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HomeMy WebLinkAbout0216 JAMES OTIS ROAD - Health 216`Rithes:Otis Road. ....,. . 'Centerville P A = 170 210 UPC 12534 No.2_ 15 OR ��s� HASTINGS,MN 0 TOWN OF BARNSTABLE LOCATION_ 11G !Tames` 065, A D SEWAGE VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY 1500 LEACHING FACILITY:(type) 3 5-(Vga11 /I eft!ChayG is (size) 19lf,54 311 NO.OF BEDROOMS OWNER �dP PERMIT DATE: COMPLIANCE DATE: 1 y j Separation Distance Betwee the: �(" .- Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _�> 3 - Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edie of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY TA A. arc i(;,Aes s Ff;�a} y �Z P ( i No. Cl� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co put r: PUBLIC HEALTH DIVISION - TOWN QF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for Disposal 6pstern Construction Vermit Application for a Permit to Construct( ) Repair( grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. -2l G :J W­g 0!-7 S Owner's Name,Address,and Tel.No. Assessor's Map/Parcel O (/ �!C Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building f CS I C MV�-t qI No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 41yt7 gpd Design flow provided y gpd Plan Date / Number of sheets / Revision Date Title Size of Septic Tank f,!;DO• Type of S.A.S. - $QO / f l' Description of Soil Natuurre�oof,Repairs or Alterations(Ann/ er when applicable) 1l /sue—��GM l/oS fcvw if C !5 p P/ , Arw 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 this Boar Health. Si ne ��� Date llwlzov Application Approved by Date Application Disapproved by Date for the following reasons �� Permit No. (90;a Date Issued cT r �r Fee t THE COMMONWELTH OF MASSACHUSETTS Entered in computer: a. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplicatlon for Mis' posal *pstem Construction Permit Application for a Permit to Construct( ) Repair(!�pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ;2/G Jwweg 0,�r 5 Owner's Name,Address,and Tel.No Assessor's Map/Parcel pY` (/ N 1,1,e fd� IInsttaaller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 2' Type of Building: t Dwelling No.of Bedrooms t{ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building f t-S i 6r1V i-y G No.of Persons Showers( ) Cafeteria( ) Other Fixtures. Design Flow(min.required) 41'YO gpd Design flow provided Al T- gpd Plan Date /A/ d 2 l Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. -2, - S00 4.-IIAI ►t- Description of Soil t Nature of Repairs or Alterations(Ans er when applicable) —V; d / A/r c� 4ox t vv 16,,S 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 this Board o Health. Signe '' Date J� ,4, Application Approved by Date Application Disapproved by Date R for the following reasons r Permit No. ^* ') Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired( 11) Upgraded( ) Abandoned( )by / . y v�f TN C— at ;L/(; . en e el j� �� ��v -�.i�/f�{� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Noel -0-7)4 ated � Installer !�"� ntn? Designer /�,yi0/ #bedrooms, r'/ - Approved design flow v d —gpd The issuance of this permit,shall not be construed as a guarantee that the system will f ncti nxas eg ed. Dafe (� � "` Inspector r No ' Fee r� . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS . _ Misposal 'p8trm e4ftstrUctlon Vprm t Permission is hereby granted to Construct( ' ) Repair( ') Upgrade; Bandon(' ) Sy tern located at ' �1•R 2 (�1�Ij d ,.- . 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; /must,be completed within three years of the date of this p it. k Date �/ �f/ / Approved by•'� ' r • ,. � .. ,r�ram.ril,T� *9f•'iY�;....':;.�,,,�,.4,•, Town of Barnstable Regulatory Services Thomas F.Geiler,Director _ swNEAMver"acE, _ Public Health Division eoa�� Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 308-790-6304 Dater Sewage Permit# JC01 `6111 Assessor's Map/Parcel Installer&Designer Certification Form Designer: Installer: `� A,7��� 'E� - Address: � �1/��ilxL '/ Address: `y O '12)OX. - e On S f�_was issued a permit to install a d te) (installer septic system at l& 7GMt S Dti af j,I'l based on a design drawn by �(address) dated--& (designer) /. .. I certify that the septic system referenced above was installed substantially according the:�desi dmg to gn, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils } were found.satisfactory. I certify that'the.septic system referenced above was installed with major changes (i.e. greater than 1.0' lateral relocation of the SAS or any vertical relocation of any component of the septic systerii).but in accordance with State &Local u '-+ions. Plan revision or certified as-built by'designer to follow. Stripout(if rp acted and the soils were:foundsatisfactory• OF�;jgs DAVID (Installer's Signature) y M , c E € {{ 1 { it €{€ €F 1 €€€€ r gF$PQ r �tNE Tp�� Town of Barnstable E •• '• `• ' `` `•`_ 5x?; =: �1`• :'• :: '• k d _ Public Health DivisionsSTAB A5 200 Main Street 4 oia+eg Hyannis, MA 02 'T H 5 `0 Y 601 02 1A � Q 0004606238 AUG20 2008 7206 2152 2002 1042 0477 MAILED FROM ZIPCODE 02601 J � f6 71d T . NXXIE: 029 Be 1O� 0 J 5f0 RETURN TO SENDER UNCLAIMEDUNADLE TO FORWARD EEC: 02601400200 *0969-03003-!20-4.2 �.I'Y�J.•J i��J G1"G'�J �V V.�'. 02,60104002 HIM),I,1,il„I1,,,,,fill i COMPLETECOMPLETE . . DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature I - ! I item 4 if Restricted Delivery Is desired. ❑Agent ■ Print your name and address on the reverse X ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery I ■ Attach this card to the back of the mailpiece, I I or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article°Addressed to: If YES,enter delivery address below: ❑No I NtzxtV�` l III I 1-�� 3. Service Type 0 Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. cte Delivery? Fe I � 4 Restricted D iv (Extra Fee)- ❑Yes I e�i7n r.6 1c 0002 ] 242 eW M Z2152 e 'r `4 Fo 11' r 0 is Return Receipt 102595-o2-M-1540 1 1 1 Certified Mail#7006 2150 0002 1042 0477 E ° a�� Town of Barnstable Regulatory Services �t* BARNS`TABLE.?`�� M_ "i '��*/ Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 18, 2008 Neal Van Lieu 216 James Otis Road Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION, The property owned by you located at 216 James Otis Road, Centerville, MA was inspected on August 15,.,2008 by Timothy.O'Connell,„Health Inspector for the Town of Barnsta$1e ,This inspection was conducted on the basis of a complaint. The following violations of the State Sa"itary�Co&were observed ` ' 410.450 Means of Egress: Observed room within basement being used as bedroom without second means of egress. You are directed to correct the violations listed above within twenty four (24) hours of your receipt of this notice by removing all beds from basement and ceasing and desisting from using any part of basement as sleeping quarters. Due to the fact this room. in the basement does not have the proper egress it is not considered a bedroom by Health Division. Although, it may not be used as a bedroom due to septic restrictions. Note: You must contact building Department about making in-law apartment legal. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-,comp iance will result in-a 'fine of $1,00.00 per violation. Each r day's failure to comply with an order shall constitute a`separate violation.—, QAOrder letters\Housing violations\Rental ordinance\james otis cent. PER ORDER O THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Timothy O'Connell, Health Inspector QAOrder letters\Housing violations\Rental ordinance\james otis cent. I COMMONWEALTH OF MASSACHUSETTS z ExECVTr-v-E OFFICE OF ENviRONwENT - r 1 .NSTABLE DEPARTMENT OF ENVIRONMENTAL PROTECTION j 005-APR - I PM 3: 11 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A - CERTIFICATION Property Address: 9 t 6 %� Sa��ne� Q' %L-5 � %P 0 Owner's Name:. 4 r $ ,. . , -`__ -_ Owner's Address: CW m 1 d nt<CE e s 18 z�r �C-r Date of Inspection:_.:31 l D t 04- // Name of Inspector:(pl se print) le 1 t K 44 f Company Name: Vark V%Sr&A-r*t,-T Mailing Address- 'Fol.Sax sq4 t ajt �{I Telephone Number: � g - 3$S 7b09 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 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 15340 of Title 5(3I0 CMR 1.5.000)_ The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this impection 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. Notes and Comments ****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. Title 5 Inspection Form 6/152000 page I i CO.MLMONWF.ALTH OF MASSACHUSETTS ExEcuTrvE OFFICE OF ENtiriRo NWEN-TAL AFFAIRS DEPARTMENT OF,EN-WRONMENTAE PROTECTION 5� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 916 gaL*%e-% Q is iR Owner's Name: u Owner's Address: c� od 0\-fA6A6r& tBZ�( Date.of Inspection: 1 .e.p r.917— Name of inspector:(please print) e �f _r Company Name: _(c tm� 4cAloo.s Mailing Address: p .4 Telephone Number:�508 CERTIFICATION STATEMENT I certify that 1 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 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3 ax- 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. Notes and Comments ****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. Title 5 Inspection Form 6/I5/2000 page 1 i Page 2 of 11 OFFICIAL INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE INSPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: o� Owner: tk 5 Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: A33 1 have-not found any information which indicates that any of the failure criteria described in 310 CMR 1 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section n be replaced or repaired The system,upon completion of the replacement or repair,as approved by th oard of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following ements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the se 'c tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or ure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as oved by the Board of Health. *A metal septic tank will pass inspection if it is stru y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is ailable. ND explain: Observation of sewage backu r break out or lugb static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)area obst;vdian is.m moved distn-&d n box is leveled or replaced ND explain_ The s m required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspecti if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: p? � fi� a r { Owner: S Date of Inspection: 0 A _ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to det ine 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 MR 15.303(i)(b)that the system is not functioning in a manner which will protect public health,s ety 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 wet d or a salt marsh 2. System will fail unless the Board of Health(and Pu c Water Supplier,if any)determines that the system is functioning in a manner that protects the pu is health,safety and environment: _ The system has a septic tank and soil abso on system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface er supply. The system has a septic tank and SA and the SAS is within a Zone i of a public water supply. — The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well ". ethod used to determine distance "*This system passes if t well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile o is compounds indicates that the well is free from pollution from that facility and the presence of nia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are ggered.A copy of the analysis must be attached to this form. 3. Other- 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E PART.A CERTINCATION(continued) Property Address: e9 cncs 3 /CQ� Owner- Date _ of Inspection: © 4-5 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 o(_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow 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. __AC 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 system passes if the well water.analysis, performed at a DEP certified laboratory,for arm bacteria and volatile organic.compmnds 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 mast be attached to this form.} A�O(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CNIR 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 esign flow of 10;000 gpd to 15,000 gpd. s You must indicate either"yes"or"no"to each of the folio (The following criteria apply to large systems in addition a criteria above) yes no the system is within 400 feet of a drinking water supply the system is within 200 fe of a tributary to a surface drinking water supply the system is to a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a pu ' water supply well If you have answer 'yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section above the large system has failed.The owner or operator of any large system considered a significant d9rA4 under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.II ystem owner should contact the appropriate regional office of the Department. 4 r Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: go 4e Owner. ak-WK Date of Inspection- 6 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? _ Jor- 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) J 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? A_ Was the facility owner(and occupants if different from owner)provided with information on the proper ma tenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: no 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 macc�eptable)j310 CNM 15.302(3)(b)) 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAID(` C SYSTEM INFORMATION Property Address: 7 axt 4 ©41!S N, yo cp Owner: ���n.'C Date of inspection:_ S/Co FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_,3 Number of bedrooms(actual): DESIGN flow based on 3 10 CMR 15.203(for example: I 10 gpd x.of bedrooms): 3 M Number of current residents: 0 Does residence have a garbage grinder(yes or no):A) Is laundry on a separate sewage system(yes or no): " [if yes separate inspection required] Laundry system inspected(yes or no):�?tj Seasonal use:(yes or no):A Water meter readings,if available(last 2 years usage(gpd)): C7 OY/1 q((q Sump pump(yes or no):A I Last date of occupancy: COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203}: epd Basis of design flow(seats/persons/sgft,etc . Grease trap present(yes or no): Industrial waste holding tank pres (yes or no):_ Non-sanitary waste discharge the Title 5 system(yes or no):` Water meter readings,if a able: Last date of occupanc se: OTHER(des ' e): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):A-)Q 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) —Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: •26 4PS Were sewage odors detected when arriving at the site(yes or no): /G of 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:_a�6 aN f� e Owner- dy A5 Date of Inspection: 15 ( p BUILDING SEWER(locate on site plan) . Depth below grade: 59t' Materials of construction:_cast iron V 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: d (locate on site plan) ' Depth below grade:a S,0 Material of construction: concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_60C?!�c../ Sludge depth: CR Distance from top of s)udge to bottom of outlet tee or baffle: 30 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: I How were dimensions determined: M Qis y r Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related qjwtlet tt"pveM evidence of leakage etc.): `ro-vt Gc s 4 `z IV GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal erglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of o et tee or baffle: Distance from bottom of scum to om of outlet tee or baffle: Date of last pumping: Comments(on pumping rec endations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, deuce of leakage,etc.): 7 Page 8 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: > (6 DfcS Owner: W Date of Inspection: OS TIGHT or BOLDING TANK: (tan;must pum at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete fiberglass polyethylene other(explain): Dimensions: Capacity: /fo Design Flow: Ions/day Alarm present(yes or Alarm level: rder(yes or no): Date of last pumping: Comments(conditiowitches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage' to gr out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of pump c ber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE*AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: d J awls Qf.L... Cam,; Owner: a_ Date of Inspection: o>� SOIL.ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number- leaching chambers,number leaching galleries,number: leaching trenches,number,length: Ieaching fields,number,dimensions: overflow cesspool,number. innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): :s k t`� 4 ,`F v►, to i h � CESSPOOLS: (cesspool must be pumped as part of' tion)(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 infl (yes or no): Comments(note condition soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) FFi ction: dition o oil,signs of hydraulic failure,level of ponding,condition of vegetation,etc_): 9 Page 10 of l l OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C7 16 J f- 0- S Q i^ Owner:_Al ) Date of Inspection: S 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. t a�f 3 3 � in . Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 .."M +t5 �CQ tom_ Owner: U 5 Date of Inspection:—1 to O S SITE EXAM Slope '"e--' Surface water SV& Check cellar 403 Shallow wells 00 Estimated depth to ground water a7 5- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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 elevat_ipn: S o.u. 't QL,^ S' ll .1, 0 DATE:.9/8.198 ,PROPERTY ADDRESS,. 21.6 James Otis Rdad Centerville,Mass. 02632 " On the above date, i Inspected the septic system at the above address. This system conalsts of the following: 1 . 1 -t,800• gallon septic tank. 2 . 1 -Distribution box. 3 . 1 -1000 gallon precast leaching pit packed in stone. Based bn my lnecuactlon, I certify the following conditions: 4 . This is a title five septic system. '"-( `'78 *Code )' 5 . The- septic system is -�n proper working order at the present time. S I G N AT U R r: Name J P Macomber Jr. i . -------,— ------------- Company:_`. P_Macoa;ber & Son-_'Inc . , Address: __Cente�rvilleL,Masji_02632 Phone: ` THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER '& SON, INC. Tanks-CsupoolPLaach(lelds , Pumpfd & Installed Town Sower Connections P.O. Box 66' Centerville, MA 02632.0066 77.5-3338 775-6412 D1 ` COMMONWEALTH OF MASSACHUSETTS J EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON. MA 02108 617.292•5500 i TRUDY CORE WILLIAM F.VELD SCCTCW-! Govcmor DAVID B.STRL'liS ARGEO PAUL CELLUCCI Commissions Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:21 6 James Otis Road Centervillekddress of Owner: Date of Inspection: 9/8/9 8 Mass. (If different Name of Inspector: Joseph P.Macomber Jr. I am a DEP a proved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J• Macomber & Son Inc. Mailing Address: Box 66 Centervi e[Mass, 02632 Telephone Number: 5 0 8 7 7 5 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspecto all su4bmit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: do One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/twww.magnot.state.rm.us/dep Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:216 James Otis Road Centerville,Mass. Owner: Richard Anderson Date of Inspection: 9/8/98 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe($) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipes) are replaced obstruction is removed distribution box Is levelled or replaced Alt> The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection If(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: sJ Conditions exist which require further evaluation by the Board of Health In order to determine if the system is failing to protect the public health, safety and the environment. i) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ND Cesspool or privy is within SO feet of a surface water djj> Cesspool or privy is within SO feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SKIS) and the SAS Is within 100 feet to a surface water supply or tributary to a surface water supply. AV The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within SO feet of a private water supply well. The system has.a septic tank and soil absorption system and the SAS is less than 100 feet but SO feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the prese ce of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance , (approximation not valid). 3) OTHER w�1 ls•vi••d 0�/33/!�) Y•Q• 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:21 6 James Otis Road Centerville,Mass. Owner: Richard Anderson Date of inspection: 9/8/9 8 D) SYSTEM FAILS: or'No' as to each of the following: The I have determined that the system violates one or m rd of f Health shouldgbe tcontacted tto determ e'what will^be 1 ecessary to basis You must indicate ei;�.er 'Yes' the CO"e for this determination is identified below. The Boa the failure. Yes No Backup of sewage into facility or system;omponent due to an overloaded or clogged SAS or cesspool. Discharge or Ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool. Static liquid level in the istri�obn b, o aEov b outlet Invert due to an overloaded or clogged SAS or cesspool. in rer ,/- ss than 6' below invert or,available volume is less than 1/2 day flow. Liquid dept h Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of limes pumped Q. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within 100 feet of Any portion of a cesspool or privy is within a Zone I of a public well. Any ponion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than SO feel from a private water supply well with acceptable wale( quality analysis. If the well has been analyzed to be acceptable, attach copy of well water "lysis f coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either 'Yes' or'No' as to each of the following:. The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No; /�• the system is within 400 feet of a surface drinking wafer supply the system is within 200 feel of a tributary to a surface drinking water supply. the system is located in a nitrogen sensitive area (Interim Wellhead Prote0ion Area• IWPA) or a mapped Zone II of public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment progr requirements of 314 CMR 5.00 and 6.00. Please.consult the local regional office of the Department for further information. 7•p• 7 of 10 ls•vi�•d Ot/7S/77) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropenyAddress: 216 James Otis Road Centerville,Mass. Owner: Richard Anderson Date of Inspection: 9/8/9 8 Check if the following have been done: You must indicate either 'Yes' or*No' as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. . _ None of the system components have been pumped for at least two weeks and the system has been receiving normal now rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The site was inspected for signs of breakout. _ All system components.Ucluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions;depth of liquid, depth of sludge, depth of scum. _The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) (revised 04/25/21) ?&p• 4 of 10 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:216 James Otis Road Centerville.Mass. owner: Richard Anderson. . . Date of Inspection: 9/8/9 8 . FLOW CONDITIONS RESIDENTIAL: Design flow: 3�g.p.dJbedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):_)Z� Laundry connected to system (yes or no):, Seasonal use (yes or no):—A.R) Water meter readings, if available (last two (2)year usage (gpd): `v `'�v �gJmP Sump Pump (yes or no): j g �%= ra�o �•/�t Last date of occupancy:4-7— COMMERCIAUINDUSTRIAL: Type of establishment: AM Design flow:, A)A,gallons/day Grease trap present: (yes or no)AO Industrial Waste Holding Tank present: (yes or no)NM Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if.available: 'VA AM Last date of occupancy: 02 OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sou a of information: 1 System pumped as part o inspection: (yes or no) If yes, volume pumped: J ons c t Reason for pumping: TYPE OF STEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy ,04 Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/37) Pegs 5 of 10 PARCEL a ' ASSESSOR'S MAP N0. � -7 0 LU CA T 10 Y E lY ( . VILLAGE a � b IIIS1 A LLER'S NAME ADDRES5 M 9'OILDE R OR O U A T E PECMIT ISSUED - -- DAT E C0hi.? LIAHCE ISSUED o' bh f � TV 4 � SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 216 James Otis Road Centerville,Mass. Owner: Richard Anderson, Date of Inspection: 9/8/9 8 BUILDING SEWER: (Locate on site plan) Depth below grader �� Material of construction: _cast iron L 93 PVC_other (explain) Distance from private water supply well or suction line/0*f — Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) All 1pilpe SEPTIC TANK: Qg (locate on site plan) Depth below grade: a Material of construction: rconcrete ,_metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) U jr) : r 714; A Dimensions:,•,,, Sludge depth: If Distance from top of ludge 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 botto of outlet to or baHle:_�„ How dimensions were determined: Comments:- (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) present. Inlet & outlet tees are in •ace• is structurally sound: No evidence of 1Rakaga GREASE TRAP:.Qle (locate on site plan) Depth below grade:A�y Material of construction�concretelt-4—MetallAFiberglass VAPolyethylenef/!p•other(explain) AM Dimensions: AW Scum thickness: AN Distance from top of scum to top of outlet tee or baffle:r Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,-etc.) Grease trap is not present, (:eysaed 04/=5/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property AddiessV21 6 James Otis Road Centerville,Mass. Owner: Richard Anderson. Date of Inspection: 9/8/9 8 TIGHT OR HOLDING TANK;&&(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:, Material of construaion:V.&concrete,4metalit&Fiberg lass&/APolyethyleneAj&oiher(explain) AJA I ' Dimensions: VA Capacity: Ajfi gallons Design flow: B14 gallons/day Alarm level: Alarm in working orde(AA1 Yes: &No Date of previous pumping: AjA Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holding tanksa�-present. DISTRIBUTION 8OX:-1 (locate on site plan) Depth of liquid level above outlet inven: AID Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or,out of box, etc.) Distribution box has one lateral +Nn Puidenne of solids C Arry nypr Nn avi aemco of 1 eakage lRte eE eUt ef the L_7_ PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No)) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) Pump chamber is not Pragant (r•vi•.d 0//J3/f7) 1+•p• 7 0! 10 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 216 James Otis Road Centerville,Mass. Owner: Richard Anderson Date of Inspection: 9/8/9 8 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:l leaching chambers, number: leaching galleries, number: leaching trenches, number,length:-dam--- leaching fields, number, dimensions: V overflow cesspool, number: Alternative system: -RW - Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to medium coarsp sand' No signs of hyciratil ; r• failure Or ponding;Al 1 yPgPt-at I nn i c nnrwn 1 CESSPOOLS: levvve, (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: AM- Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) esspools are not p rPgPnt- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not rPgPnt- PRIVY:dhlfk- (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.) rivy is not present. (revised 0//2$/37) page 1 of 10 SUBSURFACE SEwACE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION jcontinued) Propeny Address: 21 6 James Otis Road Centerville,Mass. Owner: Richard Anderson, D41C of Insptction: 9/8/98 . SKETCH Of SEWACE OISPOSAI. SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within too- (locate where public water supply comes into house) . `19 b 9 3/ 'TAMPS OTTS iPd (r•vl•.a 0�/71/17) 1.00 J of 10 SUBSURFACE SEWAGE DISP(:� ,t SYSTEM INSPECTION FORM ll 1:,1:T C SYSTEM INFOR-'. .fiON (continued) PropertyAddrAs: .216 James Otis Road Centerville,Mass. Owner: Richard Anderson Date of Inspection:9/8/9 8 Depth to Groundwater:5nL Feet Please indicate all the methods used to determine High Groundwater Oevation: Obtained from Design Plans on record Observation of Site (Abutting property, bservation hole, basement sump etc.) -Determine it from local conditions Check with local Board of health Check F EMA Maps Check pumping records —Zcheck local excavators, installers Use USGS Data Describe in your own words how you established the High Groun4w,rerElevation. (Must be completed) Used water contours Map. Gahrety & Miller MOdel 12/16/94 e i tr.vl�.d 0{/23/f7) D69,• '100f 10 is•nnn.•+e-n 117�•TT .wrww•nr.w�.n.yrtrn..nw•.wtnr.w,rr+.w.. nrn,1l n.ar-.r.�l win I 11.OWN OF Barnstable WARD OF HEALTH 11I SUDSURFACR SEKAUE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION .1�•411 R•'••L:.-7.IIR�•.tTPVnTI.•.I.TIITRIRtf IRwTRr1.*.VTwr'/Rw1T�T�..�./I.�T1R\ l...l n'�.�R1�+TT.TT�t•l�r T't�1i -TYPE OR PAINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 216 James Otis Road Centerville,Mass. ASSESSORS MAP, BLOCK AND PARCEL 1 /70 A M OWNER' s NAME Richard Anderson PART D - CEI?TIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inerf COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Tovn or Clty gt�te j COMPANY TELEPHONE ( 508 775 - 3338 FAX (508 790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system . ' this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendatlons regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of o: site sewage disposal systems . Check one : �s t e d PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or -.t-he environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* 1 The inspection which I have con ted has found that the system fails t protect the })tiblic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C .- FAILURE CRITERIA of this inspection form . Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applioable ) and the DOARD OF 191EAL'1'JI. IF If the inspection FAILED, th-e owner or oporator shall upgrade ' the ayetem. within o'ne year of the date of the inspection, unless allowed or required otherwise as providdd in 3.10 CMR 16 . 306 . partd .doc �<� 7 t*7 y _ Sb'j1t 3��1 THE COMMONWEALTH OF MA.SSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. Jux s. ins Acung Dirccior of the ion of Watcr Pollution Control TOWN OF BARNSTABLE LOCATION ;N Aft l d ZES 14,4d SEWAGE # VILLAGE &A1;i^,,Ji)9_ �'YJ�SS . ASSESSOR'S MAP & LOT D I D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Ave( e LEACHING FACILITY: (type) (size)NO.OF BEDROOMS / Y BUILDER OR OWNER ./! PERMIIDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 an wetlands exist within.300 feet. 1 chi acility) Feet Furnished by e. At , 3 P � i 31 i o �� AM PS 0 rrS /C'd _ .� \ � �-va ;� ` Vie. �..,, y. ..•. No —_�Q .3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------ v ---------..OF........ r-......................................... Appliratinn for Bi_gpog al Works Tonstrnrtiun ramit Application is hereby made for a Permit to Construct (,k/) or Repair ( ) an Individual Sewage Disposal systems .12...-..j4g� 0175 4,W _Ceur�1� -•--------------------------------- ------•-----•----------------.....---------------------.....----..._..---------------------------. /L cation•Ad ess _...... � Own Address a �,1�1e; Cc�._:T,�tr�4i4� ------ --------------------------- iP ....................... Instalier Address d Type of Build' g Size Lotl _s_l S.._..Sq. feet V Dwelling=No. of Bedrooms_._.....�_.•.........................Expansion Attic Garbage Grinder ( y aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures __________________________________ W Design Flow............................`7`�--- allons per person�p r ay. Total dimly flow--------s3.�5•a......................gaVonst 9 Septic Tank—Liquid"capacity-_- `'____gallons Length....... Width.__¢__-./© Diameter................ Depth.�:.-4-_- Disposal Trench—No..................... Width..-,.I Total Length..... ....._._..... Total leaching area....................sq. ft. Seepage Pit No._.__-_I..--_.__.. Diameter........k...... Depth below inlet... ............ Total leaching area._o.�.._.P.....sq. ft. z Other Distribution box ( Dosing tan ( j aPercolation Test Resu is Performed by------------ d�`LZ � ...` .......`. .._� ..... Date.....^ C?_`__ ...... g a Test Pit No. 1................minutes per inch Depth of Test Pit..�. ......_.._.. Depth to ground Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_______•-_--___-----__-. R+' --`--•----- - -------------- t ODescription of Soil........ ..........44 K... ._�7 .................................................... xf_ 7 , W " UNature of Repairs or Alterations—Answer when applicable--------------------------------------------------------__ ....._.__. ----------------------------------•--------------------------------------------------•----------------------------------------------------------•-•-------•----•----------------------------•-•-•••-•-- Agreement: The under$igned t agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 1 i:f.,1`� 5 of the State Sanitary Co —The unde ned further agrees not to place the system operation until a Certificate of Compliancq has be i sued by the b d of health. ................................................° .------------..... •---•-�--.........��w Date / Application Approved By-•--•-•--•-•--•-•-•-•................ •-•--•-• -•.....-•-........---•- �- �-------- ------ Date Application Disapproved for the following reasons:............................... `. .........................................................................................................•..........--••--•-•••-•-••---•••-•---•••---•-----------•----•-••......------•--•--......••--- Date PermitNo........ ..... S.. .............. Issued_....................................................... Date _ No 61L�i; THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 ...... t....................................................... Appliration for Diopooal Works Tonotrurtion Prrutit Application is hereby made for a Permit to Construct K) or Repair ( ) an Individual Sewage Disposal systemt: 2 JiW e 0/7..............................................................- _...._...___..........__...........__....... ...._.__..........__.................._-- ca'on-Ad ress .._. G'�e�//.... Z- ---------------........................ ------ C 0 0. w ,.a -••---.... C�:SCo ,i r/ i� XL�rn ,�s�Y-- I -------------------------- Installer Address / UType of Build i Size Lot[_� . �-S.---•_Sq. feet ., Dwelling—No. of Bedrooms_........�� i .............................Expansion Attic Garbage Grinder _)d `4 Other—T e of Building No. of persons............................ Showers a YP g ---------------------------- P ( )--- Cafeteria-(----)- d Other fixtures W Design Flow...........................5.5_........gallons per perso Aer day. Total daily flow.......3_�v_-6........................Olons. WSeptic Tank—Liquid capacity-.1U.....gallons Length_ .... Width¢.—.��.. Diameter__ p x Disposal Trench—NTo..................... Width. �..... Total Length.... .__....•...._. Total leaching area_____--_.._._._.._..sq. ft. Seepage Pit No._.___1_.__....... Diameter_._....jS __._._. Depth below inlet. '............. Total leaching area .___.sq. ft. Z Other Distribution box (L-r Dosing to V� Percolation Test Res�l is Performed by----------- T� '__.r _._N��..._�. ...... a Test Pit No. 1 L... Z-:'__mtnutes per inch Depth of Test Pit..l - . .-._-____-•- Depth to ground water.0Q YJ ...J2 GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........... .•-----.-__-. Description of Soil.......`, elZ �G ...? ..?ulS�'�G'... 0�.... - x W •---••••-------------- ------------------------------------------------------- ...........-•---•------••----•----------•---•-•••••---••--••-•••---•--•-•••••---•---•-•----•-•--••••--••-•-------....... V 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 Ts'TLa: ;of the State Sanitary C —The unde ned further agrees not to place the s stem "n operation until a Certificate of Compliance has bee sued by the d of health. X' . ....-------•---------- -----�-......�- Date Application Approved BY.......................................... ... -- -= � . I Date Application Disapproved for the following reasons------------------•----------•--•-------------------------------°-------------------------------------......---- /� Date PermitNo..........� ....... _c�.......... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OOF�HEALTH Py.......:....` !�.1.�r. ..OF...�`'......—:i....^av�?" Lc-".................. Trrtifiratr of Tontplianrle TH� CERTIFY, That -1w—b riiu al Sewage Disposal System constructed ( ) or Repaired ( ) bY-•---•............. ._��f ��t�...............E-ay�65_ - --------------------- ......... ............................................................ ^'---- Installer has been installed in accordance with the provisions of T f The State Sanitary Code as lescribed..............Works THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUN TON SATISFACTORY. y� DATE.....................=J ..................................... Inspector........I--•y-1------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS .. .....................................BOA°HEALTH ' ..O F.......................... .�..�4:�_........................_ C iV 0.... --•-•- --..... --• FEE....._..- •.......... Diopooal 10orku Tuonotrttrtion permit Permission is hereby granted---- Yd fi . -•................•----•-••••-••--••...._.......----- to Construct, ( ) or Repair ( ) an Individual Sewage D" posal System 7! at No.......... �•-•----Sr'�...........� � 'S'Y`��"`-s�'. �. �::CS.IC�v� .. Street c.' as shown on the application for Disposal Works Construction Permit N6�._, ._ Dated---ICO- ._2�1.rl&........... 2 - .� -....-- -------------- ----------------------------............................ Board of Health DATE---- v-------------•- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ASSESSOR'S MAP [ 7 0 PARCEL LtdC O — CATION ' G E p E. R, I . IV. STA LLER'S NAME ADDRESS 0 A T E P F F. M I T s s u E 3 rf-el, OAT E C0 IIA47LIANCE ISSUE D AV � a � � Q��;� �`s 30 �q __ .._ .. ...:irw:wrC.a.�eJ.-.ems-�a.�T..- •'--" -- - -e-r•vr..�T .w.v,r r-D:.s,�—. r>s'r..... ...�v-rr..�s._-_....+t.he, -. , ..1.sLe+i �.�1•�►'a«- r..,,...+.>v.•-rhU.r:r+ennlTl�sMltliR;..c•.•.•T...+«w--..._......:-_......_ .;�„�-.w.. _._._._..�.. .. �..., ....flit'w> a J,:a.�.....:::.�..---. ._.__.:�-y.�.wG+..•t•-ie:.a•<O•w•:+?t`ewswa+_•Xr •. � -•tea_.__ 4+.es,+•......:� ._.—.?—+�R�.,..•«...-..•...r sa.----s.--.r._._..a.._yn..-.. � . I: i3tF_ F1lS'FCt7t1Ri�'Ra4 .:y �,?Wn OF of Health RE-7k.,- i'liTa I r ��+�+ ' - .. _ _ _ ._ _ Sept""5_l`tiL Sy.t:`nl a �!' � 5t'r<!!: ftUt ut? irSS;•�i's:= : t_t'� Q,,Y 471- -t 1 , l'i�J• .. �v�lr/ .(� r ? r 4 r 1i`y, V s approval in r a . ! 3 ,r rm ,fr-, {f ai ! rt t. • F7.1'3�C..-+ �' 4:. '�` ��}►r]r� 1 ",- -��G-Li+w.+u"� - ��(' ! fe inStalldrton, i_• S id`if?r'ttflj rf tOCdt1G`^ j s:,ptiC cor oti.:i;vo;s ni N ! in-tdltatlC3r. Y W/ �i4'`' V ! 1.1 ti :' rntilltV SL5f4C'.i pf(ttt!v+ +S ii' i�> !3 it PVC- ?'tf distribution o hall L.� iE1iPi. Al, :.:t;ing;Urnertions To ;i;is septic_design olai� 1, c? • rl f{x property P l•:)ti's�,i�! tr. , .or any otht:: s V�' :Pose otilet s.r',_.)ttii? installatigr r /(y1�' ,/'� /y,/►� is ` ."::= rzt ti' t:Pt?t :arc• 3:_ .r?�•r�4. TIttle Vr 5 r oe.:i`:co'h�r�s. ` lows r i ki'l j shall he l?'t7ti1t.r1`:..?G f:- :� :t),':fl'3ilent5 URIe:: Z�7i•!'t•'?i`. aw H2!_}:vtf�t�`j. l.`D , �_,.+ �jj :r�- .. ar:it ,ier ritl V i exii-Ring leattting .r L*�:'.{: ;. , �r 1e F.!:::';tif d ar1Ci ... " dt. E' _ t ,r:donment nrocedl:;!c. i':3 'tint ,d cesspacits; and C_ ..rn,Trt::;;2d ?tls w►thin Cite ;iposed SAS�h=,?i be - .•.. ". idCECI with r.-Elian sandt pee Title�/Sji�' I�lf..i7tlCir?ti. a_ r se vic lin g a Nate d v r: �hr?tiule 0 PVC with 6rc#i g;criteU. r;,P water se V., l t IO �lML, ) ieeve rixh 3r; au iiie SieP,YE'. i?t''f� .?►St•3t . t =ir♦P` i ,sing; the line Q -!/a- �� i• { _ •3 ro �n, It StE'r!1 is RC}t ,., !t rsto bc. .•_r � ♦ /,� jam,- � � .,:.. l:lSt2llt'r IS rt�(:L;1?- _ _.. � ,Z:r3�:,:)P�r3r'JL'r'.. / V "[ F � . �(�� .. t r �t :i' !' ..!�s{ J':°beset,}: 99 ti I y� - -, � 't •rc:teclin t+?e st !+_tt:' :-try f:rr.,s f.�l.r'Rg t, t; 1 r i rc re5t't tits- +ste! _are be irtst,. ; r: ng T tie property owner �ILSigF;;:r:terla to dlitl!'�VP tl':'tJtn! flelrn 'r ' Of hAdit)cm�c'rii ign flow. !risti-4a}rc of •i$i'jtjr ft�m as rropr�5t'i�a;t�+ rFt u 1 ?ld?nt for the desit tt _ - O I :a:l be deemedi appro;;-?i of t'-w , ritt:r:a hi!the property n,!it. . r,t UY. +c'Val=ciity cat this lira°' ,r; •- �hY etNiratrpn of tkt?to�yri insCc a>•-r.. ern1,t r�SUt'. N.t — t.'4. } i';' piaR or the lralicil}' .'!i�Xpire r)o the explr.)j;ory Ui t;,n t el i'flCiliE of�U'tt�l�ii�rlr_ 2r• -TIC" - 1 ,.!E�d for t'rZ F. i;ij_::11c:• .. �C! ✓i ) O t r \Joeu VIA . t Iul,�fl C2-�) V410 zf�H VDI : K � I i � l �• w• , i,�tWi. __� ti � � t , I ) _ I� _.. ...� .t -� '�l �'`f►�1�.""�F if � , I ter' jo �"� -�—,.,.`� ��� �r � 1 .. yeti - --- , — -- DAVID 1- Tin J01� � ��.y 4.w>•�Y�t •.t.r ..-- ..- -it9l�.*••!•lY.z .Five�i.'4GI-:V/h 's' .-.'{1 •.•...� -)•!.g„ x f. . to 9 Flo.1066 - - iAC'' IITE ,_,.__ �-._ ._. '?� +.• '. 1„ i rl_ - {7 70 ` . 1-`�X>P.s.Y c.(.._n,.LL,..n..tom � ._.. .. 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