�
On the above date, I Inapected the s-aptic system at the above addrees.
Trnls system consists of the following:
1 . 1 -1000 gallon .septic tank.
2 . 1 -Distribution box.
3 . 2-1000 gallon precast leaching pits.
based on my InPractlon, I certlfy the following coridltlona:
4 . This is a title five septic system. ( 18 Code )
5 . The septic. system is in proper working order
at the present time.
• SIGNATURE :
Name : J . P . Macomber Jr..
----- --------------
Company : J_ P_ Macopber 8— Son _Inc
Centervi11e `Me99__02632
Phone :---`�J..5--3338------- • I
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
, OSERH WP MACOMBER & SON, INC.
T,nki-Ctupooh-Lo►chfIeIdi
. Pump+d 4 InitallrC
Town $dwor Connoctlons
P.O. Box 60 ' Centerville, MA 02632.0066
775-333$ 77t,�12
I
` COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617.292•5500
WILLIA.I F WELD TRH DY C
Govemor Sc:'
ARGEO PAUL CELLUCCI D.o�iD B STR
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commiss
PART A
CERTIFICATION
Joseph Logue
Property Address: 138 Donegal Circle Centerville.Address of Owner: 325 Regency Drive
Date of Inspection: 3/1 3/98 (If different) Marstons Mills,Mass
Name of Inspector: ,TnGpi1h P Mac-tuber Jr. 02648
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J.P.Macomber & Son Inc.
Mailing Address: Box 66 Centerville,Mass_ 02 632
Telephone Number: 'r R^u r;_3 3 3 8
CERTIFICATION STATEMENT
I cenify that I have personally inspected the sewage disposal system at this address and that the information reported below is uue, accura
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function am
maintenance of on-site sewage disposal systems. The system:
ZPasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: A A YAi /! % r Date: r1 ��
The System Inspector s all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing ih,s
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owne+ shall subm
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to me syvem ow.
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, Or D:
A) SYSTEM PASSES:
YmL I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CntiR 15.3(2
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system. uc
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined', expla r. ..hy not
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cert;iicaie of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the i,nspeo-on,
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltranon. or ta:
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a confomiing SEvic Lani
as approved by the Board of Health.
(revised 04/25/91) Page 1 of 10
DEP on the World Wide Web: httPwwww.mapnet.state ma us/oep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 138 Donegal Circle Centerville,Mass.
Owner: Joseph Logue
Date of Inspection:3/1 3/98
BJ SYSTEM CONDITIONALLY PASSES (continued)
,di,11 Sewage backup or breakout or high static water level observed in the distribution box is due to 'broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval 01 J)e
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
,Sf{J The system required pumping more than four times a year due to broken or obstructed pipets). The system wd! pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
Alb . 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A mANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) 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 to a surface water sup:)) or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water suppl,, well
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply welt.
The system has a septic tank and soil absorption system and the SAS is less than 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 A.�V9 (approximation not valid).
3) OTHER
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(revised 04/15/97) ?ay• 2 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 138 Donegal Circle Centerville,Mass .
Owner: Joseph Logue
Date of Inspection:3/1 3/9 8
D) SYSTEM FAILS:
You/nmust indicate er:• er "Yes" or "No" as to each of the following:
1 have determined that the system violates one or more of the following failure criteria as defined in 310 CmR 1 S.303. The bass
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corTecz
the failure.
Yes No_
Backup of sewage into facility or system component due to an 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 S.-.S or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
Liquid depth inyascppel is 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($).
Number of limes pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface eater supp y
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significan: threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
/12 the system is within 400 feet of a surface drinking water supply
11,Ll� 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 o; a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment prp€ram
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information
(r.vl..a 04/25/97) Pago 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 138 Donegal Circle Centerville,Mass .
Owner: Joseph Logue
Date of Inspection: 3/1 3/9 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes N-�
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
— '
All system components, eluding the Soil Absorption System, have been located on the site.
4�4 _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
X _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) Y.Q. 4 o1 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 138 Donegal Circle Centerville,Mass.
Owner: Joseph Logue
Date of Inspection: 3/1 3/9 8
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 4,71J6 K. d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):iVCJ
Laundry connected to system (yes or no): �
Seasonal use (yes or no):,&./_4`
Water meter readings, if available (last two (2) year usage (gpd): dqq " �2iBGa Q 16"1
Sump Pump (yes or no):� lC,�j ., ✓b�l lO , lI
Last date of occupancy: '�45'9,
COMMERCIAUINDUSTRIAL:
Type of establishment: Z114
Design flow: (M allons/day
Grease trap present: (yes or no)"
Industrial Waste Holding Tank present: (yes or no)�Ii<
Non-sanitary waste discharged to the Title 5 system: (yes or no)&
Water meter readings, if available:IW
Last date of occupancy: A�
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Sog- ,QX�
System purfilled as part of inspection: (yes or no)_426
If yes, volume pumped: V gallons
Reason for pumping:
TYPE OF YSTEM
/ Septic tank/distribution box/soil absorption system
_A1 Single cesspool
_41d Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Techn I gy etc. Copy of up to date contract?
Other
APPR X E AGE of all comp-Qn,ents dat installed (if own) an sources information: k i/
,L —
iiU 7 a7�.� i�sf?X4&4t00,72- er1b-�-
Sewage odors detected when arriving at the site: (yes or no),&6
(revised 04/25/97) Pegs 5 of 10
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JOSEPH P.MACQ &.SOlii,
P.O.BOX 66
CENTERVlL A MA 02 U.OM
Na : Joseph Logue 428-4395 CUSIMM Coft:
Ad*m: 138 Donegal Circle flog
Town: Centerville stab: Za:
Mang ad&m:
325 Regency Dr Marstons Mills MA 02648
Nobs: Pump every 2 years Dec
5/22/89 pump T 105.00 6/6/89
6/17/92 pump T&P 240.00 6/23/92
7/27/92 system LP 1650.00
2/95 letter
4/4/95 pump T 145.00 4/14/95
12/29/97 pump T 145.00 1/7/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 138 Donegal Circle Centerville,Mass.
Owner: Joseph Logue
Date of Inspection:3/13/9 8
BUILDING SEWER:
(Locate on site plan)
�J
Depth below grader
Material of construction: _cast iron Z40 PVC_ other (explain)
Distance frouivate water supply well or suction line �_
Diameter Y_
Co ments: (condition of joints, yenting, evidence of leakage, etc.)
Al -O C r
SEPTIC TAN K:,L&40D� t,,4
(locate on site plan)
Depth below grade 4401k^—C
Material of construction: :L-160ncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age A.4 Is age confirmed by Certificate of Compliance&K(Yes/No)
Dimensions-IT
r 6I4 E r
Sludge depth:
Distance from toff sludge to bosom of outlet tee or baffle:)✓�,
Scum thickness:11-l�'-
Dcstance from top of scum to top of outlet tee or baffle:zzy—lr Ie
Distance from bortom of scum to bottom of outlet tee r baffle: Jr.4O�P_
How dimensions were determined:
Comments:
(recommendation for pumping, conditi of inlet and outlet tees or baffles, depth of liquid level in relation to outlej invert, structural
ntegrrry, a idence of leakage, etc.)
t C
� I
GREASE TRAP:�e_
(locate on site plan)
Depth below grade:ld 9
Material of construction:, Aconcrete d metal�Y�Fiberglass4�/APolyethyleneN�other(explain)
/e
Dimensions: 40
Scum thickness: iU
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baff1e:A4
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
Z mod.�
(revised 04/25/97) Page 6 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 138 Donegal Circle Centerville,Mass .
os.net: Joseph Logue
Date of Inspection: 3/1 3/9 8
TIGHT OR HOLDING TANK:e{iL"ank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade M 4
Mater,al of construaion:A/Aconcreteei/Ametal,4JL¢Fiberglass GA Polyethylene.iv ocher(expla n)
_,1A
Dimensions: V,*
CapacrrY IV4 gallons
Design flo-- gallons/day
Alarm level. 4,14 Alarm in working order/t� Yes.1VA Nu
Date of previous pumping: A2 e
Comments
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Deptn. c: I c,,,d level above outlet invert _ �b
Comments
Incite if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
o r ovc
PUMP CHAMBER:22A)c
(locate on site plan)
Pumps - working order: (Yes or No)
alarms •n ,orking order (Yes or No)
Comments
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
1
rh"4 e ki,4)z l .f 1-1 X Y
� T
(r•vis.d 0i/75/97) ?.g. 7 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 138 Donegal Circle Centerville,Mass.
Owner: Joseph Logue
Date of Inspection:3/1 3/9 8
SOIL ABSORPTION SYSTEM (SAS):4/
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: /q
leaching pits, number: OC
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system: a
Name of Technology:727C �
Comments:
(note condition of soil signs of hydra lic failure level of ponding, condition of vegetation, tc.)
i
� . r
CESSPOOLS: a�
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: JIOII
Depth of solids layer: Al/9
Depth of scum layer: AW
Dimensions of cesspool: .t069
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Are
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:&)qw✓'
(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.)
(revised 04/25/97) Page B of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION (continued)
Propeny Address: 138 Donegal Circle Centerville,Mass .
O'vner: Joseph Logue
Date of inspection: 3/1 3/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
-:�uce ties to at least two permanent references landmarks or benchmarks
czate all wells within 100' (locate where public water supply comes into house)
C 17
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(r•vi••C C�/21/97) ➢.y. 9 of 10
SUBSURFACE SEWAGE DISP(: t SYSTEM INSPECTION FORM
P. C
SYSTEM INFOI:'.. .I ION (continued)
Property Address: 138 Donegal Circle Centerville,Mass .
Owner: Joseph Logue
Date of Inspection: 3/1 3/9 8
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elation:
Obtained from Design Plans on record
:Wbs,-,I-on �LSite (Abutting property, bservation hole, basemt(*simp etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
heck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater-Elevation. Must be completed)
Used Water Contours Map.
Gahrety & Miller Model
12/16/94
(iovirred 04/25/97) Pac, 'lbof 10
yy •rr:*.r+�n i rr—rr rnrarrr nts+mrrrt.r re*r.rr..n..•s'+•nvn'+n+n-m+ rsr*w�u*�a••s:ren rm *TTs.r.*-.-T'a�rmrrr- r---.—...
TOWN OF Barnstable BOARD OF HEALTH
SUI)SURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
`� �•••T••t•T••.-•. .-r...-^..:rnr.T..n•rt rn rl+r ssrrrrnr•-t9+•9 1TR'7anrnf`rtnrnaTe.r R*'m*amrnr•m'� mnn•rmrr-rtrnTr.-..rr.•.:r r.-•r•�. �.
-TYPE OR PRINT CI.EARL1•-
PROPERTY INSPECTED
STREET ADDRESS 138 Donegal Circle Cente'rville,Mass .
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Joseph Logue
PART D - CERTIFICATION T
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Ind.'
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or Clty State ZIP-
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 790 - 1 578
.T
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
hea1Lh or Lhe. environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have 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 .
Inspector Signature Date
t�—�.r T�•LT�•1,T--- --•
One copy of this certification must be provided to the OWNER, the BUYER
( where aPpl lcable ) and the 130ARD OF HEAL'I'1I.
* If the inspection FAILED, the owner or"" perator shall upgrade
he ayote
within one year of the date of the inspection , unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 16 . 305 ,
partd . doc
1
1
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THE COMMONWEALTH OF M:.A.SSA.CHUSETTS
DEPARTMCENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualificatigns as required and is hereby
authorized to use the title
CERT i i D TITLES SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws . Issued by The Department of Environmental Protection.
nrunx C)irccior of lltc i ion (AWitcr Pollution Control
t�1 t
TOWN OF BARNSTABLE 1
",OCATION 13W Done-ani SEWAGE #
VILLAGE /1 � � ASSESSOR'S MAPP & LOT
INSTALLER'S NAME& PH NE N0. � GBx�71^
SEPTIC TANK CAPACITY o�
LEACHING FACILITY: (type)��6� 7 /t (size) 0D
NO. OF BEDROOMS
BUILDER OR OWNERJf
PERMITDATE: 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 ( any wetlands exis
within 300 feet�acl-iinlity Feet
Furnished byr .
r
-30 �!,
L TOWN OF BARNSTABLE
LOCATION SEWAGE # 0 _
VILLAGE ;�, ° /��/��f ASSESSOR'S MAP & LOT
.�1 n _
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /
LEACHING FACILITY:(type) !1;' / (size) / �� ,,c°C,/ _
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No L/r
A�ii r
I
0�
v
ASSESSORS MAP NO:
No...�i.= &� PARCEL NO:) �� Ficwl....
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
Barnsta lecopservauonoewwunwt BOARD OF HEALTH
TOWN OF BARNSTABLE
800
Application is hereby made for a Permit to Construct or RepairX(XX) an Individual Sewage Disposal
System at:
.138 Donegal Centerville
.. .. ......... ............
Joe Logue Location ocation.... Address or Lot No
.................._ .................................................. ..................................................................................................
J.P.Macomber Jr. Owner Address
......... .........
Installer Address
Type of Buildi Size Lot............................Sq. feet
U DwellingZ fNo. of Bedrooms.__.........2.............................Expansion Attic Garbage Grinder
.-I
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit..........._......__ Depth to ground water........_-_._...........
f14 Test Pit No. 2................minutes per inch Depth of,Test Pit_-- ................ Depth to ground water......_.-_-.._.......__.
P4 .............................................................................................................................................................
0 Description of Soil................................................................................................................................. ......................................
x Sabd & Gravel
U .........................................................................................................................................................................................................
W
.......................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer hen aB?If* able................................................................................................
1—1000 gallon leaching............................................�a.........................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complian has bee th.
6/19/92
Sign
... ... ........... ............. ....... . .................I ..................
Application Approved By -------
. ----------I------------------------------------------------------------------------- ----- ..
Application Disapproved for the following reasons: ......................................................................................................................-----------------
I.................................................................................................................................................................................................. ........................................
Date
Permit No. .......?-A — —'�_ '�-d
...................................... Issued _.................................................................
Date
qq � S
No...l: ..:1� `f d Fx$.1...30.00...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_..��--3-.,,,c JOWN OF BARNSTABLE
Appliration for Uiipnsal Works Tonstrnr#inn Fermi#
Application is hereby made for a Permit to Construct ( ) or RepairX(XX)Xan Individual Sewage Disposal
System at:
_D__Qnea: ._Circle___Centerville.......... .... • ._._... .......--
• Location-Address or Lot No.
.Joe Loaue---•---•-----•----•-•---------------••---•--•---------•--•--•---•----•. --•--------••--•-•-•••------------------------•------•--••-------..............----•-•-•-......---
---------------------
Owner Address
aJ.-P R Ma c om_b_ e_r__ jr...................................................... •--•-•--•---......-••---........_.......--•---•---.................__....-•---...-----•---....--•-
Installer Address
Type of Building Size Lot............................Sq. feet
U DwellingXXNo. of Bedrooms.............9............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
� YP g --•------•-------•---•-•---- P ( ) — Cafeteria ( )
Otherfixtures ---------------•-------------------•--•--------------.-••••------------•--•--•••••---------•----...••--••-------•------------.....•-•---------------.
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. 1-___••_._-_--_.-minutes per inch Depth of Test Pit.................... Depth to ground water........................
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ,;
P4 .---•---••-----------------------------------------•---••----------.._._..------•---••--•-..._------.........................................................
Description of Soil____________________
=
W Sand & Gravel
v ..................................-•----------•----__•-• .......-•------••------------------•--•----------------------------•----•--------....----------•---•---------------
W
VNature of Repairs or Alterations—Answer when applicable................................................................................................
..------•---------------1-1000-..gallon-•-leaching-•pit•'----•--------------------------------------•-----------------------------------------------•---_....
Agreement:
The undersigned agrees to install the aforedescribe'd Individual Sewage Disposal System in accordance,with
the provisions of TITLE 5 of the State environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complian e has be issuA��V
alth.
'�.. .- - ---.-.. ---------------- ----E/19/92.........................
Signed ....�-...
Date
Application Approved By --------- z. f -� - 4'P-`??z
--------------------------------------------------
Application Disapproved for the following reasons: ....................................... . .. ... ............I......------------...........--------........ ..-------..........
.................................................----------------------------------------- -----------------......................
pDate
PermitNo. .......7 .Z----------- ................... Issued .. -----.....----------- ------............-----------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cez#iftra e of C autplizin e
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (XRXII
by J.P.Macomber Jr.
.................................................................................................................... ........... .. ........... ----------------
Installer
at .......13. 3...Dene-gal--.,C-irc le---Cen-te-rville
----------------------------------------------------- ---------------------- ---------------------------------------- --------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..........f..P...-....; ...g%...... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
.--7.;.................................. Inspector ...------. --- -.1.............
DATE.............. l ".' /C�,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Q TOWN OF BARNSTABLE
No......7.r.2..-. FEE... ...
�.-�0-
Disposal Workg T,anntrnr#inn antic
Permission is hereby granted--J._P £ cOmbe __j.r.-.-------------------------------------•-•-------------......----------.........--•-••-•---•---
to Construct ( ) or RepairX(XX)Can Individual Sewage Disposal System
at No...... _.Done al... ircle.Centerille
.......... -- -
Street
as shown on the application for Disposal Works Construction Permit .�Dated..........................................
.................................• __ -t ...._..._.----__.____._......_....................„
` Board of Health
DATE •---_9�..............................
FORM 36508 HOBBS Q WARREN.INC.,PUBLISHERS