HomeMy WebLinkAbout0125 LAKESIDE DRIVE EAST - Health 125 LAKESIDE DR. EAST, CENTERVILLE
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Town'%of Barnstable Barnstable
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P� Regulatory Services Department ;micalc
BARNS-rABLE,
MASS.
i6g9. Public Health Division
Op ��
ArF0 MAC A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
June 25, 2008
Judith E. Smith &Diran S. Zahigian
42 Amberwood Road
Winchester, MA 01890
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 125 Lakeside Drive East was inspected
on June 24, 2008 by Jaime Cabot, Health Inspector for the Town of Barnstable, because
of a complaint.
105 CMR 410.503 (C)—Protective Railings and Walls. Observed lack of wall or
guardrail on decks above 30 inches in height.
105 CMR 410.503 (B)—Protective Railings or Walls. Observed lack of hand rail on
stairway with 3 or more risers.
You are ordered to correct the above violations within thirty (30) days of your
receipt of this notice by installing protective guardrails and handrails as required by
780 CMR: Massachusetts State Building Code
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-compliance will result in a fine of$100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO
C:\Documents and Settings\cabotj\Desktop\Housing\125 lakesidedrive east.doc
FoRM30 H&W HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
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BOARD OF HEALTH
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Address `2S A �� '�a- ��1 V OccupantSvM W►t,- 94+a'Ls"'.
Floor — Apartment No. _ No.of Occupants N f A
No.of Habitable Rooms 6o No.Sleeping Rooms.3
No.dwelling or rooming units — No.Stories
u ame and address of owner_ _ v O i"f H 7A" % Gt IAa
1 z hq e7 lEYL A-j C-3 a W 1 N C 14 MA Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or othe
STRUCTURE EXT. Steps,Stairs, Porches: IEGV_S A Gov it 3o U 16 ti S'03 cc j
Dual Egress:and Obst'n.: AAD 1241 L. r 36" N u CS)
❑ B ❑ F ❑ M Doors,Windows: W t+ 144- Arbf 9E k CE ,01AP W
Roof p _
Gutters, Drains:
Walls: "1 tom+ HT.
Foundation: 0 t O-A 91 OA• e C
Chimney: 64.
BASEMENT Gen.Sanitation: VAO
Dampness: >&Ae- p 3 W
Stairs:
Li htin :
STRUCTURE IN Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y✓❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: / Supply Line:
❑ MS ElST✓❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen. Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1 t
Bedroom 2 z
Bedroom 3 I pp
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink o
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted e- O T E
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. (See Over)
"THIS INSPECTI REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF RJURY."
INSPECTOR TITLE l-111AL7y TAj
OF I A.M.
DATE 17—O TIME
-�7� A.M.
f THE NEXT SCHEDULED REINSPECTION S A P.M.
� 4
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items4hich are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is"not included in this listing. Failure to include shall in no way be construed as•a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply'of water sufficient in quantity; pressure and temperature, both hot and cold;-to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as.
prohibited by 105 CMR 410.200(B)and 410.202.
(C) ,Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required qy 105 CMR 410,250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.••
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents}egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
f ilti s s re required b 105 CMR 410.351 and 410.352
gas fitting and electrical wiring standards or failure to maintain suchac e a a q y ,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A).(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
• l
n,TOWN OF BARNSTABLE96
iLOCATION 1.'I.� �j�� � K,4$7- SEWAGE #
ILLAGE aWZPkL!, I9'II¢ 5 ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLLkNCE DATE:
Separation Distance Between the: e
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(i any wetlands exist
within 300 fe t lea hi c' ' ) Feet
f eetm� -2 3 3 C
Furnished by
WA-te/Z
4r )9c,
O � �
TOWN OF AMSTABLE
LOCATION SEWAGE #
VILLAGE �i.�e ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY G>
LEACHING FACII..ITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Lea ing Facility (If any well "s exist
within 300 feet f lea An, f Gty) � Feet
'
Furnished by - "
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DATE :4L27J98__ __ _.
has�
PROPERTY ADDRESS:-J2-5- akeside_IIriv�e
Centerville,Mass.
02632
------------------------
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank.
2 . 1 -Distribution box. \
3 . 20 'x10 ' leaching field.
Based on my inspection, I certify the following conditions:
4 . This is a title five septic system. ( 78 Code )
5 . The septic system is in proper working order
at the present time.
6 . The leachfield is presently dry.
7 . All schrubs and bushes should be removed for 10 '
all around the leaching field.
Sl G NATU R5�1
Name : J . P. -Macomber-Jr .
Company:_joseh Son, Inc . , i 9
A d d r e s s: BQx ------------
__G_eRt_QrYiUP,_.0a _Q2-632-0066 a Y2 FD
Phone: 508- 775- 3338 q°Feq 41
--- -- - --------=-
� `T hOF ll9el�
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR \NA;RRA�NTYy
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775.6412 .
YA
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
_ DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617.292.5500
HILLIANI F WELD TRUDY COXT
Govcmor Sccrctar\
ARGEO PAUL CELLUCCI DAVID B STRUI-6
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissionci
PART A
CERTIFICATION
Paul Levine
Property Address: 125 Lakeside Drive West. Address of Owner: 210 Nanhanton Street
Date of InspectionA/27/98 Centerville,Mass. (If different) APT 207
Name of Inspector: J.P.Macomber Jr.
�7 2
I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMKP'1�fJV07W��r,r MASS. 9_1 59
om • J.P.Macomber Company Name. & SOri Inc.
Mailing Address: BOX 66 Centerville,Mass , 02632
Telephone Number: 9508-7795_31-48
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 Inspector ?allbmit 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, 8, C, or D:
A) SYSTE 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:
B) SYSTEM CONDITIONALLY PASSES:
zG) 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) Dag• 1 of 10
DEP on the World Wide Web: http:l/www.magnet.state.ma us/dep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.��
PART A
CERTIFICATION (continued)
Properly Address: Paul Levine
0..ner: 125 Lakeside West Centerville,Mass.
Date of Inspe(1ion4/27/98
BJ SYSTEM CONDITIONALLY PASSES Icontrnued)
Sewage backup or breakout or high static water level observed in the distribution box 15 cue orG•e c c::
prpels) or due to a broken, sealed or uneven distribution box. The system will pass inspecliOn
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obsujcted oit'es Tme s•s:e'
,nspecj.on if (with approval of the Board of Health)
broken pip-e(s) are replaced
obstrvction is removed
FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require funher evaluation by the Board of Health in order to determine it !ne ;.;rn s
public health, wfery and the environment.
sJ SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONI',C ,', A -
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
'f
Cesspool or prCvy is within 50 feet of a surface water
�Sl(/ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPR'AT� DE': :
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAF r'1 AND T^i
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 ;ec: c a
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone i o; a :.D
,&d The system has a septic tank and soil absorption system and the SAS is within 50 fee: v a
12,z> The systems has a septic tank and soil absorption system and the SAS is less than 100 fee: o c—:
private water supply well. unless a well water analysis for coliform bacieria and voiatde or3s- cc-.o
the well is Iree from pollution from that facility and the presence of ammonia nitrogen and :'ace c3
less than 5 ppm Method used to determine distance d24. (approximation not val
)) OTHER
.r.vs..S 0./)s/f71 P.9• 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 125 Lakeside Drive WEst Centerville,Mass.
Owner: Paul Levine
Date of Inspection:4/2 7/9 8
DJ SYSTEM FAILS:
You must indicate ei:•.er "Yes" or "No" as to each of the following:
Al 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes N
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invqi due to an overloaded or clogged SAS or cesspool.
Liquid depth in.ee»peel.is less than 6" below invert or available volume is less than 112 day flow.
Z/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped 0
y Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
s� Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Y Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
017 the system is within 400 feet of a surface drinking water supply
ZUo the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Pag• 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 125 Lakeside Drive West Centerville,Mass.
Owner: Paul Levine
Date of Inspection: 4/2 7/9 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes N-i�
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
flow 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,9sicluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properly Address: 125 Lakeside Drive WEst Centerville,Mass.
Owner: Paul Levine
Date r: Inspection:
4/27/98.
FLOW CONDITIONS
RESIDENTIAL:
Design floK.'310 R p.d./bedroom for S.A.S.
Number of bedrooms:%3
Number of current residents:
Caroage grinder (yes or no)
Laundry connected to system (yes or no)
Seasonal use (yes or no).)VI
water meter readings, if available (last two (2) year usage (gpd): �U`�aDB
Sump Pump (yes or no):&& l 7/ �37, And = lvz or e. .
Last date of occupant),. !?.tip
COMMERCIAUINDUSTRIAL:
Type of establishment: /A
Design flow: t),4 Rallons/day
Grease trap present: (yes or no)a
industrial Waste Holding Tank present: (yes or no)Olt
Non-sanrtar% waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available._�Jy9
did
Last date of occupancy: AJ
OTHER: ;Describe? �7
Last date of occupancy _ 0
GENERAL INFORMATION
PUMPING RECORDS and ou�rSSe,of information:
�4�JX�f��(A,
System pumped as part of inspection: (yes or no),eo
If yes, volume pumped gallons
Reason for pumping: .0
TYPE OF SYSTEM
_ 4--� Septic tank/distribution box/soil absorption system
Z,0 Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, anach previous inspeclion records, if any)
J I/A Technology etc. of up to date contract?
Other
AP ROXI TE gG/E�f,AJI components, date installed (if knu"•n) and source of information:
Sewage odors detected when arriving at the site: (yes or no)lvd
(revised of/I5/97) page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 125 Lakeside Drive West Centerville,Mass.
Owner: Paul Levine
Date of inspection 27/98
BUILDING SEWER: .
.ocaie on site plan)
t/
Depth below grade:
material of construction: cast iron Z0 PVC _ other (explain)
Distance from private water supply well or suction line �t� -
Diameter
Comments: (condition of joints, v nting, evidence of leakage, etc.) n
WA
d
SEPTIC TANK:_A-W,04��4
(locate on site plan)
d
Depth below grade //
material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
It tank is metal. list age� Is age confirmed by Ceennificate of Compliance _(Yes/No)
Dimensions: O G I� '04 �;1d*" // e' b •L ��� I
Sludge depth
Distance from top
.sludge to bosom of outlet tee or barile:L
Scum thickness
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bottom of outlet tee r baffle: G�
How dimensions were determined: � r
Comments
(recommendation for pumping, conditi of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage. etc.) 'X
K
GREASE TRAP:vr%/,?'
(locate on site plan)
Depth below grade 4
Material of construa ion NAconcreteW,#metal/, Fiberglasst/R Pol yet hylene4,gother(explain)
A
Dimensions:
Scum thickness: A1r14
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: 1(/�
Comments:
trecommendauon 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.)
s /1 <Wr
(rwized 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 125 Lakeside Drive West Centerville,Mass.
Owner: PaUl Levine
Date of Inspection: 4/27/98
TIGHT OR HOLDING TANK: 06?(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grader
Material of con struction*,Iconcrete&f netal4�4Fiberglass.,&PolyethyleneV�i'other(explain)
_ 41A
44f
Dimensions: .U/1
Capacity: IM gallons
Design flow:_gallons/day
Alarm level:_ VA Alarm in working order r,/4 Yes;4,4 No
Date of previous pumping: �'!2
Comments.
(condition of inlet tee, condition of alarm and float switches, etc.)
WE—Op J,4 S Are
DISTRIBUTION BOX:z
(locate on site plan)
Depth of liquid level above outlet invert: IVIIA
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:,4PU`,
(locate on site plan)
Pumps in working order: (Yes or No) 1114
Alarms in working order (Yes or No) 'VW
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(rwis.d 04/25/97) Pnge 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORns
PART C
SYSTEM INFORMATION (continued)
Properly Address:l 25 Lakeside Drive West Centerville,Mass, .
Owner: Paul Levine
Date of Inspection: 4/27/98
SOIL ABSORPTION SYSTEM (SAS):z
notate on site plan, if possible; excavation not required, but may be approximated by non-intrusive met.noesi
if not determined to be present, explain:
Type
leaching pits, number:
leaching chambers, number.
leaching galleries, number:
leaching trenches, number,length._ f
leaching fields. number, dimensions.
overflow cesspool, number.
Alternative system: I
Name of Technology: / OG
Comments
(note condition of soil, signs f hydraulic failure, level of ponding, condition of vegetation, etc.)
C T --
i72741 a PL .Za 4 cA --
U
CESSPOOLS:_
(locate on site plan)
-umtxr and configuration:
Depth-top of liquid to inlet inven:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: 414
indica(ion of groundwater: ,V
inflow (cesspool must be pumped as pan of inspecz'on) _
Comments
incite condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
P R I VY: ,ea.-,e-
;locate on site plan)
Materials of construction: -l� Dimensions
Depth of solids Ae2i
Comments:
Incite condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
t ti
Ir.v11.0 04/25/91) P•0. 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 125 Lakeside Drive West Centerville,Mass.
Owner: Paul Levine
Date of Inspection: 4 2 7 9 8
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
.0
l 3�c
(revised 04/25/97) P&g• 9 of 10
SUBSURFACE SEWAGE DISP. SYSTEM INSPECTION FORM
I . C
SYSTEM INFOL .. !ION (continued)
Property Address: 125 Lakeside Drive West Centerville,Mass.
Owner: Paul Levine
Date of inspection:4/27/98
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Ne-aJon:
Obtained from Design Plans on record
Observation of Site (Abutting property observation hole, basenxnt-s 1mp etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
_ZCheck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Grounctwa-terElevation. (Must be completed)
Used hand Auger. Drove hole beside the leachfield.
Water at 5 ' 10" Water is 3 ' .6" below the leachfield.
(raviaad 04/25/97) Pac, 160E 10
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i
TOWN OF Barnstable BOARD OF HEALTH
SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
�•••sn-r••.•::r—T.II!^.•laT TT...I'.t.'iTt rnarA•etrrT:rnT.a�1•ir{tmM•var.rl�TARRa*sf m'101iflsv�..'.•f .sniRTmrarrasv*Ta•r1rr+'•.:.-rr•T••1. _j
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 125 Lakeside Drive West Centerville Mass .
ASSESSORS MAP, BLOCK AND PARCEL # 232-73
OWNER' s NAME Paul Levine
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & S(37f 'INc.
COMPANY ADDRESS Box 66 Centerville,Mass. 02632.
Strout Town or CSty 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 nddress and that the information reported is true , accurate , and
complete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check o
Systeui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection wllicil I have con icted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date 4/27/98
One copy of this c tification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF 11EAL1'll.
* If the inspection FAILED, the owner or" perator shall upgrade
he
within o'ne year oP the date of the inspection, unless allowedortrequiredsystem
otherwise as provided in 3.10 Ch1R 15 . 305 .
partd .doc
r
s
S b'kv
THE COMMONWEALTH OF MASSACHUSETTS
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 S SYSTEM INSPECTOR
as provided in 310 CMR 15 . 340 and Section 13 of Chapter 21 A of the
General Laws. Issued by The Department of Environmental Protection.
__2 f —
lunc x. tvv5
Acting Director of tltc;,W1011 of, Water Pollution Control
aR
DATE: 2/23/96.
PROPERTY ADDRESS: `125 Lakeside Drive East- RECEIVED
Centerville FEB 2 8 1995
-Mass . 00'2 6 3 2 HEALTH DEF
TJWN OF I3ARNSfMl
On the above date, I Inspected the septic system at the above Address.
This system consists of the following:
4-61x8"' block 'cesspools .
Based bn my lns.nection, I certify the following conditions:
I . This is not a title five se-p:t_ic System.
2 . : This, is a split .system.. Sewage sy-bem. --
� . ' •rn3talled in the 6013
4. The sewage system. i.s dry and in -proper
worki�g. .order- at the pr(isent time . r ;
SIGNATUR7:
Name _J_P M^acomber Jr...
--
__^____
Company -J. P . Macor)ber & Son-_Inc .
Address'
Centerville LMass__0.2-632
Phone:---5Q8iZ7�-3338------- - i
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON,. INC.
�..� Tanks-Ceupool&-LeachfIelds
Pumped & Instilled
Town Sewer Connections
P.O. Box 6E ' Centerville, MA 02632-0066
77-3-3338 775-6412
Commonweafth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Wllilam F.Weld
Gowrnor Trudy Coxe
Argeo Paul Celluccl 8iretwy
U.Governor David B.Struhs
Corrun4z1ocwr
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 125 Lakeside Drive East Centervil1 Ade
2/2 3/9 6 dress of Owner:
Date of Inspootion: (If different)
Name oflnspftun- Joseph P. Macomber Jr .
Company Name,Address and Telephone Number.
J . P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-775-3338
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:
-s'C— Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: �� d
�� 1 Date: „�
The System Inspector submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be seat to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
Al SYSTEM PASSES:
_ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303.
Any failure criteria not evaluated are indicated below.
Bl SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate, Nyes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain.Wby not)
eL The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exflltration,-or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street a Boston, Massachusetts 02108 a FAX(617)5545-1049 a Telephone(617)292.SM
i1 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
Property Address: 125 Lakeside Drive East Centerville ,Mass . 02632
owner. Estate Of Esther Hirsch
Date of Inspeotlow 2 j 2 3/9 6
BJ SYSTEM CONDITIONALLY PASSES (continued)
v
tt�.� Sewage backup or breakout or hA static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settlad or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(.)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(.). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(.)are replaced
ob
struction is removed
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
AD The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
JG��t/Cl GL2i9,4,� .i-) eacI�DG►�.
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddroas: 125 Lakeside Drive East Centerville ,Mass . 02632
Owner. Estate Of Esther Hirsch
Date of Inspection: 2/2 3/9 6
D) SYSTEM FAILS: W
e
tied I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
d, Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
NO Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
4041C Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
AV Liquid depth in cesspool is less than 6"below invert or available volume is less than l/2 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
�() Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 60 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
M 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:
10 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
J�W the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Auther information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 125 Lakeside Drive East Centerville ,Mass . 02632
Owner. Estate Of Esthe°r Hirsch
Date of Inspection 2/2 3/9 6 e
Check if the following have been done: `
je"Pumping information was requested of the owner,occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
-f/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.
it/ The system does not receive non-sanitary or industrial waste flow
ZThe site was inspected for signs of breakout.
ZAll system components,eluding 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 baMes 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 existing information or
approximated by non-intrusive methods.
Z- 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
LV X4A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
P` tTC
SYSTF—M ::;FORMATION
PropertyAddresa: 125 Lakeside Drive East Centerville ,Mass . 02632
Owner. Estate Of Esther Hirsch
Date of InspeotIon:2/2 3/9 6.
FLOW CONDITIONS
RESIDENTIAL: s
Design Slow: �1_ - na jrr-d a
Number of bedrooms•
Number of current residents:0
Garbage grinder(yes or no): 1 _
Laundry connected to system(yes or no):
Seasonal use(yea or no):46
Water meter readings, if available: 1 �y' JI�Q�Q �l�� h��5 — j��•�'II�A Q°-)'`C�'�'ti�
Last date of occupancy:144)k
COMMERCIAL/I ND U S TRIAL:
Type of establishment: 4:6
Design flow:_ALd__gallons/day
Grease trap present: (yes or no)�
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)AM
Water meter readings, if available:_
Last date of occupancy: +1
OTHER (Describe)
Last date of occupancy:_
GENERAL INVFORMATION
PUMPING RECORDS and source of information: /
r0A1A)7px1 ,4n;r.9 19"o q/ E S") .�•i-c�,
System pumped as part of inspection: (yes or no)_4__ e-3S iel' S Uty
If yea,volume pumped:eons
Reason for pumping:
TYPE OF SYSTEM
40 Septic tank/distribution box/soil absorption system
_ Single ceaspool9
Overflow cesspool;)
410 Privy
-- Shared system(yea or o) (if y attach previous inspection
L Other(explain) �1
APPROXIMATE AGE of all components, date installed(if known) and source of information: b
Sewage odors detected when arriving at the site: (yes or no)
1 '
(revised 11/03/95) 6
f
SUBSURFACE SEWAGE D19"T. 9YSTEM INSPECTION FORM
' I
SYSTEM INFO;. . _..:iON (oontlnued) i
property Address: 125 Lakeside Drive East Centerville ,Mass . 02632
Owner. Estate Of Esther Hirsch
Date of Inspection: 2/2 3/9 6
SEMQ TANKS 44Y, ' I
(locate on site plaW s
Depth below grade:
Material of con striction:40poncreto_metal_,FRP other(e.-I,;-)
Dimensions: 44
sludge depth: d.'
Distance from top of sludge to bottom of outlet tee or baffle: j
scum thickness: )I i4 II
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:,+ A
Comments:
(recommendation for pumping,condition of inlet and outlet tees or h 11-R, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.)'
i
I
GREASE TRAPaAdkG
(locate on site plan)
Depth below grade:
Material of construction;Vi _metal_FRP other(explain)
Al"Y1
Dimensions: N
Scum thickness: a,6
Distance from top of scum to top of outlet tee or baffle: 'J'&
Distance from bottom of scum to bottom of outlet tee or baffler_
Comments:
(recommendation for pumping,condition of inlet and outlet tees or ba.Mes, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) MC24
I
. I
i
i
f
(revised 11/03/95) 6
' i
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddrms: 125 Lakeside Drive East Centerville ,Mass . 02632
Owner. Estate Of Esther Hirsch 1
Date of Inspeotlon: 2/2 3/9 6
TIGHT OR HOLDING TANK:/�WC e ,
(locate on site plea) e '
Depth below grads.-A29-
Material of construction concrete metal_FRP_other(explain)
A
A9
Dimensions-
Capacity: ns
Design flow: ons/day
Alarm level: !I�
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:—t/�Ne-
(locate on site plan)
Depth of liquid level above outlet invert: ��•�
Comments:
(note if level and distn'bution is equal,evidence of solids carryover, evidence of leakage into or out of box,etc.)
VA C rYJ ryl N"i1JrS
PUMP CHAMBER—Idk*G '
(locate on site plan)
Pumps in working orden(yes or no)_ZZ�
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
(revised•11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTL'.! I'M01";%LI'I'ION (oontinued)
PropertyAddresa: 125 Lakeside Drive East Centerville ,Mass . 02632
Owner.. Estate Of Esther Hirsch
Date of Lnrpeotion: 2/2 3/9 6
SOIL ABSORPTION SYSTEM (SAS}-_
(locate on site plan,if possible;excavation not requiri,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type; ..
leaching pits,number.Q,
galleries,nnumber_.Q
leaching trenches,number,length:
leaching fields,number,dimensions:
overnow cesspool,number.,_„,
Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,ete.)
Lnam3rsand to sand & r v .1 ;no signs of hvdraulic failure or pon ink,
Al l Ire oat.at.; nn i c normal ('PGGnnn1S are dray an(3 strii(,.t ira114r 9niind No
rya-��s a-�e �aee•r�e� at this time
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: VR V
Depth of solids Dyer.
Depth of scum layer
Dimensions of oesapool: /xl
Material-of construction: e;
Indication of groundwater: /U11fU ^�
inflow(cesspool must be pumped as part of inspection)_ �/
Comments:(note condition of so' e' of hydraulic failure, level of ponding, condition of vegetation,etc.)
Loam sand to sand & gravel ;No signs of hydraulic failure or ponding.
gll vegetation is normal . Cesspools are s ruc ura y soun o repairs
are needed at this time .
PRIVY.
(locate on site plan) ,
Material-of oo /1_W Dimensions i
Depth of solids: L
Commtat(note coonndttion o soii,signs of hydraulic failure, cf p--riLl ng, condition of vegetation,etc.)
(revised 11/03195)• 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 125 Lakeside Drive East Centerville ,Mass . 02632
Owner. Estate Of Esther Hirsch
Date of Inspection: 2/2 3/9 6
Yi
SKETCH OF SEWAGE DISPOSAL SYSTEM: •
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
fv'it-tC/Z
G
O
�/q
i
DEPTH TO GROUNDWATER
Depth to groundwater.�r feet
method of n or�approsunatio�r
/d O' J� Z
(revised 11/03/95) 9
O
rrnrr rrtf•r�.•rr-te+rr.—:-i—r_--r..r...r.r.:-:r.-rr-rr:.r-r.r.—err.:z:*.—rr:=r..—. _ ._. ._ ... _.. ._.. . .-..�y.,, _... a-:-arc=.r�•r..—r•-.rrrr-.-•..-.•.r-..�:
TOWN OF Barnstable IlOARD OF HEALTH
SUBSURFACE SEWAGE? DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
�/ �••••C[•{-T••.-:'T-T.tt.:••,��S.T.r�n•n:r:.:.T.�1r.T•-t'f•t.::.��T�T�T.�-TR.T.T .... _ .- ,_ i1TrrTT•..:rrr•T•` r•�.
._... .... r_•—rx-r—rx .zr.�r.•rna-nrir. ..
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 125—Lakes4_de Dpive East Gent.erville -Mass 0 632
ASSESSORS MAP , BLOCK AND PARCEL #
r
OWNER' s NAME Estate Of ;athur Hirsch
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr..
COMPANY NAME J.P.Macomber & Son Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State Lip
—
COMPANY TELEPHONE ( ) - FAX
`
i R3Ci iti S-TC Crt.C.iT_.508 72 3338
--1-�._- -
CERTIFICATION STATEMENT ro
I certify that I have personally inspected the sewage disposaj system at
this address and that the information reported is true, accurate , and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
XXX'XXXX Sys teui PASSED
Tile inspection Yihich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 - 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 , 30.3 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature /. �%/lC?l Date2/27/96
.J% One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the 130ARD OF HEAL1`it.
* If the inspection FAILED, th'e owner or.1.operator shall u
within one year of the date of the inspection, unless allowed dortrequiredm
otherwise as provided in 310 chIR 16 . 305 ,
THE COMMONWEALTH OF MA.SSA.HUSETTS
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 S SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June S. 1995
r Acting Director of the • ion of Water Pollution Control'
i