HomeMy WebLinkAbout1851 FALMOUTH ROAD/RTE 28 - Health 1851 Falmouth Road (Rte 28)
Centerville P
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IMPORTANT-UPGRADE REQUIRED SMOKE DETECT�3�S REVIEWED
STATE BUILDING COW REt�UM THE,UPGRADING OF
SMOKE DETECTORS FOR`TIE.ENTIRE DWELLING WHEN
ONEOR MORE SLEEPING ARM MREADDED OR CREATED; A8' UILDING DEPT. s 1 DATE
R THE
lNSTAt1ATlON OF SMOKE DETECTORS
TRICAL
PERMIT SATISFY THIS REQUIREMENT. FIRE DEPARTMENT
ATE
BOTH SIGNATURES ARE RE U D
Q IRED FOR PERM/TTINO
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TOWN OF BARNSTABLE / �---
LOCATION' /�J� �� SEWAGE # L �
VILLAGE -9 !'Vt/JZ ASSESSOR'S MAP& T. _
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INSTALLER'S NAME&PHONE NO..�I P� I'►�A a /0er .Stet i✓I L
SEPTIC ITNK CAPACITY 1 S O
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LEACH FACILITY: (type) R ¢ S -- (size) D O 0
' NO.OF BEDROOMS �
'BUILDER OR OWNER '
PERMTTDATE: 57 9:5- 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) Fee[
Furnished by
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COMMONWEALTH OF MASSACHUSETTS
A' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
v
F
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
See
NlAY 0 5 2005
TOWN OF EBARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION `
Property Address: 1851 Falmouth Road(Rt.28)
Centerville MA 02632
Owner's Name: Nancy Thibault
Owner's Address: 396 Old Colony Road
Norton MA
Date of Inspection: April 1,2005 Job#05-75
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
CERTIFICATION STATEMENT
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 �1n111111
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste :` N OF
_X_ Passes
Conditionally Passes RI
Needs Further Evaluation by the Local Approving Authority = S M.
Fails ;c�
Inspector's Signature: - Date: 4/1/05
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.
Notes and Comments: Recommend pumping tank,one leaching pit has 1' standing water and other has 3'
standing water.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
1 t
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ I 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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Titles C incnortinn Rnr A/i gmnnn 2
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Page 3 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
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
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 I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title G Tnenartinn Rnrm A/1 aiInnn 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
—X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X— 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No_(Yes/No)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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
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.
T41a G Tncnantinn Rn�m 6/1 ai,7nnn 4
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Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
X_ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period?
X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X _ 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?
_X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
m aintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_X_ _ Existing information.For example,a plan at the Board of Health.
_X_ _ 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(3)(b)]
Titla t inenartinn 17nrm A/1Iqi)nnn 5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 4
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2003—153,000 gal.2004—388,000 gal.=741 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): and
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: None
Source of information: -
Was system pumped as part of the inspection(yes or no): 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)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Compliance date: 2/8/96
Were sewage odors detected when arriving at the site(yes or no): No
Titles S Inonartinn Fnrm An vInnn 6
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Page 7 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
Materials of construction:_X_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line: 10'
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 18"
Material of construction:_X_concrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10.5' long x 5.8'wide—1500 gal.
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle:30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity„liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees intact liquid level at bottom of outlet Pipe.Recommend pumping tank.
GREASE TRAP: No (locate on site plan)
Depth below grade:_
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
T41a i Tnenantinn Fnr 4/1 eionnn 7
Page 8ofll
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
TIGHT or HOLDING TANK: No (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
Trace of solids carryover,no high stains. Liquid level equal at bottom of both outlets.
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Titla C Tnenartinn Rnr 411;1')nnn 8
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Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: Two 6x6 pits.
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.): Leaching pit#1 has V standing water with no high stains and pit#2 has 3' standing water with no
high stains.
CESSPOOLS: No (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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
Titles G Inonan+inn I7^r Ail ciInnn 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
Route 28
42 51
Water service
32 40
58
28
42
37
#1851 Garage
Titles C Incnartinn Pf% m AM vInnn 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1851 Falmouth Road(Rt.28),Centerville
Owner: Nancy Thibault
Date of Inspection: April 1,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 30 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el.20 and topo map shows property at el.60.
Tit1 a Iq inennntinn Fnrm Ail eiinnn 11
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Town of Barnstable Health Inspector
�oF rti Office H6urs
Regulatory Services 8:30—9:30
Thomas F.Geiler,Director 1:00—2:00
saxrrsTnac.E.
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
F
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Office: 508-862-4644 Fax: .08-790-6304
AMNESTY PROGRAM APPLICANT-SEPTIC -QUESTIONNAIRE h°
1. General Information: Size of Prop erty: `1
Address: Map .Parcel?a7
Name: � 0�0�. Phone 7 -
2a. How many bedrooms exist at your property now?
2b. Are you planning to add any bedrooms? If es how many?
y
Y y.
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?
2d. Please include a copy of the floor plans for the entire property- showing the existing
rooms in the home plus the proposed amnesty apartment and/or addition. Please label .
each room clearly on the plans.
3. Is the dwelling connected to public sewer? YES or NO
� �'If the dwetling�s_conriected to�public sewer,Yslcipquesfa@ns�#4 tlroughs#,9�be"l�w, � ,? ;, -
4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution-t upply wells? p
5. Is the dwelling connected to an ONSITE WELL or to PUBLIC�WATE
6. Is a disposal works construction permit on file? YES or NO
6a. If yes,how many bedrooms were approved according to this permit? Bedrooms.
7. Were any building permits obtained for construction of additional bedrooms? YES or NO
.8. Is there an engineered septic system plan.on file at the Health Division? YES or NO
9: as the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
__------------------ -------------------------------------------_—�_____-----------------------
FOR OFFICE USE ONLY
ublic Health Division has no objection to�_bedrooms at this property. _
pecial Conditions:
Signed: Date: IeYY
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THE Tn
The Town of Barnstable
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Office of Community and Economic Development
230 South Street
Hyannis,MA 02601
Offim 508-8624678 Fax: 508-8624782
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September 15,2005 J
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Mr. �i
John C.Klimm,Town Manager
GaryR.Brown;Town Council President
Barnstable Town Hall UZI
367 Main Street
Hyannis,MA 02601
Re: Stephen E.Bobola- 1851 Falmouth Road, Centerville- a single-family accessory unit
Gentlemen:
This letter is to inform you that the Accessory Affordable Housing (Amnesty) Program has received
a request for a project eligibility letter under the Community Development Block Grant(CDBG)
Fund and under Article II of Chapter Nile of the Code of the Town of Barnstable and the criteria
for the Local Chapter 40B Program.
This office is reviewing the request.If the Town has any comments on the project,please forward
them to me so that they can be addressed in the site approval letter. This letter gives you official
.notice of our receipt of the above application(s). We will issue a decision as to the acceptability of
the sites and the consistency of this development within the guidelines of CDBG.
' cerely,
beth Dillen
Program Coordinator
Community&Economic Development
cc: Town Attorney's Office
Building Department
L,-'Public.Health Department
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IMPORTANT —.UPGRADE REQUIRED SMOKE DETECTOR RVI
STATE BUILDING CODE REQUMS THE UPGRADING OF EKED
SMOKE DETECTORS FOR THE ENTIRE DWELLING MEN
ONE OR MORE SLEEPWG AREAS ARE ADDED OR CREATED. fig' UILDWG DE Al
PT. DATE
NOTE: A SEPARATE PERMIT iS REQULRED FOR.THE
INSTALLATION OF SMOKE DETECTORS—THE ELECTRICAL
PERMIT ZO M SATISFY THIS REQUIREMENT, FIRE DEPARTMENT
ATE
BOTH SICaNATURES ARE REQt.:IREQ FOR pFRrj
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1.00 =`"RCN 195-1 .0 �cl�� t2�t.Z� SEWAGE # NS�ec'1�'at�
VILLAG ASSESSOR'S MAP & LOT) ®S'
2NffAff1tM'S NAME&PHONE NO. L/(� I �'1-7'7
SEPTIC TANK CAPACITY l5-60
LEACHING FACELITY: (type) (size)
A
NO.OF BEDROOMS
BUILDER O<j R L) 'r
PERMTTDATE: C-@MNeBOICE DATE: ®S�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
ITI 2�
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AW 'X
o THE COMMONWEALTH F A�HUS S Fe O. 00 6�
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PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppItcation for Mitpotal *potem Comaruction permit
Application is hereby made for a Permit to Construct( )or RepaiiMX)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No. 61 7—9 6 4—1 3 0 0
n n 1851 Route 28 Attorney Robert Tennant
Centerville ,Mass . 02632 29 Craft Street Suite 500
Installer's Name,Address,and Tel.No. 5 0 8-7 7 5—3 3 3 8 �i 9 �kd &;t an 1.AP
oseph P. Macomber Jr. Joseph P. Macomber Jr.
Box 66 Centerville ,Mass . 02632 jBox 66 Centerville ,Mass . 02632
Type of Building:
DwellingXX No. of Bedrooms Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil Loamy sand to sand & gravel
Nature of Repairs or Alterations(Answer when appli and leaching pit. - T-n-,taqlling! ie
D
Date last inspected: 2/6/9 6
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss d by this o Vofelth.
Sign . Date 2/6/9 6
Application Approved by a
Application Disapproved for the f llowing reasons
1L,_K_L3-U_L118 Sjouum has failed.
Permit No. Date Issued
———————————————————————--•———————————————
A/y/ fn
40-00
THE COMMONWEALTH-QF- A SAC US TTS
'w
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE S MASSACHUSETTS
01pplication for Mi000l *pe;tem Congtruction permit ;
Application is hereby made for a Permit to Construct( )or Repaij�(KX)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No. 61 7-964-1 3 00
1851 Route 28 Attorney Robert Tennant
Centerville,Mass. 02632 29 Craft Street Suite 500 "
Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Eeq.Yn r9 dhi `eAR&A an °T 1. o.
oseph P. Macomber Jr. Joseph P. Macomber Jr.
Box 66 Centerville,Mass. 02632 jBox 66 Centerville,Mass. 02632 a
}
Type of Building:
DwellingXX No.of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
•Design Flow gallons per day. Calculated daily flow gallons.
—Plan Date Number of sheets Revision Date
Title
i
Description of Soil Loamy sand to sand & gravel'
r
i
Nature of Repairs or Alterations(Answer when appii e Q 1 rino, an 1
and leaching T 1 a
o i
Date last inspected: /6/9 6
Agreement: r
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
irf accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed by this o of H 1th.
Sign _~ ZDate2/6/96
Application Approved by c141Yj
Application Disapproved for the f Ilowing reasons „__ failed.
1
Permit No. W7 Date Issued
4 '
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate oUCompliance -
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaceAX )on
by .Toseph P. Macomber Jr. for Thelma Scannell
as 8151 Route 28 Genterville,14ass. It bpa constructed in accordance
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:
i
No. C / 111A/V l f 1 UM r6AS16L� COA�OEJ 4
1 J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
i
Migw6ar *pztem Construction Permit
Permission is hereby granted to TnsPnh P. Mnx-omhPr jr-
to construct( _)repair K;X)an On-site Sewage System located at 18.51 Route 28
Centerville,Mass. 02632
i
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to j
comply with Title 5 and the following local provisions or special conditions.
All construction ust a completed within two years of the date below. @ &(7
Date: Approved by l/I�'�(� s �J
c
'r'
n
III
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
i
I, J,P.Macomber Jr. , hereby certify that the application for disposal works
construction permit signed by me dated 2/6/96 , concerning the
property located at j R5j R.01- o .2 Centerville ,Mass . 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 4 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: 2/6/96
i
LICENS SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
!� TOWN OF BARNSTABLE �--
LC :A PION /,R.S/ .2 ,99— SEWAGE # 4-* -
VILLAGE(�e.n4erVr lam_ ASSESSOR'S MAP&1:;
INSTALLER'S NAME&PHONE NO. -I 61 a ®V't'► /IClef' _q>i Tn C_ S9�S7
r
SEPTIC TANK CAPACITY ��
,LEACHING FACILITY: (type) a ?''� -� (size) 1000
NO.OF BEDROOMS
r
BUILDER OR OWNER
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(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by j
t� Q
/ `
� a
a
No.-- .--- 5-- Fps............._....._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
—77-77
.._.......OF.......... .. .............. ....... fir.-e .-------------.....-----....
Appliratinn for Disposal Varks Tonstrixrtiutt 11nmit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
�,�e
.....:.....�.�. z�.��-• ..... _. ^^.....5a..........:...-----...------------.........--................._..........----
Location- dress or Lot No.
........................ •.--...._._..-•-••••........ ...--...... .. ..••-•--•---•-.._....................
Owner Address ..
w ... a......�p�?: ------------------- ' ...----------a .... ...�-2...
Installer Address
Type of Building Size Lot............................Sq. feet
a Dwelling
B ms1.. Expansion Attic Garbage Grinder )Oher—Type of Building .............:.. No. of peons - Showers Cafeteria
04 Other fixtures ---------------------------------•-••--•------
W
Design Flow............j.-�-�.........:..........gallons per person per day. Total daily flow........ /0.....................gallons.
WSeptic Tank—Liquid ca.pacityl�mgallons _ Length... ...... Width.Aa!........ 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 ( )
Percolation Test Results Performed bY...................-----••-----.......--••----•-----•----•---------------- Date........................................
aTest Pit No. L.:.............minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------------------------------------------------••-•-•....... .........-•----•---------•-------....--••-•---•....----•-•--•-•--------=•-----...._..
ODescription of Soil...........................................................=-•--•----•-----•---•-----------•-------------------.--.----------------------...:._......-------•--........
W . ............•----------------------------•------......--•-----------••-•------------------------------......-----•-•••..........--•------ ..•----......----------------._.....•--••... .
U Nature of Repairs or Alterations—Answer when applicable... ........
....................... � .. ..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
Signed... -� --- -=--- - _ .
Date
Application Approved BY C .. -- -------------------------- ........ .&. ...
.
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------•-••------....I..................._
---•----•---...-----•...........................................................................................-•--•------•---------------•------.........---------------------.........----•-•---------
Date
PermitNo......... ...T•24-----••--....--•---........ Issued.......................................................
No...TZ... FRic
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....OF....... ---------- ..................Appliration for Disposal Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct or Repair (-1k; an Individual Sewage Disposal
System at:
< (11A
......................................................................
Location-Address or Lot No.
.......................... ........................................................................................
Owner Address
.. ........... ..
........... ..... C..................... ............................................... ....... ................ ......... ... .......
Installer Address
Type of Building f Size Lot............................Sq. feet
U
Dwelling-No. of Bedrooms_.-I....................................Expansion Attic Garbage Grinder ( )
04 Other-Type of Building ............................ No. of persons............._._.........__. Showers Cafeteria ( )
Otherfixtures ......................................................................................................................................................
Design Flow............< <_ ........gallons per person day. Total daily flow.._.... .....................gallons.
-------------
Septic Tank-Liquid....c`a'pacity'!5KgaHons Length__- .............
............. Width.11.?�........ 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
1.4
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................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............--......_...
-----------------------------------------------------------*...........""-------------------------"-------------------------.......*------**"*'*-----'
0 Description of Soil........................................................................................................................................................................
W
------------------------------------- .............. -------------------------------"-------**---------"---------------------------"......*------------------------
................................................................................................................. ......................................................................................
Nature of Repairs or Alterations-Answer when applicable__..,7.-.v- ---------V -'S rrr) .... �7
.......................... .........
........................................... ....... ......... ......................................................................
Agreement: I..)
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of I 1E 5 of the State Sanitary Code-The undersigned further agrees not to place the system in
=
operation until a Certificate of Compliance has been issued by the board of health-
�i�7 Signed. ................................... .............. ..........................
Date
Application Approved By..............K)...........a...... ..........................
Date
j
Application Disapprovedjor the following reasons:...............................................................................................................
.........................................................................................................................................................................................................
Date
Permit No.........Rl.::...
........................... IssuedL.......................................................
Date
————————————————---———————————————————————————————————————————-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... ........OF..... .........................
Trrtffiratr of Tomphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by.....................-4 0-e_ 1- 4-t'g""? ....................................................................................................
;— 0 Installer
k Y2--
..................P.7.....I. ..--
---
has .............................................
at..........................i . _.::� ... ......................................................................
been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__.... ........... dated------------i....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
................................................
DATE.................. .............. Inspector............ ........................
----—------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........OF ...�Z)...
FEE....
Disposal Works T.onstrurtion "Vrrmit
Permission is hereby granted.......... A'I (� '&:�fv-t ) e,
..............................................................................................
to Construct or Repair ( 1)__an Individual Sewage Disposal System
at No...._..... ............R-71 .......Ac/T............'_� :- L',--
.... ........................................... ...................................................................
Street
as shown on the application for Disposal Works Const ction Permit Dated..........................................
........................�'\ ......................................
Board of Health J
DATE................................................................................
TOWN OF BARNSTABLE
"LOCATION.' L.�St (�� SEWAGE #
VILLAGE ASSESSOR'S MAP 6t LOT
169-a57
INSTALLER'S NAME & PHONE NO.:
SEPTIC TANK CAPACITY i�C1 c1 �� ,, �•�� _�.{�w.
LEACHING FACILITY:(type) �r��+�,
NO. OF BEDROOMS WI PRIVATE WELL O UBI:IC WAT
BUILDER OR OWNER kay-N a
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: '7-
VARIANCE GRANTED: Yes No
T
iiWWIII
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