HomeMy WebLinkAbout0288 HUCKINS NECK ROAD - Health 288 Huckins Neck Road
Centerville P
A = 282 133
No. 4210 1/3 ORA
CEO
10°/a {
0 0
No.G/'� / r Fee �® -
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation for Disposal *pstrm Construction j3ermit
Application for a Permit to Construct( ) Repair()6 Upgrade( ) Abandon( ) ❑Complete System [(Individual Components
Location Address or Lot No. egg E4vtWws I a:y- I_t> Owner's Name,Address,and Tel.No.
C�NTt7e►otec.� �+4t�►S lao�.�
Assessor's Map/Parcel ".2 52 133 (ocap [,�t�wpai� t��15 �C64 L
Installer's Name,Address,and Tel.No. 50Z-C -j7_$E?77 Designer's Name,Address,and Tel.No.
AA6Q4AW &I-TWAVgtr5, 0.1
153
Type of Building:
Dwelling No.of Bedrooms Lot Size d-;)---- sq.ft. Garbage Grinder( )
Other Type of Building G-7S CIDt7tff c Ar , No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan. Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) =&j g-Wu_ O-AQ b—BOX W t1n� 'k15G�
Date last inspected:
.Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by t ' rd of Heal
S ned Date 14 ' "a1®4`t
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. /L] Date Issued w 3v
---------------------1=_— ---- ----
No. � / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH"DIVISION - TOWN OF,OARNSTABLE, MASSACHUSETTS Yes
application for �DispoSal 4pstetn Construction Permit
Application for a Permit to Construct( ) Repair A) Upgrade( ) Abandon( ) ❑Complete System Individual Components
rt Location Address or Lot No.;kg$ k oci 1 vs �Itc Y. P-1> Owner's Name Address,and Tel.No.
CGN'IL�2srltl.l' -SAt Jl S PoiI TE{i;
a Assessor'sMap/Parcel ;L52 133 (,cap L,M<r=ttloa-0 Fb 1?64j5 Ei0CA ti-L
Installer's Name,Address,and Tel.No. 15dg-q77-$2 77 Designer's Name,Address,and Tel.No.
dA%t4AbG� &VTW"-eA,- tv/,4
15 3 04 ew6g
}Type of Building:
Dwelling No.of Bedrooms Lot Size a3`S sq.ft. Garbage Grinder( )
Other Type of Building R FS tCjt7tJr 1 Arc. No.of Persons Showers( ) Cafeteria( )
Other Fixtures {
,r. Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) =!J 5 t'3iu, t -Aa b—DQX Lu t'14- RtSElk
4J S?*L- P I SQe O AJ 7,,AO L— OoTC fi r'
Date last inspected:
n
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions,of Title 5 of the Environmental Code and not to place the system in operatio jnntii a Certificate of
'%%,.-Compliance has been issued by this-B rd of Heal ,4
Signed
�, Date d -.3 a 0 c
Application Approved by ._ Date '
i Application Disapproved by Date
for the following reasons
L ,rt
Permit No. Date Issued 10 3O
----- ----------------- ---------------- --- ----- ------------- ------
n���� THE COMMONWEALTH OF MASSACHUSETTS -
F (/ BARNSTAB'LE,MASSACHUSETTS E;
�ed"ificate of Comphante
THIS IS TO CCERTIFY,that the On-site Sewage Disposal system Constructed( ) --Repaired(X) Upgraded( )
Abandoned( )by 0A?G W I D(:5 G TSCPX1S�,C ,:
at �$� �,�VCXl&)g J CL P2t3 C V I has been constructed in accordance, / f C
with the provisions of Title 5 and thefor Disposal System Construction Permit No�l it_ y��ated" /�f
Installer C&PEwlnir CNTEXVK�S>✓T CJ✓G Designer Ae
#bedrooms Approved design flow r gpd
The issuance of this permit shall of be construed as a guarantee that the system ,Aiillftinctionlas desiMed. i 0
Date Inspector i ?17
7 t �a�.�' �� v • v I
---------------------------------J--------------------------------------------' '-----------------------------------------------------
No.
t) Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,AVASACHUSETTS
]Disposal :bpstrm (Construction Permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at Q g Hock_ SUS Q&V7GX_V1 U_4!9
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction m'uust O e comp to thin three years of the date of thi permit.
Date �� j� / Approved b-v
ov 08 1410:54a p.1
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner owners Name
information is required for every Centerville MA 02632 11-7-14
p8ge City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms rr�aiyat,kte,,a,tehn any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information ````����� 0 'Mq�i,,,����
filling computer,
om forms f �,�/1 `
on the com uter, 0%, •• q�,'�.��
use only the tab 1. Inspector
key to move your =i;• JAMES
cursor-do not James D Sears y
use the return Name of Inspectorso*
key. %'�� •
�f II1I CapewideEnterprises,LLC -
Ibl Company Name 74, 5 I N S
153 Commercial Street �
Company Address
Mashpee MA 02649
Cityfrown State Zip Code
508-477-8877 S 1623
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 and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
11-7-14
pedors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a'design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable,and the approving authority.
""This report only describes conditions at the tane 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.
Bins•dl13 l de s olFdai llspection F oe sewage DWP0921 syelsn•Pape 1 of 17
Nov 08 1410:54a p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner Owners Name
information is required for every Centerville MA 02632 11-7-14
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D
A) System Passes:
® 1 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:
The system is a 1000 Gal.Tank D Box and two pipe fields
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 exfdtration 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):
t5ins•W13 Title 5 Mist 6apepan Fomc Subunfaoe Sewege Disposal System-Page 2 or 17
Nov Uti 14 1U:b4a p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner Cwnefs Name
klforrnation is Centerville MA 02632 11-7-44
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpsialarms are repaired.
B) System Conditionally Passes(cunt):
❑ Observation of sewage backup or break out or high static water level in the distribution 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 ❑ ND (Explain 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 ❑ 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 will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system Is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Tale 5 Official Inspection Forth:SubsuRace Sewage Disposal System-Page 3 of 17
Nov U8 14 10:55a p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Properly Address
Janice Porter
Owner Owner's Name
information is Centerville MA 02632 11-7-14
required for every
page. CWrown State Zip Code Date of Inspection
B. Certification (cons.)
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:
❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ 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 fecal
coliform bacteria indicates absent and the.presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
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 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 ink is less than 6"below invert or available volume is less
than day flow ,- CA)(1111A &
t51ns-3113 Title S Official k npedion Fomt:Sub&Ldam Sewage Disposal System-Page 4 d 17
Nov 08 1410:55a p•5
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner owner's Name
int«maaon Is required for every Centerville MA' 02632 11-7-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times 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. frhis
system passes If the well water analysis,performed at a DEP certified
laboratory,for fecal coliforrn bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
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 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) urge 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 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
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 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department
Ohs•3/13 Title 5 Official Inspection Fwm Subsurface Sewage Disposal System.Page 5 of 17
Nov 08 1410:55a p,g
Commonwealth of Massachusetxs
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner Owner's Name
information is required for every Centerville MA 02632 11-7-14
page. Citylrown 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 components pumped out 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?
® ❑ 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) 1310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NA Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
thins-3113 Tdle 5 0%dar inspedion Form:Subsurface Sewage Disposal System-Pape 6 of 17
Nov 08 14 10:56a p.7
Commonwealth of Massachusetts
U1; Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner Owners Name
Information is Centerville MA 02632 11-7-14
required for every
page. cityrrown State Zip Code Dale of Inspection
D. System Information
Description:
The system is a 1000 Gal.Tank D Box and two pipe field.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ID No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2012-105,000Gal
9 y 9 �9Pd))' 2013-130,000GaI s
Detail:
Sump pump? ❑ Yes ® No
last date of occupancy: NA
p �' Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day C%d)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap 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 available:
t5he-3113 Title 5 Official Inspection Forth:SubstMace Sewage Disposal Syslem-Pape 7 of 17
Nov Q8 1410;56a p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner Owners Name
information is required for every Centerville MA 02632 11-7-14
page. CityrTown State Zip Code Date of Inspection
D. System Information (cunt_)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 11-4-13
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
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)
❑ Innovative/Alternative 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):
Wins•8113 Title 5 Oftal kspecdon Form Subs skm Sewage Disposal System-Page 8 d 17
Nov 08 14 10:56a p,g
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner Owner's Flame
information is required For every Centerville MA 02632 11-7-14
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed(if known)and source of information:
NA New D Box 11-7 14.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
8`
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 condition of joints,venting,evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40. .
Septic Tank(locate on site plan):
Depth below grade: T
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
1,
Sludge depth:
(Sins-3H3 Me 5 Olfichd Inspection Form:Subsinface Sewage Disposal System•Page 9 of 17
NOV uu 14 1u:b/a p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
280 Huckins Neck Road
Property Address
Janice Porter
Owner Owner's Name
information Is required for every Centerville MA 02632 11-7-14
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cons)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle NA
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? Asbuilt-Tape Past Report
Sludge Judge
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 at working level. Tank at T below grade,w/inlet cover at 1',out let cover at 6".Two inlet
tee's. No sign of leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑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: pate
t5ins-3I13 Title 5 Official hspwWn Fow Subsurface Sera Disposal Sewage sp0 System•Page t0 of 17
iwv uo '14'1 u:b to p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments .
288 Huckins Neck Road
Property Address
Janice Porter
Owner Ownees Name
information is required for every Centerville MA 02632 11-7-14
page, cityfrown State Zip Code Dale of Inspection
D. System Information (cont.) .
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 Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons r da
9 per Y
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
IVOV Ub "14 1U:b/a p 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner owner's Name
information is
required for every Centerville MA 02632 11-7-14
page. Cdyfrown Stale Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x 21"-8' Below Grade wlcover at 6"Two lines out. Box is new 11-7-14.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No*
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required).
If SAS not located,explain why:
t51ns.3113 TNe 5 016da1 In apec5m Forut Subswfam Sewage Disposal System•Pape 12 0117
Nov U8 14 10:b8a p,13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner Owner's Name
information Centerville MA 02632 11-7-14
required
for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cunt.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
23 leaching fields number, dimensions: 1
❑ overflow cesspool number.
❑ innovativetaltemative system
Typeiname of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a two pipe field per camera and past report 20' long. No sign of over loading or
holding water.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3113 Title 6 Official Inspection Form.SubwAaw Sewage Disposal Syslem-Page 13 or 17
NOV Ud '14 1U:bba p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janioe Porter
Owner Owner's Name
information is required for every Centerville MA 02632 11-7-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
,Sins•3/13 Title 5 Official lnspedon Foam Sut surfece Sewage Disposal System•Page 14 of 17
Nov Ud 14 1U:bba p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road _
Property Address
Janice Porter
Owner Owners Nerne
infuriation is required for every Centerville MA 02632 11-7-14
page. Cityrrown State Zip Code Date of inspedion
D. System Information (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 attached separately
3-�1
3-1 r J J'
t�
a r
Oins.3113 Title 5 orricial Msl)Wion Form•,Subsuflace Sewage Disposer System-Page 15 or 17
Nov 08 14 10:59a p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
¢ 288 Huckins Neck Road
Property Address
Janice Porter
Owner Owner's Name
information is
required for every Centerville MA 02632 11-7-14
page. Cityrrown State -Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells Ajt?
Estimated depth to high ground water: 40'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
® 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:
Abutting property and rear of lot 4V+to G W
Before Fling this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•3113 Tlge 5 oRdel Inspedton Form:Subsurface Sewage❑Isposal System•Page 16 of 17
Nov,08141.0:59a p'17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
288 Huckins Neck Road
Property Address
Janice Porter
Owner Owner's Name
information is Centerville MA 02632 11-7-14
required for every
page. Cityrrown State Tip Code Date of Inspedion
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
t5ins-W13 reds 6 official Inspedian Forth:Subsurtace sewage O'Wposal System-Page 17 or 17
Hazardous Materials Inventory Sheet Checklist
i . -
Date
Physical Street Address-Check database to ensure it exists
Working Phone Number
o_
Actual Amounts -( ie. gas being used to fuel machines,thinner to
clean brushes all count as hazardous materials-no blanks)
Storage Information -location of storage, how long is storage for?
If none, note that.
Disposal Information -where and who? If none, note that.
Applicant Signature -understand what is listed and noted
Staff Initial -any questions, know who to ask
Vehicle Washing/Rinsing? -give a vehicle washing policy and
explain it
Attach the Business Certificate with your sign off and comments
"The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
YOU WISH TO OPEN A BUSINESS? y'
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
t3'.!'t�illt DATE: �J��� ✓ Fill in please:
APPLICANT'S YOUR NAME/S: s�N {�/1�F�
"r QSIN SS7YOUR HOME ADDRESS: Lr LEPHONE # Home Telephone Number
F NAME O CORPORATION k
jN7 f
NAME OF NE1N BU5INESS 77/I/ TYPE OF'BUSINESS N
IS TIN
YES : �p
ADDRESS OF BUSIIVESS� s... G " . .: JT `1%1 'MAP/PARCEL NUMBER_
[Assessing]
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
COMMENTS: Authorized Signature**
2. BOARD OF HEALTH
This individual Ma eer neypn rmit requirements that pertain to this type of business. MUST r;®MPLY WITH ALL
HAZARDOUS MATERIALS REGULATIOt,ic.
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
TOWN OF BARNSTABLE Date:O3,/,Z�/ /3
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: CIA 11 6010 r-Me T rV99e-11 's Jr'A JJT[t*)
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: 776 Pd--?OX - f/Y•�JNrt/i��O.Qj®v�l11�. TOTAL AMOUNT-
TELEPHONE NUMBER: - 4/ - Z 0,31
CONTACT PERSON:
EMERGENCY CONTACT fEl EPHONE NUMBER 7 -7—d?/ Z -,//4SDS ON SITE?
TYPE OF BUSINESS:
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes, No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
0 NEW MUSED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Q Caulk/Grout • Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes• Other chlorinated hydrocarbons,
02 Lacquer thinners (including carbon tetrachloride)
❑ NEW MUSED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous(please list):
Metal polishes
Laundry soil &stain removers
/0 (including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solventse
Bug and tar removers
Windshield wash*
Applicant's Si
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Staff's Initial
s -
el
DATE :12/7/02
PROPERTY ADDRESS: 288 Huckins Neck-Road 9
--Centerville,Mass
02632
------------------------ Sri `}a 3
On the above date, I inspected the septic system at the above address IVED
This system consists of the following: "���'
1 . 1 -1 000 gallon septic tank. DEC 2 6 2002
2. 1 -Distribution box.
3. Leachingfield with three laterals. ( 20 'X20 ' ) ??? TOWN OF BARNSTABLE
Based on my inspection, I certify the following conditions: HEALTH DEPT.
4— This is a title five septic system. Upgraded 1996
s5. The septic system is in proper working order at the present time.
6-:Tank -is 8 ' below grade. Did not excavte to the leaching field.
No signs of back up in the house or the septic tank.
7. Pump tank annually. Depth of tank requires this.
8. Plans on file do not tell us what size leaching field is present.
SIGNATUR
Name :- J ._ P . _Macomber .Jr .
Corripany :lg5.tPh _p,_ M�pQmttt, & Son, Inc .
Address :__@Q; _6-6 ------------
__C-us2zYiLLe-,_ba.._Q2.632-0066
Phone : 508- 775_ 3338 ______
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
C
P. MACOMBER & SON, INC.
anks•Cesspools•leachflelds
Pumped & InstalledTown Sewer Connections 66 Centerville, MA 02632.0066
775.3338 775.6412
L
COMMONWEALTH OF M-ASSACI USETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:288 Huckins Neck Road
Centerville.Mass,
Owner's Name ,aui .,a Caravel & per, Mark Collins
Owner's Address: Same
i
Date of Inspection: 1 2/7/02
'came of Inspector: (please print) Joseph P.Maeomber Jr.
Company Name:J_P.Macomber & Son inc.
Mailing Address:Rox hti
02632
Telephone Number: 508-775-3 38
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 the inspection. The inspection was performed based on my
.ratntne and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
• � Passes
Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authoriry
Fails
Inspector's Signature:
The system inspector shall mit a copy of this inspection report t the Approving Authority(Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design now of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
"•This report only describes conditions at the time of Inspection and"under-the'conditions of use at that
tttne. This inspection does not address how the system will perform in the future under the same or different.`
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
'Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 288 Huckins Neck Road;
Centeuil e,Mass
Owner: Louisa GTCJ - — -K .7,yltins
Date of Inspection: 12 7 0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A.'�Sys�emPasse-�s)*
�4 1 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:
The septic system is in proper working order at the
rrpssent t:l RIG _
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
4 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
existiAg tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to 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
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
I
Page 3 of I I
er
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properry Address: 288 Huckins Neck Road
Centervi e,Mass.
Owoer:Louisa Grace & Dr. Mark Collins
Date of Iaspectioo: 1 2/7/02
C. Further Evaluation is Required by the Board of Health:
416 Conditions exist which require Nnher evaluation by the Board of Health in order to determine if the system
is failing to protect public health..s.afety orihe environment.
1. System will pass unless Board of Health determines In accordance with 310 CMR 15.303())(b) that the
system is not functioning in a manner wbich will protect public bealtb,safety and the environment:
rIJO Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is witbin 50 feet of a bordering vegetated wetland or a salt marsh
2. S,N stem 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:
,tl The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or rributary to a surface water supply.
.40 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple
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 eater supple well•� Method used to determine distance
"This $\stem passes if the well water analysis,performed at a DEP certified laboratory, for coli form
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are rriggered. A copy of the analysis must be anaehed to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 288 Huckins Neck Road
Ce itr ,grvi11e.Mass.
Owner: Louisa Gravel & Dr Mark Collins
Date of Inspection: 12./7/o 2.
,
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of tlfe following for all inspections:
Yes No/
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due 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
sspool
quid depth in cesspaal.is less than-6"below invert or available volume is less than ;4-day flow
v Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
-f times pumped 0 .
y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
ater supply.
�y portion of a cesspool or privy is within a Zone 1 of a public well.
y Portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes If the well water analysis,
perl'armed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
�d (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
2the system is within 200 feet of a tributary to a surface drinking water supply
Zthe system is located in a nitrogen sensitive area(]nterim Wellhead Protection Area—1WPA)or a mapped
Zone 11 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 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
i
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Louisa Gravel & Dr. Mark Collins
288 Huckins Neck Road
Owner: Centerville, ass/.
Date of Inspection: 1 2/7/0 2
Check if the following have been done. Yod-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 componenys pumped out in the previous two weeks
/Have
Has the system received normal flows in the previous two week period?
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?
Were all system components� luding 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:
Yes no
Existing information.For example,a plan at the Board of Health.
y — 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(3)(b))
5
f
Page 6 of I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properly Address: 288 Huckins Neck Road
Centervi e, ass.
Owner: Louisa Gravel
Date of Inspection:12/3/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): � Number of bedrooms(actual):
DESIGN flow based on 310 CMR 5.203.(for example: 110 gpd x M of bedrooms): X
Number of current residents:
Does residence have a garbage grinder(yes or no): �
Is laundry on a separate sewage system.(yes or no): (if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use: (yes or no):NO
Water meter readings, if available (last 2 years usage(gpd)):2000-1 29, 000 gal lons=353. 43 GPD
Sump pump(yes or no): 2001 —1 61 , 000 gallons=441 . 1 0 GPD
Last date of occupancy:� � � Sprinkler system is present.
COMMERCIAUINDUSTRIAL
Type of establishment:
Design flow.(based on 310 CMR 15.203): t,'i9 gpd
Basis of design now(seats/persons/sgft,etc.): V4
Grease trap present(yes or no): A0
Indusrrial waste holding tank present (yes or no):&—IA
Non sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available: �,S!
Last date of occupancy/use: AOF
OTHER(describe):
• GENERAL INFORMATION
' Pumping Records
Source of information: A fJr�/
Was system pumped as pan of the inspection (yes or no): _
If yes, volume pumped: _gallons — How was quantity pumped determined? ' O.A
Reason for pumping: WOL
TY�t OF SYSTEM
V Septic tank,disrribution box,soil absorption system
470single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained fiom syste owner)
&Tight tank Attach a copy of the DEP approval
Other(describe): A0
Approximate age of all components, date installed(if known)and source of information:
.SXc�c_m iincgrarla in 1996
Were sewage odors detected when arriving at the site(yes or no):,G
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:288 Huckins Neck Road
Cen ervi e,Mass.
Owner:Louisa Gravel
Date of Inspection: 12 7 0 2
BUILDING SEWER(locate on site plan). ,
Depth below grade:
Materials of construction: cast iron /40 PVC other(explain): A0
Distance from private water supply well or suction line: id",-
1-Comments(on condition of joints,venting,evidence of leakage,etc.):
joi ntc appear t i qbi- No euiden Pelf leakage rj"h_a__czctam i s
vented. , 1
SEPTIC TANK: Zoocate on site plan) A00rA W
Depth below grade: ftoneA40
Material of construction: metaWO fiberglass�polyethylene
other(explain) eQ
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):,V,� (attach a copy of
certificate)
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 baffle:/-v
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.leakage, etc.):
Pump the septic tank annually Garbage disposal present Also the
depth of the tank is an issue for pumping The tank is structurally
sound and shows no evidence of leakage.
GREASE TRA]Rdkq.(Iocate on site plan)
Depth below grade: I&
Material of constructionXM concretefM metaLf( fiberglassolypolyethylene4kother
(explain): A'W
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: .0,4
Distance from bottom of scum to bottom of outlet tee or baffler
Date of last pumping:AR
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
GrPact� trap i S nnt- present
7
r
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 288 Huckins Neck Road
CentPryillpfMacg,
Owner:Louisa (,raval
Date of Inspection:12.471 02
TIGHT or HOLDING TANK,Q4&—,Z (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 42A
Material of construction: concrete.r A metal A14 fiberglass polyethylene j* other(explain):
'4/�
Dimensions: _
Capacity: AN allons
Design Flow: AM allons/days
Alarm present(yes or no):dl�
Alarm level: A),4 Alarm in working order(yes or no):A-W
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
Tight or hol (3i ng tanks a.A notlzresent;
DISTRIBUTION BOX:Zof present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Unknown
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
R-X. not ti1QCQVered. Box is 91611 below oracle
PUMP CHAMBER /G(locate on site plan)
Pumps in working order(yes or no): A00
Alarms in working order(yes or no):.,&¢
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump chamber is not present-
8
'I
f
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 288 Huckins Neck Road
Centerville,Mass.
Owner:Louisa Gravel
Date of Inspection: 12 17 f 0 2
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
Lp-achfield 20 'X20 ' ????? ( 10 ' below grade)
If SAS not located explain why:
T.ncated• See pane 10
Type
t,W leaching pits,number:0
N leaching chambers,number:6
A o leaching galleries,number: O.
da leaching trenches,number, length: 17
)ii leaching fields,number,dimensions: ^ /O e
4AN overflow cesspool,number: ej
innovative/alternative system Type/name of technology:i��-e ie&
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
Limy sand to sandy loam to silty boney sand to fine sand
Sol c ara drV Vegetation i G nt-irmal lei d no x aya to the
Teaching field.Field is 1.0 ' below grade.
CESSPOOL�(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: ,10
Depth of solids layer: Z20
Depth of scum layer: �yQ
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no): / —
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspools are not present.
PRIVY(locate on site plan)
Materials of construction: 414
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Privy is natprnsent
9
Page 10 of I I
, OF
FICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:288 Huckins Neck Road
Centerville,Mass.
Owner: Louisa Gravel
Date of Inspection: 1 2/7/0 2
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
• WaV
tl
10
l
Page 11 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 288 Huckins Neck Road
Centerville,Mass.
Owner:Louisa Gravel
Date of Inspection: 12 7/0 2
SITE EXAM
Slope .
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to detepnine the high ground water elevation:
R
d from system design plans on record-if checked,date of design plan reviewed:ed site abutttn roe bservation hole within 150 feet ofSAS)
d with local Board of Health-explain: CST 4,PY �lji�7 SQL 1>�
hecked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:http: //town.barns table.ma.us.
You must describe how you established the high ground water elevation:
Used: Gahrety & Miller Model. 12/16/94 Ground water elevations above sea level.
Used: URrG-Ter•hni r•al hi,l 1 pti n 92-000-1 Plat— #2 January 1992 Annual ranges of
ground .water elevations
Used: Udata - June 199?
I. Leach
Field ,
20 'X20 ' ???? to :eet
10 ' below grade.
As built does
not tell us the
size of the field.
9
Groundwater- =eet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet.
11
Copy of as built from the Barnstalbe
Board Of Health. 12/7/02
a
•rmnr.r -n.•rerTrzrnrwn•mrr�-nrtr�nrerrr.�rst.srfi�.,r*nem n�rn7t�n�rtRn - •�'
TOWN OF Barnstable BOARD OF HEALTH j
SUDSURFACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
«•rn ter••.-•.+.—T.1I7t".�TT,lttT.tl.'It.•tS.TRTI�i'1f7R1R'1'T—.5'I-11RT�71'R7C7—TITIl�/�1RIR/�et�7trt not i v :•+�rrr•r-•
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS288 Huckins Neck Road Centerville,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Louisa . Gravel
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Sono. Inc.-e
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City Stat• LIP
COMPANY TELEPHONE (508 ) 775 -3338 FAX ( 508 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
this address and that the information reported is true, accurate, and
omplete as of the time of -inspection. The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposai systems ,
Check one: ,
y_t._._- System PASSED
t
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 15 . 303t Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con acted 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.
"r
Inspector Signature Date
0[nd copy of t)Iis ce ification must be provided to the OWNER, the BUYER
77
where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade
within one year of the date of the inspection, unless allowed or trequiredeVatem
otherwise as provided in 3.10 C�IR 15 , 305 .
partd .doc
CERTIFIED SEPTIC SYSTEM REPORT
LOCATION
288 HUCKINS NECK RD
CENTERVILLE, MA
MAP 252 PARCEL 133 LOT 97
PREPARED FOR
SELLER
MR. & MRS .. PAUL DUBIN
288 HUCKINS NECK RD . ��!.�
CENTERVILLE, MA 02632 �i
JON
BUYER 9
- b
MR. MARK E . COLLINSQ 99
MS . LOUISA J . GRAUEL
379 LAKESIDE WEST e �
CENTERVILLE, MA 0.2632 �<
PREPARED BY
HILLIARD HILLER
P .O . BOX 250
CENTERVILLE, MA 02632
508-778-14.72
i
i
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of _
Environmental Protection
Trudy Cox*
Wjbm F..Wald
o,,.,,W David B.Struhs_
Arg"Paul Callueel c,mmii«»�
u.oo•em«
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Properly Addr•w. oZ 8 // /tiS �•XG''C �C Address of Owner.
(If different)
Dale of Inspection:-
Name of Iaspeetor /GG//�/10 !7t/GG2lC
Company Name,Address and Telephone Number. .p0 doX a5-z, :
3,
CERTIFICATION STATEMENT
the sewer disposal system at this address and that the information reported-below is true,accurate
I certify that.I have,personally inspected and experience in the proper func'.ion aad
and complete as of the time of inspection. The inspection was:performed based on my training
of.on-site sewage disposal:systems. .The system:
!/Passes
_ Conditionally Passes.
Needs Further:Evaluation By the Local.Approving Authority
— Fails G
Date:
L-
Inspeatoes Signatued • 2�
shall:submit a copy,of•this inspection report'.to the Approving Authority within thirty(30)days of:completing this
The System�= flow of 10,000 or ter,the inspector and.the.system owner,than.submit the,
If the:system,is.a•shared.system.or has-a:design gPd 8�
ent•,of.Environmental.Protection._
raport to tbs appropriate regions office'of.the Department,origiaaT.ahaild. r and.capies sent to the buyer,if applicable and'.the approving authority-
The
be.sent to:the system owne
INSPR=ON-SUMMARY::.
Cheeko-_C"
A] SYSTEM PAMES:
IbM.not,icuad_say information_which indicates•that the system violates any of the failure criteria as defined is 310 CMR 15303.
AM.bibn%criteria twr evahrated.are=indicated below.
B] SYSTEM c0 NDTTIONALLYPASSES.
• Oar or mots s7soem.oompownts used to.be replaced or repaired. The system,upon completion of'the:replacement,or,repair:Passes:
msPsdioa-.
Iadioata yes,Mar not'.determinsd(Y;N or ND). Describe basis:of determination.iivall instances; If,"
determined";e:plaia.why mtl
The septic•tack it,metal,,cracked.scructsu ally unsauad:shows+substantial.infiltration or exfrltration or-tank failure is
iwa�;nw�t. The-systerrr vvill..pass;inspection.i£.tlie�.existing�septimtank'�is:replaced..with=ayonforming_septic.tanlr,as.approved,. .
by the-Board.of Health.
• FAX` 5'S6-1049" • Tsiephorw:(617)292-5500
One WUstat Street. •> Boston,Massaahusetts t:0210 (617)
`• ._ - r,:;, :- edam Recwied.PaPer
.. Pnm /�zs
V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addr esm.
Owner. ,k/�t 'O(/6/.z/
Date of-Inspection:
'Check if the following have been done:
✓Pumping information was requested of the owner, occupant, and Board of Health.
r/Nose 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.
An 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
vThe site was inspected for signs of breakout.
'All system components,excluding the Soil Absorption System. have been located on the site.
_jZl�he septic tank manholes were uncovered opened, and the interior of the septic tank was inspected for condition of baf leg or.
tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum.
The we 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 owner(and occupants,if different from owner) were provided with information.on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddr.
Owner. M/iy X,4U1&
Date of Ingwotion:
FLOW CONDITIONS
RESIDENTIAL-
Design flop:�llons .
Number of bedrooms: 3
Number of current residents:
Garbage grinder(yes or no):yC.S
laundry connected to system(yes or no):E
Seasonal use(yea or no):A10
Water meter readings,if available: /�i�i5 /�5� oOy
7
Last date of o=pancy: �(?/�6',rirz-y
COMMERCIAL/INDUSTRLA.
Type of establishment:
Design flow:_gallons/day
Grease trap present*.(yes or no)_.
Industrial Waste Holding Tank present: (yes or no)_
Nonaanitery waste discharged.to the Title 5 system: (ves or no)_
Water meter.readings, if available:
Last date of.o=pancy;
OTEIER Meseabe)
Last:date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Au t�Pw
System.pumped as part.of inspection: (yes or no)QUO
U yes,vohame pumped: gallons
Roma for pumping:.
TYPE OF SYSTEM
(�Septic tankMistrubution bo:/soil absorption.system
8itr�s oasapool
Owrflaw oaespool.
Privy
Shared system(yes or no) (if yes,attach previous inspection.records; if any)
Other(Crplain)
APPROXIMATE AGE of all components,date installed(if known) and source of information:
Sewage odors detected when arriving at thesite: (yes or,no) V-0
(revised It/03M.) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addreaa a Sb ff lr✓C%LS ��G/� ,Q.J G�'.t/I�2 U/GG:�Owner. �w�ir► /�f��/L O</Kiit/
Date of Inspection
SEPTIC TANK .v
(locate on site plan)
Depth below grade:Z
Material of oonebmwtion:Looncete_metal_FRP_other(explain)
Dimensions: L/)"
SbAp depth: 9"
Distance from of �•top sludge to bottom.of outlet tee or baffle: /�1
Scum thidmees: D
Distaste from top of scum to tap of outlet tee or baflle: /a
Distance from bottom of scum to bottom of outlet tee or baffle:
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.) Ti9!//, A,!/o
Ld,9 5 LO
GREASE TRAP:
(locate oa site plea)
Depth.below grade:
Material of conshuction:_concrete_metal_FRP_other(ezplain)
Dimensions:
Scom thickne":
Distance from top of scum to top of outlet tee.or baffle:
Distance-from bottom of scum to bottom of outlet tee or baffle;
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.)
(revised 11/03/95) 6,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (.continued)
Property Address: e2.Z/T,ereU/LG�
Owner. /`s/h ',�g G/L CJ!//3/x/
Date of Inspection
TIGHT OR HOLDING TANKL
(locate on site plan)
Depth below grode:
Material of construction:—concrete_metal_FRP_other(e:plain)
Dimensions:
Capacity gallons
Design 11ow: ¢allons/day
Alarm level: I
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BO&1/
(loots 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.)
Gt�p �O S/G y 4�" L e�f-i�G,c` ff.!/V lsG2�/✓ S eOf//j/1%/otJ Q T,//�/ v
PUMP CHAMB El:R:
(locate on site plan)
Pumps-in working arder.(re-or no) .
its:
(now oondi m of pump clamber,condition:of pumps and appurtenances, etc.)
(revised 11/03/95) 7
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �? �' ffG�Q/,Gs , G.� . !Z,0
Owner. .00r'/
Date of Inspection: b
SOEL ABSORPTION SYSTEM (SAS):_
(lorete an site plan, if posnble;excavation not required,but may be approximated b9 non-intrusive methods)
If not determined to be present,explain:
Type
ImAin8 pits,number:_
Ieaehing.ebombers,number:_.
�8 flallerim, number
l aching trenches,number,length:
Leching Selds,number, dimensions: /
overflow cesspool, number:
Comments:(note condition of soil, signs of hydraulic failure, level of podding, condition of vegetation etc.) _(foved ae-G y f7Oyr� i,..gr�
O,t/ 7W S/2'S— r3.c T /EG�1. %fJ`G /�SP3�GG S D�h'�2�i'7 r�cc�s y A/- S
C988POOLS:
(locate on.site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of.solids layer.-
Depth of scum layer.
Dimensions of aaespool:
Materials of construction:
Indiana"of grmodwater:
inflow(oaespool must be pumped as part of inspection)
I ,
Comments:(note oomdition of soil,signs of hydraulic failure, level of ponding,condition of:vegetation, etc.)
PRTVY .
(beats ate plan)
Materials of construction: Dimensions:
Depth of soiids:
Camments:.(note condition of soil,signs-of hydraulic failure, level of podding, condition of vegetation, etc.)
(reiiised.11/03/95) - 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Pmpwq Ad a k yvc,r/,t,6 ,vLG� �QO ` G L'.UTr2 UGL c
Owner. 14t� A<JI�L Dv6/,v
Date of Inspeotion:
S=MB OF SEWAGE DISPOSAL SYSTEM:.
iwjl ties to at least two permanent references,landmarks or benchmarks -
Weate aII Wong within 100'
I
I
a �
DEPM,TO QWUNDWATER
to —L� _fwt- .
=9dwd.of dsterssiaataoa or apprasimation: ,19,1W,vs,1.9 l3G.0 6/S S oy ,s Lj�,,c S/T,c 6GG'vAr�. To ;e4C
/=/�O/' TNT 6Qvvv� i t9.E �rLJ�f /.vl1YCT, 1455�//tL
�L� Tit E G�OlTo�`1 0l T hE OvIG d T //(Jl/ i. 'r///5
_/1`�/D /S ,/�L°T,Cv���.v /� ,Qs:�'S /�`v.+ri/] �9.vq S/tAGGd�✓ ,�vvo, /",i►x /itil'yTi2 J.?.�G-,C 3� 8"3�
(revised11/03/95)- 9.
...... ..-.....
THE COMMONWEALTH orwAssAo*ussrre
BOARD���� K���� HEALTH
�°="" "" ~�° �~"
..........OF- ........................ ........ .......................................
-��-'
� = ��m�� ��� �� °� �� �� ��
���������v��� ��� ���������� ������ «������������ ������^�
�
/\pplicu600 is hereby made for u Permit to (Construct ( -,-,or Repair ( ) an Individual Soxugc Disposal
System at:
'~�����ke---
^Z....... .............. --........................
Location Address or Lot No.
--------~ ...................... ----------.--------------------'----------------
, Owner Address
-.----- .-- ............................. -------_---------------------..--..-------_--
znstau= ' AddressType of Building � Size Lot............................Sq. feet
Dw�liog--l�o. of Bedrooms---.-...��.-_-_----IIzpaov�n Attic ( ) 6ucboge 6cudcr ( )
PA Other--Type of Building .. No. o[ persons---------------------------- Showers ( ) -- Cafeteria ( )
P-4 Other 6,torca ------- ------------------------------------------------.----.-----.-.----.----..~--.-_--_---.-
Droigu Flow..................�Z__-'__.gallons per person per day. Total daily 8m°.----gq��..--'_--..-gallons.
Septic Tank--Liquid Length---------------- Width................ Diameter------ --------- Depth----------------
Disposal Trench Nv. Lcogt6_-.-'--' Totalarea--'_--sq H'
Seepage Pit 2qu_-'��_- D�meter below i�c�._'__-'-. Iota �ac6iugarrz----._�Y. b.
Other D�t�6u600box ( ) Ddio� �uob ( )
~~ Percolation IcmL Results Performed by---------- -------------------------------------------................ Du1c''-----'------'
Ies Pit No. l.--_--z minutes per inch Depth of ][cm Pit.................... Dcnrb to ground water..,---------------------
rXq Test Pit No per inch Depth of Test Pit.................... Depth to ground water.---.----_ �
_--------...........................................................................................-_----.-,._._-
[) �
Description of Soil ---.. -_-'--___-'-_-__-------'—__.-_------------_-'
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------ ----------------------------------------------------------------------------------------------------------- ....................... '---__----.-.---_-_- �
U Nature of Dcpuca or Alterations—Answer when applicable------------'-_-----------------. �
----'--'''--'--''--'--'--'------------'----''-'-'-'''------'---''---'--''----
Aigcecozeot: �
� The undersigned ugrcc» to install the aforcdescribed Individual Sewage Disposal Svousn iu'uccorUaocc with
the provisions of Article %Iof the State Sanitary Code—Themdersigned further agrees not mplace the system in
operation until a Certificate of Compliance has beenjspCe
Date
ale
-----------------------------'----'-'''''''- '''''' ^
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_._.......... ... . ...... O.F....................:................ ------------------------------........
Applirtttion -for Uhipl ottl Works Tonfitrurtion Vamit
Application'is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Systeirr at
Location-Address or Lot No.
1✓ .4. --------------•-----•- -•-------•---------••-•-•-•---....._...._..........._....._:
Owner Address
a ----•---•- ......... f 2-.eZ'&.(------------------•---------•- --•---•----•--•-•--••------
Installer Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms-----------------3----------------------Expansion Attic ( ) Garbage Grinder ( )
PL4 Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures _______________________________ __
d •------------------
W Design Flow................. " ...................gallons per person per day. Total daily flow.............0-tom_-________-_-.--....gallons.
WSeptic Tank—Liquid capacity/,am—gallons Length_-_•_-•-__--___ Width_-------------- Diameter:............... Depth.---------------
x Disposal Trench—No. __-_____..__•___.__- Width_________ ______ Total Length-------------------. Total leaching area--------------------sq. ft.
Seepage Pit No........./---------- Diameter.,l_ ,�- Depth below inlet.................... Total leaching area-----__--.--- -__sq. ft.
Z Other Distribution box ( ) Do`hing tank
aPercolation Test Results Performed by-------- -----------------••-•••--•---••--.........--•----•••••...--••--.. Date----------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water--;-----__--..-.--.--...
fZ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-_._--_-.---.._.----.
9 ----------------------------------------------------------•-•-•-••-•--•-•-•--•-••--------------•----.........................................................
0 Description of Soil--------------- - ---------------------------•---.---•-
c.� --------------•---•------•---------------••----•-••--••••---••---•--•---•----------•---------•--------••••---••--•-•---••---•••-•----------•----•------•----•--•--•-•------••----•--............-•----.
U Nature of Repairs or Alterations—Answer when applicable........................................................................_-----_-----_---_..-. .
----------------••---.-..-------------------------••------------- ------ ---------------------------------------------------------------------------------------------------------------------=--------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been s�tled by th and of health.
f
Signed � t�" ---- Y— -------------------------
4.�' i` t ,+ ,� ,, ate^� .
Application Approved By - ....
- y, - r'.Y •J" •--------•--- ---------- --------------------
°°� Date
Application Disapproved for the following reasons:---------- •-••--.........5L4--------------------------------------------------••-•- ----------•--
-•--•--••-•••---•-•••--•-----•----•-------•------------------•-•----•------••---•---•-•••-••---------•-•-----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
K .
BOARD OF HEALTH �� � ,tea
Tntifiratr of 'Tompliattrr
THIS IS TP-CERTIFY, That-the-Individual,Sewage Disposal System constructed (4-) 'or Repaired ( ).
b r i e P1
Y ----•-
Installer
at------ 'a f' ,' 1't-1 a•. '•• _ . -- '" - =, ��� �1��,'"�.�r'_f �"�,_..... -..----
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----- ____________________ dated y_ ';5. .- ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE,THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----•-------•--•-------•--...-•-------•........................................ Inspector...................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH t '�
...........................................
�i��o�ttl ork,� �o�#r�tr�ioit �rr�ti#
Permission is hereby granted---.. ... ,+ -r ! ' `° a� trK .....
.........................................................to Construct or Re air ( ) an Individual Sewage Disposal System }
at No........'�_`___�"��_.....-¢ . �.......................
r. t `p � r' �; �� �+ < , yE � e.�� �.` �- � �� ? A d�` �y. ---— :_.
Street 6
as shown on the application for Disposal Works Construction Permit No-------- __ " : Dated---- f �11 ....: ........
................... -------------------------------- ..............................................
- DATE..................... " --------------------------------------------------••- Board of Health
FORM 1255 HOBBS & WARREN. INC..-PUBLISHERS '
TOWN OF BARNSTABLE
LOCATION . FF lA�Iel,c s Le&C IL XP SEWAGE#
MILLAGE ASSESSOR'S MAP&LOT 2S2 3 3 t?S7
9�l✓s�,i'��`es
NAME&PHONE NO. /� �/LG�l1 7��=/S'72
SEPTIC TANK CAPACITY !av-1
LEACHING FACILITY: (type) &X e--o (size) le— )f at:,,�
NO.OF BEDROOMS 3
EMEMR OR OWNER /"7i<
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 of leachin�fa/cili ) Feet
Furnished by /��
t
l ,
kV c
r
SEWAGE INSPECTIONS
LOC,0110N ,2 8 Huckins NPrk Road DATE 12/7/02
VILLAGECentervi l l e,Mass_ ASSESSOR'S MAP & LOT
-INSpECTOR Joseoh P Macomber Jr
SEPTIC TANK CAPACITY 10 On + how
LEACHING FACILITY: (rype)20 ' X.20 ' Field (size)
NO. OF BEDROOMS 3
BMDER OR OWNER Louisa Grave
OWNER MAILING ADDRESS
Same
_ i
w#f