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HomeMy WebLinkAbout0044 HEADWATERS ROAD - Health 44 HEADWATERS RD.,CENTERVILLE A=228-43-1 17l/Ilielu�® UPC 12534 No.2_ � HASTINGS.MN i A commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name information is required for CENTERVILLE MA 02632 7/15/2009 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out A. General Information When forms on the computer,use 1. Inspector. only the tab key to move your DOUGLAS A. BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A.BROWN INC IW� V Company Name 11 P.O. BOX 145 IL If Company Address CENTERVILLE MA 02632 rm� Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was,performed.based on,my training.andexperience.in.the proper_function and..maintenance.of on.site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 pf� Title 5(310 CMR 15.000).The system: "?" C3 ® Passes ❑ Conditionally Passes ❑ Fails a (" -n ❑ Needs Further Evaluation by the Local Approving Authority w=) 7/15/2009 Inspector' nature pate C,3 M The ystem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health.or D.EP)within-30.days of completing.this.inspection...Ifthe.system-is a.sharedaystem.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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. '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 tens•09oe Title 5 Olrc®I Inspection Form:Subsurface Sewage wsposal •Page 1 of 17 ` • J Commonwealth of Massachusetts Title 5 Official.Inspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name iRfbFis- requireStiOnd is CENTERVILLE MA 02632 7/15/2009 required for every page. Cdy/Town state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A). System.Passes::. 01 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: SYSTEM MEETS.PASSING.RE-QUIREMENT$.AT THIS.TI.ME B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for yes","no"or"not determined'(Y,N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): 15h s-ORM Title 5 Oftat hmpech.£arm:Stbm dace Se wage Disposal System•Pap 2 of 17 Commonwealth of Massachusetts Tiffe.5.Officia!-Ins Dection- Form Subsurface Sewage©lsposa!System Form-Not for Voluntary Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name informetion-.is.. required for CENTERVILLE MA 02632 7/15/2009 every page. City/town Stage Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cunt.): .0 Observation of sewage:backup-orbreak-Wor high-:stab-waW Leval the-distt bution-box due- to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): . distribution box-is leveled or.replaced ❑ Y ❑ .N .❑. .NO(ExpWn below).: ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed Q Y ❑_ N ❑. ND(Explain below):, C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System wilt pass unless Board of Health-determines in accordance with 310 CMR `5.1303(4') y that the system is not functioning in a manner which wig protect publtc 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.. t`hs•09= Title 5 Ofrclef hiaPection FbTm:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 6,Official--inspection- Form Subsurface Sewage-:Disposal System Form.-Not for Voluntary Assessments " 44 HEADWATERS RD Properly Address JAY OBRIEN Owner Owner's Name information motion is CENTERVILLE required for MA 02632 7/15/2009 , every page. f ittyy/Towrl state zip Code Date of Inspection B. Certification (cunt.) 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:. Ttle system has a:septictank and soiP absorption system-(SAS)and the SAS is within, 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"". Method used to determine distance: This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less�than.S ppm,.prpvided-thai no_other„failure_critefia..are_triggered,A copy.of..the..anaws-must he_. attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the-fotlomdng.for alt.inspec ions: Yes No ❑ ® Backup 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 to an overloaded or dogged 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%day flow +sins•oese Title 5 Olfxial Inspection Form:Subsurface Sewage Disposal System•page 4 of 17 Commonwealth of Massachusetts Title 6- Officlat Wspection Form Subsurface Sewage Disposal System Form-Not for Voluntary-Assessments- 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name information: CENTERVICLE required for MA 02632 7/15/2009 every page. Cityfrown state Zip Code rate—of Inspection B. Certification (cunt.) Yes No ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed'pipe(s).Number oftimes pumped: . ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of 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. [This s asses i system p f the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonla nitrogen and nitrate nitrogen is equal to or less than 5 ppm, providedthatno other fallure criteria arletriggered.A copy of theanaiysis: and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 31'07 CMR-15 3D3,therefore the system fails.The system<ownershould contactlhe;Board of Health Codetermine-What will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"'or"no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ the-system is-w4hifl 200 feet of a-t6butaFy-tea sur#aee•drinking-water supply. ❑ ❑ "the system is located in a nitrogen sensitive area(interim'Wellhead-Protection Area-IWPA)or a mapped Zone It of a public water supply well If you have answered'yes"to any question in Section E the system is considered a significant threat, or answered`yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3't0'CMR t5.304 The system owner shouldcontact the appropriate regional>ofce-of•the<Depadment. t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 { Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name information is CENTERVILLE required for MA 02632 7/15/2009 every page. Cdyfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner,occupant,or Board of Health Were any,of the system corrtponsnts pumped put:in.the previous;two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ El Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility 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'on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302.(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins 09M TMe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 6 Official Inspection For- M.- Subsurface.Sewage�Disposal-System.Form Not-for Voluntary Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name In ma€ n*js CENTERVILLE required for MA 02632 7/15/2009 every page. City/Towrl state Zip Code -pate of Inspection 0. System Information Description: SYSTEM CONSISTS OF A 1500 GAL TANK, D-BOX,AND TWO LEACH PITS Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0_ No Is laundry-on-a separate-sewage system?[if-yes separate inspection required] ❑ Yes E No Laundry system inspected? ❑ Yes ❑ No Seasonal-use? Q Yes R. Na Water meter readings, if available(last 2 years usage(gpd)): 08-241/07-197 Detail: -Sump pump? ❑ Yes 0 No Last date of occupancy: Date Cn - f! :GQnd►tioMz Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(sad) Basis of design flow(seats/persons/sq.ft.,etc.): .Grease,tr-ap present? Yes.-❑ ,No, Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water,meter readings,if avaWabie: t5ins•09M Title 5 Official Irre pection Forth;SuCsudace Sewage Disposal System•Page 7 of 17 . Commonwealth of Massachusetts o Subsu4we.Sewage.Disposal.System Fora Not for Vok4ritary Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name requm;dfor CENTERVUE NIA 02632 7/15/2009 i required for every page. Gityfrown State Zip Code Dete of`Inspection D. System Information (cunt:) Last date of occupancy/use: Date Gthejr,(descdbe:below)'„ General linformatio.n- Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes;vo)ume-purnped: gallons How was quantity pumped determined? Reason for pumping: Type of System: 0 Septic tank,distribution>box, soil absorption system. ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Tight tank.Attach.a-copy of the DEP approval. ❑ Other(describe): t5ins•09M Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts itte, 5, --#'Vial-tarp-ecttoirt-Fofn Subsuaface-Sewage;Disposat Syste n.Fwm,=Not-for.Voluntary:Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name ie fo is CENTERVILLE requitedfor MA 02632 7/15/2009 every page. Cftyr'rown Slate ZIP Code -Date ocinspecton 0. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: INSTALLED 1998 BY LARRY NICKULAS ACCORDING TO AS BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material:of,construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on cor.IditiQ[l.of.)dints,vaift.eu det>ce:of:leakage, Septic-Tank-(Locate on sde•plan): -Depth'belcw grade: 5 feet Material of construction: ®concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age: years Is age._eonTiftnied by a Cemic to 4f Cn npuance?(attar i acopy; .f ❑+ #i rate c "Ye ❑..'No.., Dimensions: 4500 GALLON Sludge depth: t5ins•008 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Witte 5.Official Inspection Forte SiubsudaceSe 'Disposals System.Fevrn:-.Not for Voluntary:Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name ingrm"on is CE�ITERVlLLE required for MA 02632 7/15/2009 every page. Oityrrown State Zip code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance fromtop:ofsludgeto 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 baffle 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.): TANK LOOKS VERY CLEAN AT THIS TIME Grease Trap(locate on site plan): Depth below grade: feet Material-of construction: ❑concrete ❑metal ❑fiberglass g El polyethylene El other(explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 1Sins•g90.19 7iCe5.Official.G+eP�?iad;Fwm.Sub�ufacs.SewagedJispasa4Sys�m>PapeaO.at:17... Commonwealth of Massachusetts Title 6-Official- l pectlon-Form.- Subsurface-Sewage-Disposal System,:Earm.- Not for voluntary-Assessments.. 44 HEADWATERS RD Properly Address JAY OBRIEN Owner Owner's Name requmation is required MA 02632 7/15/2009 required for every page. City/Town Sfate Z Code Date orinspecton D. System Information (cunt:) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 'Tight or RdhNng'Tank'(tank must be pumped at-time o'f ihspectiori)"(locate on site plan): Depth below grade: Material of construction: concrete. ❑metal ❑fiberglass ❑polyethylene [].other(expPC1in):. Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments:(condition,:of alarm and float,switches,etc.); •Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No Mims•09= Title 5 Ofrxlai Ins pection r-rnm:Subsurface Sewage Disposal System•page 11 of 17 Commonwealth of Massachusetts . Title 5 Official -Inspection Form ZMEWA 'Sub surface-Sewage.Disposal--Systern forma w Not-for,Voluntary.Assessme.nts, )W 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name information is required for CENTERVILLE IMA D2632 7/15/2009 every pope. CWTown State Zip Code Date of Inspection D. System information (cost.) Distribution Box(if present must be opened)(locate on site plan): . level above outlet invert 0 �t�of trgvrd - Comments(note-if•box-is level-and distribution to outlets-equal,aq,evidencerof-:solids-carryover;:any -evidence of leakage into or out box,etc.)- Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes El:No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): $oiLAbsortion System(SAS.).(locate on site plan,excavation.not required): lf''SAS'not located,explain why: f5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Qispcsal System.Form-Not for Voluntary.Assessments, 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name iriformation rs CENTERVttLE required for MA 02632 7/15/2009 every page. Citylrown State Zip Code Date of Inspection D. 'System tnformation (cons:) Type: leaching pits number. 2 ❑ leaching chambers number: 0 leaching galleries number: ❑ leaching trenches number, length: leaching fields number,dimensions; ❑ overflow cesspool number: ❑ innovative/altemative system Typetname of technology: Comments(note condition of-soil,signs of`hydraulic failure,level of'ponding,damp soil;condition of vegetation,etc.): Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): .Number.and­conftgurathnr 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 ❑ No THW5 Offoid-Ins,9ectim Form:Subsurfam Sewoije{31sp©sat&Atem+Page latt 17 Commonwealth of Massachusetts m Title 6 Official -inspection For Subsurfaee,Sewage�Dlsposal:System-form—Not-for-Voluntary Assessments. 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name information is CENTERVtI t_E required for MA 02632 7/15/2009 every page. 0ty/Town State Zip"Code Dateof1nspection D.-System information(coa) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth-of solids Comrnants(note condition of snit,signs of hydrautia failure, level of pending;condition of vegetation, etc.): l5Ms-09MB Title 5 Oft-W Imspecim Form:SubsuAace Sewage Disposal System•Page 14 of 17 c Commonwealth of Massachusetts Title 5 Official #ion Form Subsufface-SCWIge::t?sposa],System-F.or-m-„NoL-for.Voluntary Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name information is required for CENTERVILLE MA 02632 7/15/2009 every page. City/Town Stott Zip Code Data of inspection D. System 1formation(cunt:) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate :where public Water supply enters.the building.Check one of the boxes below: ❑ hand-sketch in the area below drawing atteched separately t5ins•09M Title 5 ORicW Irr;pection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts WjTitle 5 Official -ins tion Form Subsurface-Sewage.,Disposal.System:Form-<Not,for voluntary.Assessments 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name ieg6iredfo CENTERVILLE MA GM2 7/15/2009 required for every page. Cityfrown State Yip Code. Date of Inspection D System Information (writ) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high.ground water; 20.., few Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 7/15/0 If checked,date of design plan reviewed: Date 9 b ❑ Observed site(abutting property/observation hole within 150 feet of SAS). ❑ Checked with local Board of Health-explain: Checked with local excavators,installers-,(attach documentation) ❑ Accessed USGS database-explain: You-must..describe:how.you established the.high.ground-water elevation: Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5M+A9= Tits 5 orrriw..inspection.F.orm:subsurface senge Disposal8r-tem•page•16 af-17 i Commonwealth of Massachusetts Title 5 0- iciaI- Inspection Form- Subsurface.Se.wage._Disposal System Form•--Not.for.Voluntary.Assessments- 44 HEADWATERS RD Property Address JAY OBRIEN Owner Owner's Name information is required for CENTERVttt_E MA 02632 7/15/2009 every page. City/Town State.. Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B,C, D,or E checked "Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5mg•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 � , a TOWN OF BARNSTABLE ��F4s LOCATIONt� f7�"e�e` i -1 SEWAGE # �SG' oo VII,LAGE �'�� ASSESSOR'S MAP &LOT Z Z — y�/ V `L� INSTALLER'S NAME&PHONE NO.G�iff�� i✓tl'Ae C? o SEPTIC TANK CA �� — y PACITY t «� 46��S (size) f� tl y i 00 LEACHING FACILITY. (type) .0 00 /7 NO.OF BEDROOMS J d BUILDER OR OWNER /Cf PERMTTDATE: G COMPLIANCE DATE: Separation Distance Between the: f Leaching Facility2 Feet Table and Bottom o Maximum Adjusted Groundwaterg M J Private Water Supply Well and Leaching Facility (If any wells exist 00:VCf,-7--? Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist ���Z Feet within 300 feet of leaching facility) Furnished by w l �J li / .� i I r TOWN OF BARNSTABLE LOCATION �r� f7/�� �.io► i /ZC'./ SEWAGE # % " ze,v a-_ VILLAGE ASSESSOR'S //MAP & LOT ZZ- INSTALLER'S NAME&PHONE NO.Z�------V �l�rlw la SEPTIC TANK CAPACITY 5-� IV LEACHING FACILITY: (type) ZA f' (size)_/f NO.OF BEDROOMS / BUILDER OR OWNER / PERMITDATE: G COMPLIANCE DATE: / Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Z Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) . z . I Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / 7-7t Feet / Furnished by C!ram"%/V, Cv( J f ��`, r �� -a N (`� I � iSl � I �� � � �� a�� i �� a �� �� / �� __ ,. .. ,, I ' Q- V J , TOWN OF BARNSTABLE /� LOCATION Z t// ��` °C 1 Z�� SEWAGE # �— VILLAGE Cam/``!' ASSESSOR'S/MAP & LOT ZZ — V TY INSTALLER'S NAME&PHONE NO.!f i,2-'% i /Z la I SEPTIC TANK CAPACITY CZ� /� S LEACHING FACILITY: (type) _ f (size) NO.OF BEDROOMS / BUILDER OR OWNER PERMTT DATE: G COMPLIANCE DATE: / Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Z 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 14 3 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplicatton for Miopool *proem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lotlio. ` Owner's Name,Address and Tel.No. Assessor's Map/Parcel 7i p !/ Installer's Name,Address,and Tel.No. 7 Designer's Name,Address and Tel.No. Gar•- y .♦�/c -tv A, f ��.,.y /)/,G.�., l J Type of Building: j Dwelling No.of Bedrooms e y 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 U Type of S.A.S. V- f Description of Soil c�dn C.P .S �rQ b�! Nature of Repairs or Alterations(Answer when applicable) 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 Environ tal C and n t to ace the system in operation until a Certifi cate of Compliance has been issued by this Boazd of / Signe Date (f Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No. �. y1 `'.,.:# 4 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Digoaf *patent Construction Permit ,,Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Z/,/ 6/P C�Ge4J n r S y Assessor's Map/Parcel Z4 Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. a- /tt J At Type of Building: ry Dwelling No.of Bedrooms Lot Size-�—a�—(�t sq.ft. Garbage Grinder( ) Other Type of Building No. of Persorfs G 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, Nature of Repairs or Alterations(Answer when applicable) 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 Environ tal Co and n t to lace the system in operation until a Certifi-/�' cate of Compliance has been issued by this Board of / Shmed \ Date (/ AF Application Approved by r Date Application Disapproved for t e following reasons ' Permit No. — Date IssuedZHX ———————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewag Di posal System Constructed( )Repaired( )Upgraded(� ) Abandoned( )by G „` 'c atr Z, ta�.-d onstructed in accordance with the provisi ns of Title 5 and e forr�ispo al S stem Construction Permit No. Installer c/ l4t_l Designer The issuance of t is permit shall t be construed as a guarantee that the system will function as designed., Date Inspector ""., Q -- — — --------------------------- No. "4 Fee i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ;i5pozat *pgtem Construction Permit Permission is hereby granted to Construc ( )Repair( Upgrade( ), batndon( ) System located at �� ,`-P c v�G./ra�-T✓ �J/�J 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 oft ; ermi d Date: 47 Approved by e/ • 10/9/97 NOTICE: This Form Is To BeYsed For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, J, of , hereby certify that the app 'cation for disposal works construction permit signed by me dated , concerning the property erty located at e'i( meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will=be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) y '� B) Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: /�lic/el __a /11 1� -/ / 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]. q:health folder:cen TOWN OF f?BARNSTABLE LOCATION yN lznd W(�-jer- 1 1 SEWAGE # VILLAGE ry1j, Xc- ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. J. P Mocom her SEPTIC TANK CAPACITY LEACHING FACILITY:(type) I? Jl,T (size) )j6D 9L NO. OF BEDROOMS- PRV/AZE-WE66OR PUBLIC WATER BUILDER OR R C DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No n�ti 0 o , �z i &->�13 ail ' • V •0 CQ 4y -7 ct GS 0 Cis SOF ppun 0821 - '�'+ J� /�Soa • _ Tan k � zt - z _ � / f - 0 S • TOWN OF BARNSTABLE t _I LOCATION 4y Ye AW6 R�r I � U SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. �r,P r�4r-o m her SEPTIC TANK CAPACITY LEACHING FACILITYAtype) 'P1�.r (size) ) G L NO. OF BEDROOMS PR -A-TZ B :. OR PUBLIC WATER BUILDER ORIOWR DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: / VARIANCE GRANTED: Yes No r7 2R� o ' Ile o sh' I ' J qqr �� : NO....I 31z Fims .$....30-00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Disposal Works Tonstrurtiurt throb# Application is hereby made for a Permit to Construct ( ) or RepairX(X ) an Individual Sewage Disposal System at: 44 Headwater Road Centerville, ................__ .........-•- ................................................. --•-------•-------.....-----------•---------------•--------------------.......................... Location-Address or Lot No. Jay O 'Brien •W J.P.Macomber Jr. Owner Address a -•-•--...-•-...-----•--••...---------•.............••-•-.._....._..------•---•---•....-------•--•- --•-•••---------•-••-•-----•••---••••--•-------•--•-------.............._........---------------•- Installer Address PQ d Type of Building Size Lot............................Sq. feet U Dwelling X-.No. of Bedrooms.............2.............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures -----•----------••-------------• . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter--.----------.-- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.----............... Depth to ground water-----.----.------------ (i Test Pit No. 2................minutes per inch Depth of Test Pit--..........--...... Depth to ground water........................ a •---•-•------•-•-------------•-••---........••-•-••-•--••.........•-•-------•-....._---•-•--•-----•-......................................................... 0 Description of Soil........................................................................................................................................................................ x Sand & Gravel v -••-•-•-••••---••---•--•••--•-••••••-•••-•-•----••--•-•-••-•--•-••••-•----------•-••••------------•-••••••--••--•-•••----•-•••......-••••-••----•...................................................... W .-----••••--•----------•--•--------=--------•------------------•-•---••--•••••----•--•••••••-•••--•-----••---•--•----•----------------------------------•---------•••••-•----------•---------••--••--••-- VNature of Repairs or Alterations—Answer when applicable...............................................:............................................... 1-1000 gallon leach pit' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of .TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com' lia ce has e issued by the oard f health. Signed .- - 7/11/90 --' .. c-------------------------- --"------'-'----'----.................. Daw Application Approved By ....--'------ ....---- -- � V " ... ... .............. .... �........ Application Disapproved for the following reasons- ------------ --- ---------'----------------....---------._.....-----'----------------... ................................Da[ .............................. .... ........................................ Da[e PermitNo. .....-- " '3-1/-.---_---- ' ....... Issued ---------------------------------------.......................... ...------. Date U Fss.. ...'30. 00 No.....---...••..._....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE r Appl ration for Disposal Works Tonstrudiun jinmit Application is hereby made for a Permit to Construct ( ) or RepairX({ ) an Individual Sewage Disposal System at: 44 Headwater Road Centerville, ...........- ___..__......---- - -- ......................... .•----.._..---------------.......------------•- Jay O'Brien -- - ---.......... Location-Address --.-or Lot No. .................................................. ...........•._..... ---•------••-•--••••........................._...... W J.P.Macomber Jr. Owner Address Installer Address dType of Building Size Lot............................Sq. feet U DwellingX—No. of Bedrooms............. .............................Expansion Attic ( ) Garbage Grinder ( ) 04 04 Other—T e of BuildingNo. of persons............................ Showers — Cafeteria 04 Other fixtures .................................. ---------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid-capacity...._.......gallons Length................ Width................ Diameter................ Depth..-_-__--___-_-. xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area--__..---::---------sq. ft. Seepage Pit No..................... Diameter.....__..__......... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground 'water-----------------_...... (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------------------------------------------------ Descriptionof Soil-------------------------------------•-------------------------•------•---•--•-------------•-----•--...........-------•----------•---------------------............._.. Sand Gravel -------------------------------------------------------------------------------------------------------------------------------------------------- w ------------------------------------------------------------- --------------------------------------------------------------------•---------------..._.....-----•------........_.....----...--•....... U' Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•--•--------•--•--•-----......-•-------------------•-----1-100.0...aallon...leach---fit•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has a issued by the board ofhealth. Signed --'/--- ------------------------- ---7/11/9�--.......... --------- ------ Application Approved By . / �! �/' Date ............................. ..........-................................................................-.............................. .....---........................ ' Date Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------....-----------.....-------------- .. ........................ Permit No. 3��.......................... Issued Date —...................................... Dare --................---"------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (fPrtifirate of (1:11-antylinore THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired t X ) byJ.,.P.*Mac-omb.I�r...Jr.-----------------------------------------------------------------------------------------------------------------------------------------------------........................................ - Installer at44...Headwater Road Centerville ------------------------------------------------------------------------ -------------------------------------------------------- ------------------------------------------------------------ has been installed in accordance with the provisions of TITLE 5 of The �t to Environmental 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.... ... ........... .. ........................ Inspect :::... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a TOWN OF BARNSTABLE No.A................ FEE ...?n•nf?..... Disposal Works 'unstrurtiun f ami# Permission is hereby granted.....J 5...Macomber Jr. to Construct ( ) or Re air ((,�� ) an Individual Sewage Disposal System at No.. ...Headwate Road Centerville .......................••.........- ---- ------------------.--.... ...........------...................... Street t*- 11 as shown on the application for Disposal Works Construction Permit Nat* Dated.......................................... ...............•-••••....._ ...----•- ---------- ......... Board of Health DATE_--•........................................................................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS 4