The URL can be used to link to this page

Home My WebLink About0164 FULLER ROAD - Health 164 Fuller Road, Centerville = 189 - 114 1111 ® z UPC 12534 No.2� NASTIN®*Y MN i No. 9� Fee $ 5Q.O THE COMM NWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpprication for Mtgoot *p5tem Con5truction permit Application for a Permit to Construct( )Repair(XA Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 164 Fuller Road Owner's Name,Address and Tel.No. 164 FU11er Road Centerville,Mass. 02632 Centerville,Mass. 02632 Assessor's Map/Parcel Q � 4 i� Gladys Wii nikainen Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.MACOMBER & S on I nc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XX-14o.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building Res No. of Persons 1 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3 x 1 1 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 11 S 0 0 Type of S.A.S. 2-500 gallon chambers- Description of Soil Sand & gravel Nature of Repairs or Alterations(Answer when applicable) Omitting c e s s poo 1- _ Installing 1 -1 500 gallon t-anlc , 1 —di stribliticln box, -2-599 gallon chambers packed in st-nnP 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 this Board of Health. Signed Date 1 0.12 0 Application Approved by P Date Application Disapproved for the following reasons Permit No. Date Issued G `` �' j� 'No. f" "r Fee !g 5 n (1 THE COMM NWEALTH'OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS 0(pprfcation for 3Digpotal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(XXUpgrade( )Abandon( ) ❑Complete System ❑Individual Components r Location Address or Lot No. 164 Fuller Road Owner's Name,Address and Tel.No. 161 Fuller Road Centerville,Mass. 02632 Centerville,Mass. 02632 Assessor'sMap/Parcel 1 S_�L- 1 Gladys Wii nikainen Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8-7 7 5—3 3 3 8 J.P.MAROMBER & S on I nc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XXTio.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other - Type of Building Res. No. of Persons 1 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 , gallons per day. Calculated daily flow 3 x 1 1 0 gallons. Plan Date ; Number of sheets Revision Date Title Size of Septic Tank 1 500 Type of S.A.S. 2-500 gallon chambers. Description of Soil Sand & gravel Nature of Repairs or Alterations,(Answer when applicable) Omitting cesspools. Installing 1 -1500 gallon tank. 1 -distribution box` 2-son V " gallon chambers packed in stone. Date last inspected: j 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 EnvirOe-mental Code and not to place the"system in operation until a Certife- cate of Compliance has been issued by this Board of He lth. Signed tP7 4 / t Date 10/20 Application Approved by Date ��'�G► F Application Disapproved for the following reasons .� ✓�_3 7 , ,. Ae €. Permit No. 7— .5 P"" ------.-.-_....,,..D_ate Issued•( �1 ——————4—————— —————————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(XX) Abandoned( )by J.P/I.Macomber & Son Inc. at 164 Fuller Road Centerville,Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. J.P.Macomber & Son Inc.Installer Designer J.P.Macomber & Son Inc.I.nc The issuance of this permit shall not be construed as a guarantee that the system will function as designed. s Date T1 Inspector No. .�7 ��-- -------------------------Fee 50 . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS ligonl *pztem C.on.5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(x-)5 Abandon( ) System located at 164 Fullter Road CEntervilleMass. and as described in the above Application`for Disposal..System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this it. Date: �� ` _ ,�" Approved b ff �r t CERTIFICA'I'ION Or, si LTCII AND APPLICATION FOR A DISP(., . WORKS CONSTRUCTION pc. it�•11'1' (1V1'I'IIOU"1' DESIGNED YLANSI I Joseph P_MnrnMR�n_- = = artily th:lt the application for disposal works �� construction permit signed by me d.-Icd concernng the- _ pr,.)perty located at 164 P 1,1'-r meets all of the following criteria: �• There are no wetlands within 30U fc.t of the proposed septic system �• There are no private wells within 15o tvct of the proposed septic system • Tlic observed groundwater tnbk •1 rtet tYr};renter belo\y tllc bottolll of the Icaclllllb facility f/• There is no increase in flow and/or changt: in use proposed There are no variances requested or uecd,d. SIGNED : DATE: 1 0/20/97 LICE ED SEPTIC SYS'fEilvi !NSTALLER 1N 1'1-iE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. l , -� l�a�� »�l� 0 s6� �� . � �� . \ �'`, J .,-r• . ,. TOWN ORBARNSTABLE l LOCATION._I�� e-� I l�Q_ ...r. . ._... _ StWAGE # ASSESSOR'S MAP&LOT INSTALL-ER'a♦.r F1' r T�..'.'aa�1..4'\aQn1..47.J�.�.,�'. ....� . � �.. �.rp�wY'-- ._aT?.�•,5�1.FLOW!?k.: - _ SEPTIC TANK C��l' 1TY _...J.t4 G0 .._:._ , LEA.. .. 1'ACIi.IT il: (typr?7S bK�,t�.�.Y.tom�.«5.••.. (size) �.�� _ �' 0 NO'.OFBEDRM�-.. BUILDER OR OWNER ''ERMTfDATE: iA - .--�. )o twee�.tu"•". .._ . .:.- .� •;,,; •.:,.-._.� i S arati6u ep Dislatice P Feet maximum Adjusted Griuedwatei Table and Bottom of Leaching l�acility Private Water Supply.Well and Leaching Facility '('�f any welds- �+Ast Fit on site or within pil feet of ieachinig facility) Edo 6f Wetland and.Leaching Facility(If any wetlands exist,, Feet within 300 feet of leaching facility) Furnished by —. ---- -• -- ' i�.i c µ�' �+fir j�; �'�'•.._ - r.................. a \ Yi I� . k - ay � • j TOWN OF BAR 4STABLE LOCH--rION J.CQ<l 1(f-j SEWAGE # 24 �- VILLAGE_�,�Aw--,.,s'x_rf le.— _ASSESSOR'S MAP & LOT INSTALLCR'` 1�� : is T T'F� YT—: � t 1� R 2-f 1 � SEPTIC TANK C:f�l'3:....1TY _.J_c'�_6�_ i-- . - ,- LEACHNG 1='/CR...Tr: f T �� ,size NO. OF BEDR0-OMS .k BUILDER OR OWNER u�:A ... .ERMrr DATE: Separatiol,artctAtiC t-pPtvNEr!t1,. _ r. Maximum Adjusted GrQuedwater`Table ind Bottom of Leaching Facility Feet Private Water Supply.Well and Leaching Facility 'Ji1 any on site or within 200edrof•leaching.facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist,-- within 300 feet of leaching facility) . FwTdsb.ed by - I I I !AIL fi nL ILO 9 r� DATE : •9/ /9a, PROPERTY ADDRESS : - 164 -Fu11er Ro T a to B Centerville,Mass : r ° F"STga�199� 02632 1 � On the above date, I Inspected the s.aptic 'sys;tam at the above address. This system consists of the following: I 1 . 2- V xV. bloc cesspools . I i Based on my InPnectlon, I certify the following condltlons: 1 . This is not a title five septic system. 2 .. This is a sewage system, t T 3 . The sewage system- i-s in failure. Reasons for failure. is_ that the overflow cesspool is-in neighbors. yard. 4 . A ne title five-septic system must be .installed. According too the new 95 Code. I SIGNATURE : Name : J . P , Hacomber Jr. i -------�--------------- Company J_. P_Macomber &- Sol4 lnc __CencervilLe �,Mass__02632 I , ---------- — u Phone :---SCZ__'72_5_J338_------ -- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY (SOSEFRNP, MAGOMBER & SON, INC, T+nki-CvupoolrL4schfleldi Pump+d L Initallyd Town Sowor Connection{ P.O. Box 66 ' Centerville, MA 02632.0066 775-3338 775-b-412 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS C DEPARTMENT OFI ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 6I7.29'-5500 uILLI.i,N1F NELD 1^' Go�cmor ARGEO PAUL CELLLICCI DA', It Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C)T. PAR r A CERTIFICATION Property Address: 164 Fuller Road Centerville Address of Owner: Date of Inspection: 9/30/9 7 (If different) Name of Inspecior: ,TOGpph P Macomber Jr. 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: 1 Mailing Address: Box 66 epnt-prville, MaSS 02632 Telephone Number: CERTIFICATION STATEMENT I cenify that I have personally inspecned the sewage disposal system at this address and that the information reponee relo-. is U.e, ac and complete as of the time of inspection. The inspection was perform:ed based on my training and experience in the [)roper iunct.cr main(enance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes _ eeds Further Evaluation By the Local Approving Authority Falls Inspector's Signature: / r Dale: The System Inspect r shall submit a copy of this inspection repon to the Approving Authority within thirty (30) days of compfe;,ng mspect-on If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system o-n2r shall s, the report to the appropriate regional office of-(he Department of Environmental Pro(ection The original shovic ce sent to re svve- and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as deime-d n 3!0 C�R Any failure criteria no( evaluated are indicated below. COMMENTS: r 8) SYSTEM CONDITIONALLY PASSES: o- One or more system components as described in the "Conditional Pass" section need to be replaced or repairec `ne 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 determinK-, exD:a,, ,The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cer-..;:,c.a:r Compliance (anached) indicating that the tank was installed within rwenry (20) years prior to the date of !-.e ns the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exiilira: or'• (ailure.is imminent. The system will pass inspection if the existing septic tank is replaced with a coniorm.ng Se�::c as approved by the Board of Health. (r•vi.•d ➢&q• 1 of 10 ' I I DEP on the World Wide Web. hU nwww.magneL state ma us/oeD Printed on Recycieo Paper i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) Properly Address: 164 Fuller Road Centerville,Mass .l 02632 owner: Date of InSpection:Gladys Wiinikainen 9/30/97 B) SYSTEM CONDITIONALLY PASSES (continued) t �-- _ AMN(4 Sewage backup or breakout or high static water level observed l,in the disi ibuiion box s due to oro,en .�r pipe(s) or due to a broken, senled or uneven distribution box. The system will pass inspection :: t -) ao= J`_• Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due'to broken or obstructed pipe(s) Tne system —!. cass ,nspeciion if (with approval of the Board of Health) broken pipe(s) are replaced obstlucsion is removed Cl. FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require funher evaluation by the Board of Health in order to determine if the system 's is i:n5 ;c Dice public health, safety and the environment. U SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THATI THE SYSTEM IS NOT FUNCTIONING Iti A •�%A-'NER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 10 Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within SO feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HFALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE DE?ER.1w—S T;� 'T 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 sunace wager >_� •• 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 oublic mate sua t. wet The system has a septic tank and soil absorption system and th.e SAS is within 50 feet of a Pr-a:e -a.e The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 ie-et c, rote cT. a private water supply well, unless a well water analysis for coln•orm bacteria and volatile organic corn;c_—s the well is free from pollution from that facility and the presence of ammonia nitrogen and nitra:e n,(rozer. is less than 5 ppm. Method used to determine distance 'to L (approximation not valid) 3) OTHER 'x tr.�1..d 0./7f/f71 P.Q. 7 of 10 j it SUBSURFACE SEWAGE DISPOSAL St'STEM INSPECTION FORti PART A CERTIFICATION (continued) Properi} Address Gladys Wiinikainen t owner: 164 Fuller Road Centerville,Mass . 02632 Date of Inspection:9/ 30 97 DJ SYSTEM FAILS: You must indicate e,: el "Yes" or -No- as to each of the following v I have determined that the system violates one or more of the following failure criteria as definec in 310 Cgr I) = r w for this eeiermination is identified below. The Board of Health should be contacted to determine wnat r,(l De neces; " the failure Yes N'o / Backup of sewage into facility or system component due to an overloaded or clogged SAS or cess:,ce Discharge or pondrng of effluent to the surface of the grc;und or surface waters due to an o er!oaae-c or c:ogg: cesspool V, Static liquid level in the"distribuncin box above outlet irrren due to an overloaded or cloggec SAS o: cess_cc: Liquid depth n cesspool is less than 6" below invent or available volume is less than 112 Required pumping more than 4 limes in the last year NC)T due to clogged or obstructed Number of times pumped 0— Any ponron of the Soil Absorption System• cesspool or privy is below the high groundwater eie,a:,o, Any ponion of a cesspool or privy is within 100 feet of it surface water supply or tnbutarn �o a s.ria:e s_.-o:• �L Any portion of a cesspool or privy is within a Zone I of a public well. Any ponion of a cesspool or privy is within 50 feet of a (private water supply well. Any ponion of a cesspool or privy is less than 100'feet tiut greater than SO feet from a pn ate -ater s o. -,e acceptable water quality analysis. If the well has been analyzed to be acceptable, anach coos of rent —. e• a-.a col,form bacteria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen I d I Ej 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 ;s a s i�!-a: :. public health and wfery and the environment because one or mote of the following conditions exist Yes No (L/1� the system is within 400 feet of a surface drinking waterisupply �lp the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (In(erim`Wellhead Proteciion Area • IWPA) or a r,,cr_ Zoe= public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundNater trea:..e, requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Depanment for funner tr.�3..d 0�/71/97r ➢•q• ] o! 10 P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 164 Fuller Road Centerville,Mass . 02632 Owner: Gladys Wiinikainen Date of Inspection: 9/30/97 Check if the following have been done: You must indicate either "Yes" or:"No"Ilas ro each of the following. t Yes No 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 recei- ng nor cal now rates during that period. Large volumes of water have not been introduced into the system recer:k o as pan of this rnspeclion. 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 inspec7ed for signs of breakout. t _ All system components. 4ludrng the Soil Absorption 5ystem, have been located on the site. _41.4ye. The,septiC tank manholes were uncovered, opened, and the `nterior of the septic tank was nspecled for cond,�,on o, baffles or tees, material of construction, dimensions, depth ofEliquid, 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 land occupants, if djfferent from owner) were provided with information on Ine proper rnain;enance e Sub-Surface Disposal System. J/ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of d,s,ance �s unacceptable) (15.301(3)(b)) 1 . The present sewage system has been failed for one reason only. The overflow cesspool is in the neighbors yard. u Ir.v1..d D.9. 4 of 10 I it ' ( I .I SUBSURFACE SEWAGE DISPOSAL SYSTEM, INSPECTION FORM PART C , SYSTEM INFORMATION Property Address: 164 Fuller Road Centerville,Mass . 02632 Owner: Gladys Wiinikainen I Date of Inspection: 9/30/97 t FLOW CONDITION' RESIDENTIAL--. . Design p.d./bedroom for S.A.S. Number of bedrooms:_ Number of current residents: 1 ; Garbage grinder (yes or no): i Laundry connected to system (yes or no) Seasonal use (yes or no):A)d water meter readings, if available (last two (1) year usage (gpd): Al ) Sump Pump (yes or no): 0 AW, I Last date of occupancy ',r� r COMMERCIAUINDUSTRIAL' Type of establishment. A-14 Design flow: 1,44 gallons./day Grease trap present: (yes or no).�l/4 industrial Waste Holding Tank present: (yes or not 41W Non-sanitary waste discharged to the Title S system: (yes or no)AN � Wale( meter readings. if available 4-)A Uf? f Last date of occupancy. OTHER: (Describe) Last date of occupancy i GENERAL INFORMATION PUMPING RECORDS and source of information: $ System pumped as pan of inspeclion: (yes or no)" i l If yes, volume pumped XM gallons f Reason for pumping 1 TYPE OF SYSTEM X10_ Septic tank/distribution box/soil absorption system / Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) !Q I/A Technology etc. Copy of up to date contract? Other I APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) ) li I 04/25/f7) P.9. 5 of 10 I j i � I II I • i t I SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 164 Fuller Road Centerville,Maiss. 02632 Owner: Gladys Wiinikainen ' Date of Inspection: 9/30/97 BUILDING SEWER: -ocate on site plan) Depth belo-1 grade Material of construnion Zclasl iron _ 40 PVC — other (explain) ; Distance irom p`rale water supply well or suction line � { D,ameter �_ Comments (cond,t,on of )oints, ventin evidence of leakage, etc.) y s .0-r ve �cr1- i i SEPTIC TANK:&V_-15,1? ovate on s'te plan" i Depth below grade Hatenal of construc't,or4,4 concrete"metals/i7Fiberglass4/APolyethylene 40other(explain) u tank is metal. list age J& Is age confirmed by Cenificate of Compliance.-V.4' (Ye,/No) I I� D'mens'ons Sludge depth. Distance from Ioofsl i�sludge to bonom of outlet tee or baffle:4 Scvm thickness Doiance irom top of scum to top of outlet tee or battle ItI141 r D,stance from bonom of scum to bonom of outlet tee or baffle t Q ; "ow d,mens-ons were determined. Comments recommendation for pumping, condition of inlet and outlet tees or baffles. depth of liquid level in relat,on to outlet inve'1. ntegnry. a-dence of leakage, etc 1 _ E CREASE TRAP:=/�,�/� Uocale on site plan) I ,p I Depth below grades! Mater.al of con concreteA�metal44{4FiberglasW/VPolyethylen",)ther(explaln) Dimensions:_ Scum thickness. I 117 D.stance from top of scum to top of outlet tee or baffle: tW ! I Distance from bonom of sc m to bonom of outlet tee or baffle: 6� Date of last pumping. i Comments trecommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet n.ver-., ntegnry. evidence of leakage. etc ) t it tr.�t..d 0�/15/971 ➢.9. 6 of 10 I r , I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 164 Fuller Road Centerville,Mass . 02632 Owner: . Gladys Wiinikainen Date of Inspection: 9/30/97 TIGHT OR HOLDING TANK4d&LJ�.(Tank must be pumped prior to, or at tune, of inspection) (locate on site plan) Depth below grade A2& Material of con strucaroryir/$concretetr),4meta[ //¢FiberglassyAPolyethylener(,�-gother(explain) Dimensions. IVAI Capacity: gallons Design flow. gallons/day Alarm level. Alarm in working ordeWW Yes O No Date of previous pumping Comments (condition of inlet tee, condition of alarm and float sw-tches, etc.) r �Si .I DISTRIBUTION BOX/ f� (locate on s-te plan) Depth o: Iicu-d level above outlet invent ', '1 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence Df leakage into or out of box, etc ! PUMP CHANIBER (ioca(e on site plan) Pumps - —orking order: (Yes or No) Alarms n working order (Yes or No)'�a Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) l (r•v1.•G 04/7s/97) P.g• 7 of 10. t n it i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 164 Fuller Road Centerville,Mass . 02632 Owner: Gladys Wiinikainen Date of Inspection: 9/30/97 SOIL ABSORPTION SYSTEM (SAS): !! locate on site plan, if possible: excavation not required, but mad be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits, number: 0 leaching chambers, number:0 leaching galleries, number:_Q_ leaching.trenches, number,length:_ leaching fields, number, dimeisions: overflow cesspool, number: Alternative system: V9 Name of Technology:AA Comments (note condit n of o f, s, ns f hydraulic failure, level of ponding, condition o.` vegetation, etc.) /14: arr�h i CESSPOOLS: (loca(e on site plan) Number and configuration: r ��7 Depth-(op of liquid to inlet <�en: " 1�d� az1e41 uow C � Depth of solids layer: B Depth of scum layer: 1 Dimensions of cesspool. Materials of construction: Indication of groundwater: in I w (cesspool must be pumped as pan of inspe i n)�f� � /C J Comments. (note condition of soil, signs of hydraulic failure, level of ponding, condition ofvegetation, etc.) PRIVY: docate on site plan) Materials of conurua� n: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) OF tr.�s..d Y.g. a of 30 t _ __ _ ________________ __ _t ._ _� ___ � � � �� , �� i � �� , �> `TT ,� p� � � � ,� c,�� , if SUBSURFACE SEWAGE DISP; SYSTEM INSPECTION FORM r C SYSTEM (NFOI: iON (continued) Properly Address: 164 Fuller Road Centerville;Mass 02632 Owner: Gladys Wiinkainen f Date of Inspection: 9/3 0/9 7 7 7 i Depth to Groundwater, et Please indicate all the methods used to determine High Croundwat(Y EIS a6on: _ Ootalned from Design Plans on record Observation of Site(Abuning property, observation hole, baserreril-limp etc.) Serm,ne it from local conditions Check with local Board of health Check FEwA Maps r I//`heck pumping records r Check local e•CaratOrs, installers Use USCS Data Descr,oe n Your own words how You established the High Groundralcr I levat'on. (Must be completed) Used Cape Cod Commission Map September 1995 Cape Cod Water Table Contours And Public Water Supply Well head Protection Aresa lr•rl••G 0�/75/97) ➢•5• of 10 ' ' I I� I I .1n n.'T TT lT11.-1T.'nTl'TlTTr'T'T.nn�l:•.Tr.•.TIi 1TT"1TT7.ft�IZ�T1fTSR'n•1f.'1I �TTi"T•'-•+• --+-- •. •� T I TOWN OF RarnstahI P BOARD OF HEALTH SUNSURFACF 9F.WA(;E DISPOSAL SYSTEM INSPECTION FORM - PART D - CFWFIFICATI014 �_ f•••r.. r .--..i ---r.r.-n•n:mr•rr.r.rrrt�-r-.r-•.�-• rrrt�anrvr'�**mamrnrvrms-�•m� mnn-.+rn-.'rt rv-m-.+,-.r.—rr.- .-._. -. —TYPE OR PRINT -CI.EARL)'— PROPERTY INSPECTED STREET ADDRESS 164 Fuller RoaD Centeaville,Mass. 02632 ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Glayds L.' Wiinikainen . T PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr . , COMPANY NAME Joseph P. Macomber & ``on , Inc . COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066 Street Tovn or City Stat• t I P COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspec 'Ied the sewage disposal system nt 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 , maintenan< e , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : ..r li System PASSED The inspection which I have conducted has not found any information which indicates that the system fails toladequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any faililre criteria not evaluated are as stated in the FAILURE CRITERIA section of t is 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 , 310 CMR 15 - 303 , and. as specifically noted on PART C - FAILURE CRITERIA of this inspecti n form . ' - Inspector Signat Date - One copy of this -certification must be/provide'd to the OWNER , the BUYER ( where applicable ) and the BOARD OF NZAL7'1I, • If the inspection FAILED , the owner or operator shall upgrade the eyatem wit1lin one year of the date of the inspection , ' unless allowed or required otherwise as provided in 310 CmR 16 . 305 . partd . doc 1 W Ul 7J tiJd- TI-ECi COMMONWEALTH OF MA.SSA.CHUSETTS DEPARTMENT OF ENYI[ 20NMENTA.L PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Denart-ment', qualtf rnriranc ac rPnii-rAri "J, A 1 1 authorized to use the title CERTWIE D TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws " Issued by The Department of Environmenlal Protection" A( iwA 1)1tcCtor of the O1 itlon W11ct Polluuon Control t_�`