HomeMy WebLinkAbout0378 GREAT MARSH ROAD - Health �378 Great Marsh Road, Centerville
A = 190 - 099
No. 42101/3 ORA
ESSELTE
10%
O ® 0 O
-
TOWN /OF BARNSTABLE
1
LOCATION 1W,4HJ4 /?d SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT /90-0 Qq
INSTALLER'S NAME&PHONE NO. 1177-o.3 S'q le-P4 o-c 30P,19s
SEPTIC TANK CAPACITY /S00
LEACHING FACILITY: (type) 641 Zgye,� Qv!!►'-i, size) 25-X 1 .5
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE: L 12 Z7 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.
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No.
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THE COMMONW
P�'"--'EALT`H OF MASSACHUSETTS
Entered in computer:
. Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Miquar 6potem Cow5truction Permit
Application for a Permit to Construct(&,,fRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3 g �?%/sue �%�� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. 41-77- Designer's Name,Address and Tel.No.
Joscio/ U� /341-Nas
A/ WAN
Type of Building:
Dwelling No.of Bedrooms 3 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
Title
Size of Septic Tank Type of S.A.S.
Description of Soil tSh�
Nature of 7
epairs or Alterations(Answer when applicable) F��� 1=x��T/�o9 G/=SS�OO� al,r_4 4f1r=1!i
!¢h d0 ' 0 0 rs/ r
' i-o " �
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 e. Date S -/-1-y7
i
Application Approved by Date
Application Disapproved for a following reasons
Permit No. 7— Date Issued l
r /- No. , Feev
f `�'� Entered in computer:
THE COMMON*Ek OF MASSACHUSETTS
Yes
+ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
� r
12ppiication for Migogal 6pglem Congtruct on Permit
` Application for a Permit to Construct(4,j"Repair1( )Upgrade( )Abandon( ) O Complete System ElIndividual Components
I 3 7 /"�=� /fo�s Owner's N e,Address and Tel.No. �/2 g'
Location Address or Lot No.
Assessor's Map/Parcel i"
/fv a?? J7& CGrc�or /��rs� �� � ht,Er✓�//,G
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: 1`
Dwelling No.of Bedrooms 3 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
Title
Size of Septic Tank / Type of S.A.S.
Description of Soil �S i4rlc/
i
Nature of epairs or Alterations(Answer when aappplicable) a,71 /=XI.C77 9�' G/_=S 61,91 wl t4 efl oe
�ti h T / / oo jol 1. 2 - ov 641 L F,acli
aH !/N
Date last inspected: f
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 eal h.
Signed of a Date $ -/.1 .97
Application Approved by erA,, A Date
t' Application Disapproved for t e following reasons
s
Permit No. Date Issued
--------------------------------7-------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired ( ) Upgraded( )
Abandoned( )by Jo,57e4 A-, /3rorva.S
at 49i0r,%4 C15H a b constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No "' dated
Installer .413c,0� )1 /.�RrrOs Designer oS e .9rra
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date C! - 1 ) ei 7 Inspector
t
—-------------� ------
a� /�4 019 Fee
—I�_e�"—�'" a.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC-HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Moogat *pgtem Congtructton Permit
Permission is hereby granted to Construct( Repair( )Upgrade( )Aba on( )
System located at 3 78 ��^�s4r' �I.�rS7a /2o.r G s4ri' V//�F
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 nd the following local provisions or special conditions.
Provided:Copgruc on mu a co pleted within three years of the date ofthis pe it. /
Date: Approved b
- PP Y
NOTICE i This form W to be used toe the repnir of toiled Neptic
systems only
ATION Ok Sk1 ICH AND AULiCA1,10-N Volt A 01VOSAL
WORKS 00-NMuS ION PI;Mt t(W1111OUt DE IuMb PLANS)
t, _✓os�,bl /,�� ���s , hereby vettiry that the application rot-disposal works
construction permit signed by the dated g -- /.,2 q, , ct)hcefning the
property located at 17, Gr���/' c�rS� �� �'i�Nrj ✓,*eets all of the
following criteria:
K/'fhere nre no wetlnnds within 100 feet or the ptoposed septle§yStetn
There are no private[bells WhIthi 110 feet or the ptopomd septic§y§lent
�U 111e obsetved groundwater table 1s 14 fed of gteatet below the bottom of the leaching facility
'there is no hicrease in flow rand/or change In tine ptoptMed
6/1-here are no votiance§teciue§ted of needed.
�1
5lt3NEU:G��� � �iLe�?/ t)A'fp: $ —/_2 —97 —
LIcpNSP.D SEPTIC SYSI-EM INSTALLPR IN 11It tOWN or, t3AttNStA131,p NUMOVI fy
[Attach a sketch plan of the proposed system. Also It'the Hcetised installer posesses n certified plot plea,
this plan should be submitted].
q:henleh rolder.cerl ~
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TOWN OF BARNSTABLE
LOCATION. -,47 eJh SEWAGE #
VII,LAG>r` ; �nf2r✓i/�F_ '- "ASSESSOR'S MAP & LOT IV-=aQQ
INSTAI I;EWS NAME&PHONE NO. 47 7-031"1 Jase-Pl Q•c QHrr0 5
SEPTIC:7ANK CAPACITY /SDD
LEACH]N.G:sFACILPTY: (type) -500 Gp/LEAcy 6,0269-asize) 2 S'X 11
NO.OF-W)ROOMS 3
BUII.DhR.OR OWNER n i PERMfTDATE: f7 COMPLIANCE DATE: 1 D-1-1-9:)
Separation;Distance Between the:
Maximuii,'Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Privates.atof Supply Well and Leaching Facility (If any wells exist
on 44: 'within 200 feet of leaching facility) Feet
Edge ofWetlan.d and Leaching Facility(If any wetlands exist
withi6*300 feet of leaching facility) Feet
Furnishes:by:
i
�lq
lcr7 DATE: - 6/25/97.
PROPERTY ADDRESS:- ,-' 9 l�
n
378 "Great Marsh Road RF�'4rf'n
Centerville, Ma. 02632 , as �UL . 21 1997 N
TOWN OF
HEAL,
On the above date, 1 Inspected the septic system at the abov ress.
This system consists of the following: E
1 . 2-61x8 ' block cesspools .
Based bn my int%oactlon, I certify the following conditions:
1 .. This is not a title five septic system.
• 2. This is a sewage system. ,
3• The sewage system is in failure . System must
be upgraded to a title five septic system. ( 95 Code)
4. Waste. water is above the inlet outlet of the amin cesspool and
over the invert pipe to the overflow.
'SIGNATURP':
Name: J . P ,Macomber Jr...
------_y----------
Company _J • P_MacoMber &—Son—Inc ;
__Centerville , Mass__02632
Phone:---548�Z7�-.3338------- '- 1
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER. & SON, INC,
Tanks oupools-Leachflelds
. Pumped & InsLlled
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632.0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
ID 94
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
C DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617-292.5500
N'ILLIAM F.WELD TRUD1'CORE
Governor
Secretan•
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 378 Great Marsh Rd, Centervill6ddress of Owner:
Date of Inspection: �2 5/9 7 (If different)
Name of Inspector: 0seph P. Macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Joseph P. Macomber & Son, Tnc.
Mailing Address: 13OX en erville M 2-0066
b
Telephone Numer: bb— — 33$
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_/Needs Further Evaluation By the Local Approving Authority
_/ Fails ']
Inspector's Signature: s Date: /
The System Inspector all submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
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 defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BJ SYSTEM CONDITIONALLY PASSES:
_ Q 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Pay 1 of 10
DEP on the World Wide Web: http:Nwww.magnet.state.ma.us/dep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 378 Great Marsh Road, Centerville, Ma. 02632
Owner: Walter Hallett
Date of Inspection: 6/2 5/9 7
BJ SYSTEM CONDITIONALLY PASSES (continued)
104 ``' Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
.bD The system required pumping more than four 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
Cl 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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
&V Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply. '
,�JV The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_�)d The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance 4-10— (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 378 Great Marsh Road, Centerville, Ma. 02632
Owner: Walter Hallett
Date of Inspection: 6/2 5/9 7
D] SYSTEM FAILS:
Yo u t indicate ei:!.er "Yes" or "No" as to each of the following:
1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303, The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yeses No
� Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped W.
r� Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
.} The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
/.V_y/ the system is within 400 feet of a surface drinking water supply
V 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 378 Great Marsh Road, Centerville, Ma. 02632
Owner` Walter Hallett
Date of Inspection: 6/2 5/9 7.
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, o upanl, or Board of Health.
None of the system components have been pumped for at least two weeks and'the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recentiv or
as part of this inspection.
A)k Alk As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,li cluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ — The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
41 Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) P&p* 4 of 10
' L5.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 378 Great Marsh Road, Centerville, Ma. 02632
Owner: Walter hallett
Date of Inspection: 6/2 5/9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: �(9 p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):_
Laundry connected to system Eyes or no):15
Seasonal use (yes or no): LU
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):-VA
Last date of occupancy:_�Z'
COMMERCIAUINDUSTRIAL•
Type of establishm nt P/rt
Design flow: allons/day
Grease trap present: (yes or no),&/4
Industrial Waste Holding Tank present: (yes or no)�
Non-sanitary waste discharged to the Title 5 system: (yes or no)AO
Water meter readings, if available.
Last date of occupancy: i[-4
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING REC04DS and 5ource,of in( at
Q Qn:
System pumped as pan of ins ection: (yes or no)_
If yes, volume pumped: _gallons
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)
_ VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)Ao
(revised 04/25/97) Page 5 of 10
011
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 378 Great marsh Road, Centerville, Ma. 02632
Owner: Walter Hallett
Date of Inspection: 6/2 5/9 7
BUILDING SEWER:
(Locate on site plan)
J/
Depth below grade:
Material of construction: cast 'ron _40 PYC _other (explain)
'eq/-
Distance from pr vate water supply Al or suction line
Diameter y _
Comments: (condition of 'oints, venting, evidence of leakage, etc)
SEPTIC TANK:_&6?IC_
(locate on site plan)
Depth below grade:
Material of construct ion A14 concrete.l�metaWAFibergIass., Polyethylene,//9bther(explainI
If tank is metal, list aged Is age confirmed by Certificate of Compliance 4JO(Yes/No)
Dimensions:
Sludge depth: 109
Distance from top of sludge to bottom of outlet tee or baffle:'V4
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_ VX
Distance from bottom of scum to bottom of outlet tee or baffle: J)/
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
Q �14 7rV Jv� hYlr /ie S��V
GREASE TRAP: C '
(locate on site plan)
Depth below grade:-,,.,&
Material of construction:'v/concrete/L/'lmetaliY�Fiberglassd/�Polyethylene4J/lother(explain)
Dimensions:
Scum thickness: W
Distance from top of scum to top of outlet tee or baffle: 4M
Distance from bottom of scum to bottom of outlet tee or baffle: A14
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
E .Q
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 378 Great Marsh Road, Centerville, Ma. 02632
Owner: Walter Hallett
Date of Inspection:
6/25/97
TIGHT OR HOLDING TANK:A/wC(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:ti",4
Material of construction WIf concrete4/Ameta I AAF i be rglass/j/'4Po lyethyl ene AvAther(expla in)
Dimensions: 464
Capacity: IVIY gallons
Design flow � _ gallons/day
Alarm level: Alarm in working order W1,VYes4A,1 No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
-T77F U Al,-,,T $SP[>;r
DISTRIBUTION BOX:A�At�
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
j0i-gTr1tam4, lknc L )ue-r RM-ge )
PUMP CHAMBER:
(locate.on site plan)
Pumps in working order: (Yes or No) 4,1,4
Alarms in working order (Yes or No)-Jj4
Comments:
(note ondition of p mp ch mber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 378 Great Marsh Road, Centerville, Ma. 02632
Owner: Walter Hallett
Date of Inspection:
6/25/97
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
if not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology: VA
Comments:
(note conditiAr of soil,stns of hydraulic failure level of pond ing, ondition of vegetation, etc.)
J• Q6�N Y
r'_ N T
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: (110j"
Depth of solids layer: :tle
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs f hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:_
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) P&g• B of 10
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
�n .1 N t
(revise d o4/25/97) 31 C + •� �° y1aICsy ,F'd
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 378 Great Marsh Road. Centerville, Ma. 02632
Owner: WaLTER Hallett
Date of Inspection: 6/2 5/97
Depth to Groundwater/�2 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
�p G��Dit, � x/n Z &iv�i vXi' Gd�? r' "- ✓'
(revioad 04/25/97) Page 10 of 10
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TOWN OF Barnstable BOARD OF 11EALT11
SMISURFACF SFWAGF DISPOSAL SYSTEM IN311FCTION FORM - PART D - CF.R'rIFICATION 1pI
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-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 378 Great Marsh Road, Centerville, Ma. 02632 '
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Walter Hallett
PART D - CERTIFICATION 1
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME Joseph P. Macomber & ''Son, Inc .
COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066
Street Town or City, state-LIP
COMPANY TELEPHONE (508 ) 775 -3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa! system at
this address and that the information reported is true , accurate , and
complete as of the time of :inspection , The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
System PASSED
The inspection «hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe 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 c 'Ucted has found that the system fails to
Protect the Public health and the environment in accordance with Title
.5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signatur Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF IIEALI'!I,
* If the inspection FAILED, the owner or " parator shall upgrade the ayetem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CMR 16 , 305 ,
partd . doc
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THE COMMONWEALTH OF MA.SSACHUSETTS
DEPARTMENT OF E ONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualificatigns as required and is hereby
authorized to use the title
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
)unc 8. 1995
Acung Dircctor of the ion of Watcr Pollution Control
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TOWN OF BARNSTABLE
LOCATION Jev ; SEWAGE # y
VILLAGE f ASSESSOR'S.MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
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 le hi cility) Feet
Furnished by - a
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