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HomeMy WebLinkAbout0228 FIVE CORNERS ROAD - Health 228 Five Corners Road Centerville A =. 168.; 107 SMEAD No.2-153LOR UPC 12534 wmad.com • Made in USA v 0.41 rAmuSwwrrmp 0 wuI* OF TI*SA FWWW MIINW-SEiPROGRAMlOIE6 DATE :11�/6/02 PROPERTY ADDRESS : 228 Five Corners Road Centervi 11e,Mass. / 19 02632 9 ------------------------ On the above date, I inspected the septic system at the a ov sy This system consists of the following: 1 . 1 -1 000 gallon septic tank. NOV 12 2002 2. 1 -Distribution box. TOWN OF BARNSTABLE 3. 2-1000 gallon. precast leaching pits. HEALTH DEPT. Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78. Code) 5. The distribution box is rotted. Must 'be replaced. Once box is replaced. The system will pass the title five inspection. 6. Presently the system passes conditionally. _ 7. This must be permitted and inspected by the Barnstable Board of Health. SIGN / ATUR Name : J . P . Macomber Jr ._ I 7-_--_--------------- Corripany :_,7osp_gh p__ Macomber 8 Son , Inc . VI-ej-- Address :__B(2x._tip..........QRn- ffrytL1-p-,_ba-_tZ?-632-0066 Phone : 508- 775- 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P, MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632.0066 775.3338 775.6412 .\ COMMONWEALTH OF ", SACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL, PROTECTION TITLE 5 OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 228 Five Corners Road Centerville,Mass, Owner's Name: Lois &ndrP Owner's Address:Same Date of inspection: 11 /6/02 Name of Inspector: (please print) Joseph P. Macomber Jr. Company Name: J.P. Macomber & Sons Inc Mailing Address: Box 66 C'Pnt eryi l l P Ma 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certih that I have personally inspected the sewage disposal system at this address and that the information reposed belo, is true. accurate and complete as of the time of the inspection. The inspection was performed based on my cratntno and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes . J6�lconditionali Passes Nleeds Funher Evaluation by the Local Approving Authoriry Fa s Inspector's Signature: i Date: The system inspector sha I bmit 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 now 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 approvutg authoriry. Notes and Comments •••'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 228 Five Corners Road Centerville,Mass. Owner:Lois Andre Date of Inspection: 1 1 / f n 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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: Septic system is presently working. Distribution box is rotted out ana must be repiacea. B. S s Conditionally Passes: Z60ne 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 existih 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 b[2o mor structed 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 //�� _ /�G-distribution box is leveled or �ep�la�cedA 6ev�- ND explain: ,'-'d 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: Distribution box is rotted out. Must be repalced: 2 r Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:,228 Five -ornery Rr)at7 Cente-villa-, Miss. Owoer: Lois Andre Date of Inspectioo: 11 /6/0 . C. Further Evaluation is Required by the Board of Health: 4y') 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: A)O 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. ALO The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple. Ll�vThe system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. �Q The system has a septic tanl: and SAS and the SAS is less than 100 feet but 0 feet or more from a private water supply well'•. Method used to determine distance •'This s�stem 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 anached to this form. 3: Other: /ren1a ,.ed QnCa i s is done c systgay will parr,. Ct` 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 228 Corners Road Centerville,Mass. Owner: Lois Andre r Date of Inspection: 11 6 02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No G ackup 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 t gr o an overloaded or clogged SAS or cesspool Static liquid level in t e distribution box above outlet invert due to an overloaded or clogged SAS or cesspool , _)j ?'at �iquid depth in cesapeerl is less than 6"below invert or available volume is less than %day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number �of times pumped 6. y portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. e," , y portion of a cesspool or privy is within a Zone I of a public well. ijny 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 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.) (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 now 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(I.nterim 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 co sidered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or opera r of any large system considered a significant threat under Section E or failed under Section D shall upgr the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional o ce of the Department. 4 Fasc 5 0( OFFICIAL INSPECTEWAGE DISPOSOAL O STEMtINTARY SpECTION FORMATS SUBSURFACE S PART B CHECKLIST Properrn Address:228 Five Corners Road Centervi Lle,Ma as Owner:LOis Andre Date of lospectioo: 9 1 16 /09 Check (the following have been done You must indicate "),es"or"no" as to each of the following: Yes \o/ Pumpusg 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 ? ZHa-.c I arge volumes of water been inrroduced to the system recently or as partofthis inspection /Were as built plans of the system obtained and examined? (I(they were not available note as N/A) — was the (aciliry or dwelling inspected for signs of sewage back up ? Was the site Inspected for signs of break out were all system componcnts,�% luding the SAS, located on site 2 Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the conel::0- 0'!nc Da((les or tees. material of cons7vction, dimensions, depth of liquid, depth of sludge and depth of scum Was the facilirr 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 or. Yes no Existing information. For example, a plan at the Board of Health. _j!� ; _ Determined in the field (i(any of the failure criteria related to Pan Cis at issue approximation of dts—.cc ;s ;nacccp1a01c) 010 CMR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 228 Five Corners Road Centerville,Mass. Owner: Lois Andre Date of Inspection: 1 1 /6/0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): "�4 Number of bedrooms(actual): DESIGN flow based on 310 CM}� 15.203 (for example: 110 gpd x # of bedrooms): llXlf� ents: �f Number of current resid Does residence have a garbage grinder(yes or no):4b Is laundry on a separate sewage system(yes or no): iecps (if yes separate inspection required) Laundry system inspected(yes or no): �9 Seasonal use: (yes or no): 4'le Water meter readings, if available(last 2 years usage(gpd)): 2000-90, 000 gallons=246. 58 GPD. Sump pump(yes or no): A- 2001 —90, 0000gallons=246. 58 GPD. Last date of occupancy: COMM E RCLA L/IND USTRIA L Type of establishment: �0 Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): W.4 Grease trap present(yes or no):Lt/G4 Industrial waste holding tank present(yes or no):&>O Non-sanitary waste discharged to the Title 5 system (yes or no):AI,4 Water meter readings, if available: Last date of occupancy/use: OTHER(describe): /2A GENERAL INFORMATION Pumping Records Source of information: Was system pumped as pan of the inspection (yes or no):i If yes, volume pumped: _gallons •• How was quantity pumped determined? _ Reason for pumping: TYPE OF SYSTEM _1,�eptic tank,distribution box,soil absorption system Single cesspool Overflow cesspool /vim 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) ,o�JD Tight tank of Attach a copy of the DEP approval Other(describe): Ah Appro ate age of all components,date installed (if known)and source of information: i, .�i� i Were sewage odors detected when arriving at the site (yes or no): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert), Address:228 Five Corners Road Centerville,Mass. Owner:T,ni s AncirP Date of Inspection: 1 6 f 02 BUILDING SEWER(locate on site plan) � Depth below grade:_ 'W Materials of construction:4Vcast iron,GQ40 PVC ✓other(explain): 4" Lite PVC pipe Distance from private water supply well or suction line: /d`f Sc Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight. No evidence of leakage. The systemis vented through the house vents. SEPTIC TANK: I/ (locate on site plan) /"PPA 5; Depth below grade: 14e �� Material of construction: �Concrete&� metal AO fiberglass 44tyolyethylene ND other(explain) 40 If tank is metal list age:db Is age confirmed by a Certificate of Compliance (yes or no):Ak(attach a copy of certificate) Dimensions: '9"a Sludge depth- 1 Distance fron top of sludge to bortom of outlet tee or baffle::/.�,acl� Scum thickness: -4444!s Distance from top of scum to top of outlets tee or baffle:� Distance from bonom of scum to bonom gfoutGetee o:baffler How.were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump the septic tank every 2-3 years. Inlet & outlet tees are in llacp ThP tank is structurally sound and shows no evidence of leakage.Liquid level at the outlet invert is EASE TRAlclocate.on site plan) Depth below grade:14110 Material of construction Xoconcrete&metal.,&fiberglas4#y&polyethylent�oother (explain):_ AU Dimensions: Scum thickness: Distance from top of scum to top ofoutlet tee or baffle: Distance from bonom of scum to bonom of outlet tee or baffle: _ Date of last pumping: All? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GrAaczp trap J g not prPsPnt_ 7 • Page 8 of 1 I e'.'r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 228 Five Corners Road Cen erviTle,mass. Owner: Lois Andre Date of Inspection: 11 6 02 TIGHT or HOLDING TANK41L.(tank must be pumped at time of inspection)(locate on site plan) Depth below grade:�114 Material of construction: AM concrete metal d/i9 fiberglass polyethylene AW other(explain): Dimensions: Capacity: AW allons Design Flow:_ gallons/day Alarm present(yes or no): Alarm level: i /- Alarm in working order(yes or no): W.4 Date of last pumping: Comments(condition of alarm and float switches,etc.): Tight or Holding tanks are not ptesent DISTRIBUTION BOX: !/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: '' 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.): Di_s_t_rihution hox hag one lateral Distribution box is rotted [ arrd must he replaced. The system will pass inspection once the box is replaced. PUMP CHAMBE (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.): Pump chamber is not present 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:228 Five Corners Road Centervl e,Mass. Owner: Lois Andre Date of Inspection: 1 1 6 02 SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan, excavation not required) 2-1000 gallon precast leaching pits 6 ' X9 ' If SAS not located explain why: 1oeated: See nano to J l Type leaching pits, number: 0Z leaching chambers, number: C leaching galleries,number: d I leaching trenches, number, length: 0 leaching fields, number, dimensions: D overflow cesspool, number: 0 innovative/alternative system Type/name of technology: 7" /'iL0 C Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to medium fine sand.No signs of hydraulic failure or ninind; na Soils are .dry. Vegetation is normal. CESSPOOLS Ve (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.): cesspools are not present 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.): Pri -,w i not, present 9 Pit( IO o/it OFFICI-4—' INSPECTION FORA- NOT FOR VOLVNT 5U85URYACe SEwnCE DISPOSAL SYSTEM INSpc rioNEFOMR,`r T ' PART C SYSTEM INPORMATION (conllnvco) a,op.rr) ,,00,,,, 228 Five Corners Road en er , . s. Loig An re DI'l or lnlp<<I.00: 1 6 02 SKETCH Of 51WACC DISPO AL SYSTCM P'o. o� 1 i►,icA ol�ni i1wi11 oilpol�I IYIIIm Intivftj Iltl 10 11 It1II rvyQP(rmintnlltfcrcntt Iln o""�'+v►i /++loci ..�ni ..,,n n 100 h(l Locri, whit, pvalit writ! Iv I C i , ; DP Y tnitrl IAt Ovilo�nl 2 2 8 r1'\1{ (oar,.rS Foal (S24)4de0i 1L1 i / I � / I Iy7 '`'t • 18 ; � �� ��� I Frov,+ o� 40V_-,c wa»a to ,A r Page 1 I of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 228 Five Corners Road Cen ervi e, . ass. Owner: Lois Andre Date of Inspection: 1 1 /6/02 SITE EXAM Slope Surface water Check cellar Shallow wells D Estimated depth to ground water A:v feet Please indicate(check)all methods used to determine the high ground water elevation: UQ�_ Obtained from system design plans on record - If checked, date of design plan reviewed: NA DES Observed site(abutting property/observation hole within 150 feet of SAS) NQ Checked with local Board of Health-explain: NA yE.S Checked with local excavators, installers-(attach documentation) YFS Accessed USGS database-expIaih-ttp; //town,barnstable.ma.us. You must describe how you established the high ground water elevation: Used; Gahrety & Miller Model. 12/16/94 Ground water elevations above sea level. Used; USG • Observation well data. June 1992 Used: USGS:_ TP-chnical. bulletin 92-000-1 Plate #2 Annual ranges o "' ground water elevations. Leaching Pit ��� ;eet ax,�1 Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom , Of the leaching pit and the adjusted groundwater table is feet. 11 ` •R1.'1 T1�R1'f•r�•TT 1TfT.-T'rtT�I T.flTrT.T:::T't'TT:'ra"'CT�TR'�C.:.'T1C'b'TCT.1'T'S' TOWN OF Barnstable UOARD OF HEALTH 1 0SU13SUNFACP SEWAGE DISPOSAL SYYS�TF;M INSPECTION FORM - PART D .- CERTIFICATION I •••r••t•T•••••.-T.ta^.:.T.r..-•n•r.:mrl.rr..rR rrcn•.'-•.9�tVs'-rs.:rnLrr nT9T.T1'�q'ror ternrtTnraRsr+�rT+rnr.:-.rr-'r-1• -. A -TYPE OR PRINT CI•EARL1•- PROPERTY INSPECTED STREET ADDRESS 228 Five Corners Road Centerville,Mass. ASSESSORS MAP , BLOCK AND PARCEL # 49k"/ff OWNER ' s NAME Lois Andre- PART D - CERTIFICATION NAME OF INSPECTOR Joseph P . Macomber Jr COMPANY NAME Joseph P. Macomber &'"ion Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street Town or City State 11P COMPANY TELEPHONE ( 508 ) 775-3338 FAX ( 508 ) 790-1-578 CERTIFICATION STATEMENT I certify that I have personally. inspected the sewage disposa`1 system at this address and that the information reported is true , accurate , and omplete 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 : �r__ Systern* PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this in pection form . r , Inspector Signature Date O( ne copy of this certification must be provided to the OWNER, the BUYER Where applicable ) and the DQARU OF HEAL'1'll. * It the inspection FAILED , thti owner or "oporator shall upgrade ' the eystem within one year oC the date of Chu inspection , unless allowed or required otherwise as provided in 3,10 Ch1R 15 . 305 . partd . doc .. OWN OF BAMSTABLE L:31,:ATIOIN (slit-f*cAW(tJ SEWAGE # VILLAGE C t#JT2 Ujt.-t_r ASSBSSOI?'S MAP & LOT INSTALLER'S NAME &PHONE NO.� SEPTIC 'TANK CAPACITY 1►tzb� �._ LEACHING FACILITY:{type) :22- wJ If (size) _ NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER MKM" s,eA _ DATE PERMIT ISSUED: � S DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No r e �N V\ elk a _ `^' y r F bra! 4i 4�'✓�/d�d?.� �� vy c- j SEWAGE INSPECTIONS DATE . 11 /6/02 1!ON 22R Five Cnrners Rnaa'L C,i.., // VILL--AGE en eryi 1 1 e,Mass_ ASSESSOR'S MAP & LOT -INSfAECTORJoseph P.Macomber Jr. SEPTIC TANK CAPACITY 1 000 gallons + ID-BOX LEACHING FACILITY: (type)) 2-1 000 pits. (size) 3, 000gls. NO. OF BEDROOMS 4 BUILDER OR OWNER lois Andre OWNER MAILING ADDRESS Same 2 2i�� `-..... IN P / I / I / I FravrF v� oti5,e WATEg No. � Z- �o� Fee 5 0.0 0 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Miopogal *potem Construction Permit Application fora Permit to Construct( )Repair XXXUpgrade( )Abandon( ) ❑Complete SystemX)MIndividual Components Location Addressor Lot No.2 2 8 Five Corners Road Owner's Name,Address and Tel.No. 5 0 8—4 2 8—3 41 6 Centerville,Mass.02632 Lois Andre 2228 Five Corners Road 6s8-1r's07aplParcel Centerville,Mass. 02632 Installer's Name,Address,and Tel.No5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.Nos 0 8—7 7 5—3 3 3 8 .P.Macomber & Son Inc. J.P.Macomber & Son Inc. ox 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: DwellingXX No.of Bedrooms 4 Lot Size sq.ft. 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 j Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)R P p l a c in q rotted out distribution box.. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t i rWHealtY Signed ,r Date 1 1 6 0 2 Application Approved by 4j� Date f � a-� Application Disapprove or the ollowing reasons Permit No. oOL0Oa— s o`1 � Date Issued —0 OQL -- ——————————————————————————————————————— TOWN OF BARNSTABLE `� C Al �' S SEWAGE #.2 06 2 LOCATION 9 VILLAGE V I%/a ASSESSOR'S MAP & LOT 'Illy INSTALLER'S NAME&PHONE NO. - W,4 C 0 ,44 e e R i SEPTIC{TANK CAPACITY 1 d O LEACHING FACILITY: (type) _ iT`s (size) NO. OF BEDROOMSak� BUILDER OR OWNER �- i PERMITDATE: I��Ff''�a COMPLIANCE DATE: {I 0 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 4 I a�a1b iC I i < i 'No.4 o �Q�— CJ�� / Fee 5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in compute E� f Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Zigpogal,6pgtem Congtruction Permit Application for a Permit to Construct( )Repair(KX)jUpgrade( )Abandon( ) [J Complete SystemX?QIndividual Components Location Address or Lot No.2 28 Five Corners Road Owner's Name,Address and Tel.No. 5 0 8—4 2 8—3 41 6 Centerville,Mass.02632 Lois Andre 2228 Five Corners Road Assessor's Map/Paccel 16 Centerville,Mass.02632 Installer's Name,Address,and Tel.Nos 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.Nos 0 8—7 7 5-3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. �ox 66 Centerville,Mass.02632 Box 66 Centerville,Mass.02632 Type of Building: Dwelling XX No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) j Other Fixtures i Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) R A n 1 A n i n rr rnt-i-o+A ni i f- distribution box. I Date last inspected: Agreement: { The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ued by i . H d ealth F `• Signed7 #+ { Date 1 1 /6/0 2 Application Approved by Date Application Disapprove or the following reasons Permit No. o�UO2t"1 Jc'a. Date Issued fr ---.---------'----.-.---.-.-.-----.---.---.----------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired KKK�Upgraded( ) Abandoned( )by J.P.Macomber & son Inc. at 228 Corners Road Centerville,Mass, has been constructed in accordance ,I with the provisions of Title 5 and the for Disposal System Construction Permit No.9=— 59 E dated Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & Son Inc, �. . The issuance of this ermit shall not be construed as a guarantee that the syste .11 function as designed. Date 11k i 2 Inspector . --------------------------------------- No. o�OQ�- 5a Fe,$ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogaf 6pgtem Congtruction Permit Permission is hereby granted to Construct( )RepairK(KX)Upgrade( )Abandon( ) System located at 228 Corners Road. Centerville,Mass. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to r comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: I I — O g doh. Approved by '" t Fmc.....No. . -- ---- ..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....................O F........................................­_L------------------------------ Appliratiuta for UiupuuFal Works Tangtrur#ion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal System at: • !...=Z% _ -��1..•g--•-...O...vtS l20?!a�......•..... _ Location-Address or Lot No. ......................................... -•--.......+�T£!L✓/L..-................-•-------------------------------------------- Owner Address W �CL1i 1M► bra«' .................................................... �'©: b � eF,✓r� vr! ........................ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons-_---____._______-__._____-- Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------•_-_--_-. _ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacityi j29?...gallons Length------ Width::S.___...__ Diameter----�.G..... Depth................ x Disposal Trench—No..............1..... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No......../--------- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------____---__--_-___ --•-•----------•------.R+' •------------•---------------••••- ..........--------•---•----•......•.................................--------------------------•--- t. ZZ O Description of Soil Q' �� � x w VNature of Repairs or Alterations—Answer when applicable.._:ff�____-___��_ _____ .7WQ!4AW_ .�� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT:. p 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. ,�J Signed 1 -- ...JIA-��, -----------------••------- ---�`�� _ p� t Application Approved BY ----���° ` e�.... � ate Application Disapproved for the following reasons-------------=--------------------------------------------------------------------------------•-----------•...._ .................•--•----....--•---------............----------- .....--•-••------------..._•----------..__....._....-•---•-••---•-----•--•-----------•-----------------------------•-_...--•---...-•--- f V / Date PermitNo--- ---- -----------�/-�,-/�--•---...--••-•------•----•--- Issued...-------------------------------••---------.._..----- No.......... ..............�/ Fps.... .._ THE-COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _":-\x. 4�J tl... .. .............OF.......C` N� t*JST.! LC ----------- -------------------------------- Applira#ion for 11ispoii al Works Cnowitrurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( - an Individual Sewage Disposal System at: _ Location-Address or Lot No. .....ry� dV N �So+J .......... .....................................................--..... Owner Address aSc�V t+ni �1C.ic.`�`�' fill- 6�1+' Z,�d C£r�.?E�•t//t�-�- Installer Address UType of Building Size Lot............................Sq. feet �-� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ........................................---•--------......------•--•------•-......-•-------•----•------•-------------------••--------........_...•... w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.!Ste...gallons Length.__.......... Width__&.......... Diameter................ Depth................ x� Disposal Trench No------ Width idth___- toinlet Total leaching a q Seepage Pit No-------- Diameter Depth below ................... Total leaching area ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..._____________--__---. fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water________-.------__-____. -----------------------------------------------••-•--------------------------------........--------......................................................... 0 Description of Soil. (_2....--`£� '- ...............................................' '.. ter---'-------•-----------------•-------------------------------•-•------------. x w U Nature of Repairs or Alterations—Answer when applicable_.f►�________—OA__S-...... .)....... rub! Rw ................ .... .W k..Wv,).......I'� .c- �-,.-----•.`t= l------•-•-a-.... TOgsw v •-----• -------- -------- -------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T�'1�^ the provisions of 'T y t LE 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. j Signed........., - s:1__�rt .......................... .......14 l 8....... Application Approved By.. .•-- �._.............•.• . . --.' ter .---•-- �Q a�`-•----------- - ate Application Disapproved for the following reasons----------------•-------------•--•----------------------------•-------------------...........-•------.........-- -•-•--•....---...--•-••-•.....-•-...•-••-.....--•••••••---•--._...--••--•--•-----•._.._..-•-----•---•-••--•....._....-••--••----••------••••----•••••-----••---------•-••-•••-------••-•••------•••-••.. c� •'/) // Date Permit No._�.1_5�--.. _.!�!_. .�.............•-.. Issued-------------------------------------------------------- D THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -.-...!.4.U311` ....................OF..` \,2-."... ...................................................... Trrtif iratr of T-ampliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (L., - by---•-I.0 4.J! ------•1-� C�c.-i--------------•----•--•-•-----•-------------------•--••-------•----- Installer at... ..........F............................................... C 4_\_0... Z>11 �,.� has been installed in accordance with the provisions of L I IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...............................•-------------•---..................---•-••-•---• Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Ir ...... .....................•-•-.......... L10) NO. FEEc✓ t ----•-•................. Elisposal Worko Tllni#rnr#ion rrntit Permission is hereby granted....... ` _ �.... `..�-4c. ....7 -•---- -----•----•-------------------------------------------------------••--..........---•---.-•-•• to Construct ( ) or Repair ( t-�n Individual Sewage Disposal System at No.----�'-&.------.`.\ x ..... salt 1.1 f C`f o Street / as shown on the application for Disposal Works Construction Permit ...... D d.__ .l. . �. ......... ............ i� c Board of a th DATE.......1 F �• ........................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS