HomeMy WebLinkAbout0022 HARRISON ROAD - Health 122 HARRISON ROAD, CENTERVILLE
j A= 229 070
a
1
llll ecv""�
,Z
UPC 12543
No. 53LOR
HASTINGS, MN
AMMMI
I
�.1
D
DATE:_10/16/95---
PROPERTY ADDRESS: 22 Harrisson Road
Centerville
------------ -
-Mass.02632
------------------------
On the above date, I inspected the septic system. at the above address.
This system consists of the following:: z
1 : 1-6 1 x5 l . block cesspool.. rJ,
�, C'esS 1. uvckv T, C'.4:)(w#Tro LW o 1;.0 Y);Vs �1 c
,.•- - ,
Based on my inspection,, I certify the following conditions.
1 . This is not a title five septic sytsem. .
. 2. This is a cess pool -system. This system is at' least 25 - 30
years old.
3. System is inade pAF to handle the present house.
A. System should be rdd 'to : a ti le ve hiee�tip system.
5. Present cesspoo4 inaa equate to an££e�e t size Touse.
:.. ,' SIGNATURE-
Name:
_Joseph P_ Macomber Jr.
Company:J_P_Macomber & . Son Inc.
Ad d re s s'�.oi -- - --- g
love.
OC -
terville�Mass 02632 r °9
- --- I995
e' ft
Phone:___308-775_3338 _ MOW "
THIS CERTIFICATION DOES:NOT, CONSTITUTE A GUARANTY OR WARRANTY
• . I
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachfields
Pumped & Installed ` t .
Town Sewer Connections „ .
P.O. Box 66 ` Centerville, MA 02632-0066
.775.3338; 775-6412
Commonwea4h of Mossochusetts
Executive Office of 'Environmental Affairs
Department of
Environmental Protection
William F.Weld
Gormor 0
Trudy Coxe
Uudary,EOEA e
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
erty Address:22 By /77$p Road Centerville Address of Owner:
of Inspection: (If different)
e of Inspector: Joseph P.Macomber Jr.
pany Name, Address and Telephone Number:
'IFICATION STATEMENT
ify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
:omplete as of the time of inspection. The inspection,.was performed based on my training and experience in the proper function and
tenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
ector's Sig nature: Date: �' 7
iystem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
ction. 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
sport to the appropriate regional office of the Department of Environmental Protection.
)riginal should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
ECTION SUMMARY:
:heck A. B, C, or D:
YSTEM PASSES:
1 1 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.
YSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection:
ate 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, 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. .
ised 8125195) 1
I
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 22 Harrison Road Centerville,Mass. 02632
Owner: . Patricia Reid Hunter
Date of Inspection:1 0/13/9 5
B] SYSTEM CONDITIONALLY PASSES (continued) 4 ,
e
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):
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). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
�j 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:
/dO Cesspool or privy is within 50*feet of a surface water
d,47 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system nas a septic tank anu"wi( dbburpliun.system and 6 w4hin 10101 feet to a surface water supply or tii"utar'j to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public.water supply well.
AV The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
A0 The system has a septic tank and soil absorption system and 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•
D] SYSTEM FAILS:
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.
Backup of sewage into facility or.system component due to an overloaded'or clogged SAS or cesspool.
oDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
• 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 22 Harrison Road Centerville,Mass . 02632
Owner: Leary
Date of Inspection:10/13/95
D) SYSTEM FAILS (continued):
Static liquid 1,!Vel in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
0 Liquid depth n cesspool is less than 6" below inven 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
YO Any portion :f the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
AM Any portion cf a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
JLB Any portion of a cesspool or privy is within a Zone I of a public well.
�® Any portion of;r 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.
EJ LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
,# the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (11,%rPA) 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 8/15/55) 3
_ 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
:rtyAddress: 22 Harrison Road Centervilale,Mass . 02632
Leary
of Inspection: 10/13/9 5
if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
/pAs 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
-4/-The site was inspected for signs of breakout.
4/All system components,deluding 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
(v�-tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
4/The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
, The facility ov.ne: land occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
Recommemdations .
1 . The system must be upgraded to a title five septic.
2. System ( Cesspool ) is. inadequate to handle the existing house.
ed 8/15/06) 4
• X
• V
SUBSURFACE SEWAGE DISPOSAL�SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
pertyAddress: 22 Harrison Road Centerville,Mass . 02632
ner: Leary
e of Inspection:10/13/9 5
FLOW CONDITIONS
IDENTIAL:
ign flow: gallons
nber of bedrooms:
nber of current residents:_b_
bage grinder(yes or no):_ ,
ndry connected to system (yes or no):_
tonal use (yes or no):_
:er meter readings, if available:
y �
date of occupancy:
'NMERCIAUINDUSTRIAL:
e of establish ent:•
ign flow: allon day
ase trap pr sent: (yes or no)
istrial Waste Holding Tank p esent: (yes or no)j
rsanitary waste discharged to the Title 5 system: (yes or no)—,&,-4
:er meter readings, if available: Aeilw or=
date of occupancy:
-IER: (Describe)
date of occupancy:
CENERAL INFORMATION
APING RECORDS and sourc of in(or ation: �
Aa"wi g
Systerfi pum d af part of inspect on: (yes or no) .
If yes, volume pumped: gallons
Reason for pumping:
'E OF SYSTEM
Septic tank/distribution box/soil absorption system
°� Single cesspool
f� Overflow cesspool
01
Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
'ROXIMATE AGE of all components, date installed (if known) and source of information: 1 VAi /�%MJW V457-
,age odors detected when arriving at the site: (yes or no) A20
+iaed 8/15/95) 5
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: 22 Harrison Road Centerville ,Mass . 02632
Owner: Leary
Date of'Inspection.1 0 13 95
SEPTIC TANK: e
(locate on site plan)
Depth below grader
Material of construction: concrete_metal_FRP other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: �
Distance from bottom of scum to bottom of outlet tee or b—aftlf
Comments:
(recommendation for pumping, conditionpf inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) �1/�Jt.0
GREASE TRAP:u�i1'
;locate on site pan)
Depth below grade:
Material of construction: oPcrete _metal_FRP other(explain) .
Dimensions: /¢
>cum thickness:
—40
Distance from top of scum to top of outlet tee or baffle:/1�l�
.)istance from bottom of bcum to bottom of outlet tee.or Nile:0-4
:omments:
recommendation for pumping, condition'9f inlet and outlet tees or baffles, depth.of liquid level in relation to outlet invert, structural
ntegrity, evidence of leakage, etc.) zzI LC
..i
>�r
revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION (continued)
)perty Address: 22 Harrison Road Centerville,Mass . 02632
vner: Leary
to of Inspection:)0/13/9 5
;HT OR HOLDING TANK:j1��'
:ate on site plan)
pth below grader —
aerial of constructio :A7ncrete _metal FRP _other(explain)
pensions:
pacity: gallons
sign flow: allons/day
irm level:
mments:
ndition f inlet tee, co
� ndition of alarm and float switches, etc.)
Satz
iTRIBUTION BOX:
eI� .
:ate on site plan)
pth of liquid level above outlet invert:__p_
mments:
to 4)eve and i. e(4ud', evidence of solids carryover, evidence of leakage into or out of box, etc.)
MP CHAMBER:40
:ate on site plan) A
nps in working order.(yes or no)—&
mments:
to condition of purrs chamber, condition of pumps and appurtenances, etc.)
vised 8/15/95). 7
SUBSURFACE SEWAGE DISPOSAL.SVSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address: 22 Harrison Road Centerville,Mass . 02632
)wner: Leary
late of Inspection: 10/13/9 5
OIL ABSORPTION SYSTEM(SAS): •
ovate on site plan, if possible; excavation not required, but y be approximated by non-intrusive methods) '
not determined to be present, explain:
ype:
leaching pits, number:Q
leaching chambers, number:Q
leaching galleries, number.,
leaching trenches, number,length:
leaching fields, number, dimensions: [�
overflow cesspool, number.Q_
omme ts: (note con ition f soil, si ns of hydraulic failure, level of pondin , condition,of vegetation,ec.)
JJF
ESSPOOLS:
Dcate on site plan)
umber and configuration: to X �7�•, t�OjG t�/,✓kiVpEtJdJ.
,epth-top of liquid to inlet invert: J G,��W
epth of solids layer:
epth of scum layer:
imensions of cesspool:
laterials of construction:
idication of groundwater: A&4Ae� r�
i w(cesspool mus be pum d as part f ins ion)
cd•�► y awti• '
o ments: (note c9pdition of oil, sins of by raulic failure, level of ponding, conditi n pf vegetation e�.)
RIMY:
acate on site plan) , / ,�•.
laterials of construct' /lJ/� Dimensions:
epth of solids:
omme t (note. ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
:evised 6115195) 8
;tt .
J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 22 Harrison Road Centerville ,.Mass. 02632
Owner: Leary
Date of Inspection: 10/13/9 5 .
SKETCH OF SEWAGE DISPOSAL SYSTEM: •
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
i
'4 0
J-1
! tw0 Fdi5 C 9S A -r Ueaae I
DEPTH TO GROUND A 7 ,q 9 A / �'0 N �Q ct✓' �
Depth to groundwater: feet -
method of d t rminat or approximation:11,16K S�Ah hzeg�
10 ,
(revised 6/15/95) 9
z
!•p.n,T.T/..'I�"'T—tlNrAl/eI:YIRI!'I:R7'RT T.*1'M17ifflO77t1T T7YF7'T�.7R11..`1117r.T•'}
_ 'I'OHN OP Ra rn a+.a hl A BOARD OF HEALTH
'SUIJSURFACE SEHAGE.DISPOSAL SYSTEM INSPECTION FORM PART D•- CERTIFICATION.
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 22 karrisbn Road `Centerville,Mass. 02632
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Lpnry
i
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr:.
COMPANY NAME J.P.Macomber '& Son Inc.
COMPANY ADDRESS Box 66•' Centerville,Mass . 02632
Street ' Town or City state LIP
COMPANY TELEPHONE (508 r 775 3338 FAX ( 508 1 790 - 1578
M
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposiA system at
this address and . that the information reported is true, accurate, and
u complete as of the tithe of .inspection. . The inspection was performed and any' ,
rec.otnmenda.tLoris regarding upgrade, maintenance , and repair are consistent.
with my training and experience in the proper function and maintenance of on-
site . sewage disposal systems .
Check one:
System PASSED '
The inspection which 'I have conducted has not found any .information
which indicates that the system fails to adequately protect public .
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.
XXXX System FAILEll*
The inspection which I have conducted has found that the system fakii 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.
.i.
Inspector Signature Date
One copy of this ce ification must -be provided to the OWNER, the B. ER
(where applicabl and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade the Illy,
within one of the date of the inspection, unless allowed or requ `s ,,
otherwise as provided in 310 CMR 16 . 305 :.: "
m ,
Cv�I,r Cnwec1 vi IV,Q `.C. se!',s
EXECUNe Cif lce
Department of
Environmental Protection
' WaTer Pollution CcnTroi Tecnnlcci Asslsicnce ana Training SecTlons
µnub F.Wed
Trudy Cos.
SP"wY.ECEA
Thom" e.Pow«.
06/12/tilt
ATTN: Joseph P. Macomber, Jr.
Joseph Macomber and Sall
PO Box 6G
Centerville, MA 0263 -
Dear Joseph P. Macomber, Jr. ,
I am pleased to inform you thatJyou have attended training, met
the experience qualifications, and have passed the Title 5 System
Inspector exam, pursuant to 310; CMR 15. 340 . The passing grade for
the exam was 39/52 or 75% .
This is an official notification that you are a Certified Department
of Environmental Protection System Inspector pursuant to 310 CMR 15. 340.
You will receive a System Inspector certificate at a later date.
If you have any futher questions, please write to me at the following
address :
Kimball Simpson
D. E. P. Training Center
:30 Route 20
Millbury, MA 01527
Thank you very much 11:01' von: tim'O and consideration in this matter.
Sincerely,
Kimball 7. S:mnson,
DEP Training Director
2405) Route n 9 Millbury, MA FAX 5U-755.9253 • ,n• 508-756-7"O1
6 Cofis'ervation
W. a fq r
6SATips
CHECK FOR LEAKS : y
Water Loss k-Gallons Due to Leaks
Leak ,
this Loss Per Day . , Lbss Per Month '
Size .
• . 120 3,600
• 300 10,800
• .693, . 20,790
• 1,200 30,000
• 1,920 57,600 '
• 3,096. 92;880
O 4, 96 .128.980
• ® 6,640 199,200•
6,9.84 ' 20Q,520
8,424 ' 252,720 •,
9,888 ,296,640
,® , 11,324 339.720
12,720 .381,600
1
14,952 448,560
• tix>.
TOWN OF BARNSTABLE /
LOCATION 7iZZ?J"I"JSDl1 I" SEWAGE #
VILLAGE, ASSESSO
R
'S MAP&LOTZ Z e75)
INSTALLER'S NAME&PHONE NO. ,jD/'7��413L1
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type) 961s 454• (size)
NO.OF BEDROOMS3J
BUILDER OR OWNER
PERMITDATE: 3 1/ 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 D
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
1
30
� 30�
�3J -79 91
90%
1
Z2 eq—
No. �s �li' • Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for Migool *pgtem Cougtructiou Perron
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lotpo Owner's Name Addre s and el.No. 6D3.a O— S"ZZ
�Z_#441 "d,�o� GPI �o -�l�/ Xeee kw#lei'
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
i
Dwelling No.of Bedrooms Garbage Grinder(✓tQ
Other Type of Building ke_5) e#�Ge No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow Ile gallons per day. Calculated daily flow isle gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answ r when applicable)
f}�Z� 4Grrt-" w.11, 5)vwe
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction 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 b this
Signed Date J%
Application Approved by
Application Disapproved for the following reasons
Permit No: Date Issued C7 _ Zz` G
THE COMMONWEALTH OF MASSACHUSETTS Z 7-
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
1
Certif irate of Compliance
THIS IS TO CERTIFY,that the,On-site Sewage Disposal System installed( )or repaired/replaced(�n
by d0!' �7f`/' COl7S7`�'�/G7`iO�9 for e-eer�'h� wley-
as Z. / ? Y%So/! r ^3+ J (l IChas,been constructed in accordance
f, !
with the provisions of Title 5 and the for Disposal System Construction Permit No. y' dated
Use of this system is conditioned on compliance with the provisions set forth below:
1
Z 29-47d y�--
r No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
I
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
i
Rio pozal *potem Confstruction Permit
Permission is hereby granted gel to L61y/
to construct( )repair(�/)an On-site Sewage System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
i comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date:_ ! .� ��� y Approved
1
*70
No. 9�, Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
f 01pprication for ;Digpozar *pgtern Construction Vertu
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
r Location Addresjs or Lot o Owner's Name Addre s and jel.No. 6a3-6SO- S`Zz
Ccrl�rvi'/lam wig ZGot,v ra? �}9Xvv�✓' by o3�'S`s`
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -
6prtoGm I�Dns r�c�iD� 0 o,T-v 1,0_3;1 CA 1k9►
Type of Building:
t. Dwelling No.of Bedrooms Garbage Grinder( O
Other Type of Building JQG'Sf �A'G e No, of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `lO gallons per day. Calculated daily flow 33e gallons.
a Plan Date Number of sheets Revision Date
r
Title
Description of Soil
f Nature of Repairs or Alterations(Answ r when applicable) -,/15 O)l /<S`DO '�
>~s t.(/i�` S y-OnP h5 `4" .k O X J Gf
as u,� c a ,�✓
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction a9$ , 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 b this He k�.
` Signed Date
Application Approved by
Application Disapproved for the following reasons
f
s
Permit No. �. Date Issued
{ —————————————————————————————————
I
r
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, ���r��T • Qcac.� i hereby certify that the application for disposal works
construction permit signed by me dated t/lFh , concerning the
property located at -X-2-- o LA-ys L C2aJ';6,LVI L(F_
meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• Then are no private wells within 150 feet of the proposed septic system
• T he observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : _ DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
h ..�-', �;s�j,� +'=�",7••Y""� �''�C .(���#;yr u fit?r.+....''Y�..s a r�`vy_Tq. ".'"•;:� c ^t '�� ^�.4�,'3° ��3�._.K�o� `Y�� r n�-''L "y y'� `a � r
L-
� ff
U L-.4 ,
r
TOWN gy BARNSTABLE
LOCATION 4SEWAGE #
VILLAGE E ASSESSOR'S MAP &LOT V47-670
INSTALLER'S NAVE&PHONE NO.
SEPTIC TANK CAPACITY ,
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 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
0
� I
� 2 ,� ARg AO a,,
FRIEDLINE & CARTER ADJUSTMENT, INC.
436 Main Street , P . 0. Box 338
Hyannis , Massachusetts 02601
Tel . ( 508) 771-3232
Fax . (508 ) 790-2344
TO: ( } Building Commissioner or Inspector of Buildings
(Board of Health or Board of Selectman
( ) Fire Department
TOWN HALL
HYANNIS
RE: Insured: FONTAINE, Norman V. & Margaret
Property Address : 18 Candlewick
Hyannis , MA
Policy Number : RP1692265
Loss of : Wind/Water 03/04/1998
File or Claim #: 81648
Claim has been made involving loss , damage or destruction of the
above-captioned property , which may either exceed $1 ,000 . 00 or
cause Mass . Gen. Laws', Chapter 143 , Section 6 to be applicable_.
If any notice under Mass . Gen . Laws , Ch . 139 , Sec . 3B is appro-
priate please direct it to the attention of the writer and
i-nclude a reference to the captioned insured, location, policy
number , date of loss and claim or file number . ,
On this date , T_ caused copies of this notice to be sent to the
persons named above at the addresses indicated above by first
class mail .
RONALD .A. BRULE
Adjuster
3/16/98
Date :
3e�lg�
F�.Qsc� � 4P P s�„�_ I�n �o /rv�a o� uoc✓�e
o-6
(9A
a
f olCr,..,v,-a Gw S�3 a�6
it
l
�� �� �°ie34' 11 IV
3 s�' n
�
u 1✓ ,0� .o cl Yft L Des
1582 Main Street East Dennis, MA 02641
Desl4ned for
Riazo/8enser Residence
22 Harrison Road
Centerville, MA
ph.508-619-7384 fx.508-619-7385
Q
cq
U') co
IN
0
zs
1 Co,10MBSIM
4.�omo
<
pi i
0- -0
Y-191, 13" co
Sp
1 0.1w
0
C: 0
-IN
04
C%42
0 ------
CID
(o
CV)
a.Lo G 10
to
C14 0 C\1
01 B36Q2 B27D2 B21010,
co 4LL -IN 0
co
CNI C14 N
all
0
0) C) C
0) 0 1
C)
In
co
to 11
Lo rA A
or.
1438 91=1G\HS1(TJrZ AS (3139C8S E c, 0 --
3ZAON COZZ13 .+1 .+�
LZ13 CGOLS1
'aall,zosm b >w ?19MM U-8—gum s W N N oN �9£LZM
LLIC L
0
L
co
David Ricardi D909nm6
1582 Main Street CID
4. P.O. Box 1051. IILZ 7
-0204 East Dennis, MA