HomeMy WebLinkAbout0032 LINDEN AVENUE - Health 32 Linden Avenue
Centerville P
A = 208 016
TOWN OF BARNSTABLE
LOCATION Z t-„�c��° L L SEWAGE# 2LL]-C L(Z
VILLAGE Le rOmr v M Z ASSESSOR'S MAP&PARCEL ! ►Go�Zy�I P c -IG
INSTALLERS NAME&PHONE NO. '771 -5Z�Ay
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) f-0,9 C/,y , I (size)
NO.OF BEDROOMS �{
OWNER /nc� , /
PERMIT DATE: '1-7�-'7 COMPLIANCE DATE: 9- �
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 any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
Al- 15
Al-`Lt' b
bli-
No. aoo l —'OV ,3, Fee 1i�U�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH,DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0[pplitation for �Digogal �&pgtem Cow5truction Verna
Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) ❑ Complete System U Individual Components
Location Address or Lott No. 1-.2 t `1-'e— Owner's Name,Address,and Tel.No.///ri`-7 11r<f �1
12
Assessor's Map/Parcel —1O f }) y b��y`G���- C-`t+�✓/�11�9 sm7/
Installer's Name,Address,and Tel.No. � '�/�!�`74 Designer's Name,Address and Tel.No. (J
Ors- /-� �� 9J9 �., �t
s oss-/J 4 8q��o �/
Type of Building: 41
Dwelling No.of Bedrooms Lot Size l f- ?'>f— sq. ft. Garbage Grinder (4-
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
�71 G
Design Flow(min.required) /yam, gpd Design flow provided .9 i`�' Y6 j gpd
Plan Date J'a', /2 Number of sheets / Revision Date
Title 5— S/;-t �°�Ga O �� �.r.J+., �•�-c �a�.�
Size of Septic Tank /SDp G,61 :14VA,1 Type of S.A.S. Gts�n 14e.l, j y-ad C.(
Description of Soil ��i.� �rt�
e �h caw
Nature of Repairs or Alterations(Answer hen applicable) AcJcs /j ;ra/� Cam[ Z 4C
S�S Ta .1wc�rSJ e L.� CtG/7` J� Gt � C�rsrJv't
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 of ljealth.
Si Cled , Date �/ � .Application Approved by Date c .7
Application Disapproved by: Date
for the following reasons
Permit No.__ —" 0 Date Issued
ti
Fee
No. goo
! l
THE COMMONWEALTH OF MASS'ACM'1USETTS Entered in computer:
PUBLIC HEALTI�DIVISION -TOWN OF BARNSTA4BLE, MASSACHUSETTS Yes
ZIppricatiott for Mi2;po!5a1 *pgtem Cott.5tructiott Permit
Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) ❑Complete System L Individual Components
Location Address or Lot No.3.2 Owner's Name,Address,and Tel.No,/l/4'7 ko h/ A
Assessor's Map/Parcel
l 512)t-`77? %S` ,
Installer's Name,Address,and Tel.No./-;11 �>� r��ti+I DGr�Designer's Name,Address and Tel.No. J
Type of Building:
'Dwelling No.of Bedrooms ! Lot Size l3` Y/f sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow min.required) 1144 d Design flow provided L G
g ( q ) gpd g P _ � �/lo/ gpd
Plan DateTa', /`f 2e6l-, Number of sheets f Revision Date
Title 5- S �s ��Gi+7 G ," 32 !rh J, 4- �.,�-�. �/f ,
Size of Septic Tank I5Dp G4/ Type of S.A.S.Cx,s/%7, sob 4 C
Description of Soil ,),�� ���-� ✓
Nature
of Repairs or Alterations(Answer/when applicable) c�c! // f�1a �c �.-y< �y�jc„�,.,1,_ /0-
�(jC�17��/h'f•// � �/+GJru�.+•. � � S�`�sh hJ ��Gt sSJ r C /"��//-7 � �' /� I/lcli�,PLrr'1 .
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 of ealth.
Si ned '_ Date Z le�2--
,7�
Application Approved by Date G} 7
- Application Disapproved by: Date
for the following reasons
Permit No._5 dT Date Issued
THE COMMONWEALTH OF MASSACHUSETTS '
BARNSTABLE, MASSACHUSETTS
Certificate of Compliattce
+ (�THIS IS TO CERTIFY,that the On-site/Sewage/Disposal System Constructed ( ) Repaired ( ) Upgraded
Abandoned( )by ;L,r����� L!�,✓J yr,lr y�,�•✓
tat 3� �10 Z, 1*111< /�,��.rvr li�i has been constructed in accordance /
with the p visi//ons of Title 5 and the for Disposal System Construction Permit No. "�0 7' `1oZ dated o� /7
Installerio,;1 O/ , Designer //r k-t,:u�v, r".r
#bedrooms Approved design flow 4,rl,4,,�/v / / gpd
The issuance of this permit shall not lire construed as a guarantee that the system will fu ct on as esi ne .
Date 1 Inspector
————————————————————————————————————————r————
No. —��� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
&5po�al *p9tem Cott$tructiott Permit
Permission is hereby granted to Construct ( ) Repair `( ) Upgrade (1-j Abandon ( )
System located at 3,2 ZAIC4.7
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this p i�.
Date a � e7 Approved
V
i
Town of Barnstable.
Regulatory Services
Thomas F. Geiler,Director
NAM Public Health Division
art' Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 07 Sewage Permit# 6?&Z J. G/.'-- Assessor's Map\Parcel
�1 n
Designer: Installer: 0
Address: l Address: yr G �✓��,�.,
On was issued a permit to install a
(date) (installer)
septic system at 3;\ L I n),e, 4U6 based on a design drawn by
(address)
f4,k dated �� 7
signer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
H OF 4q
ARNE H. oyGN
-- �
(Insta. �s s Signature) o OJALA
CIVIL
No. 30792
��oSSGISTE
0 � .
.(Des igner's Signa re) (Affix Desi� e p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
COMMONWEALTH OF MASSACHUSETTS
~ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
A�
t
`W
VeW
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 32 Linden Avenue
Centerville MA .
Owner's Name: Mary Kay Heath
Owner's Address: 8300 Chivalry Road
Annandale VA 22003-1338 ��
Date of Inspection: November 7,2006 Job#06-276 I ^�
Name of Inspector: PATRICK M.O'CONNELL �_ a
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779 — =
cry
v
CERTIFICATION STATEMENT '
I certify that I have personally inspected the sewage disposal system at this address and that the informa ion reported r--
below is true,accurate and complete as of the time of the inspection.The inspection was performed base on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: `��`c9 ^aettrri
J1,!O
_X_ Passes �o���P� • F� . S���.�
__ Conditionally Passes r '•may
__ Needs Further Evaluation by the Local Approving Authority T N
Fails
-- NECK
Inspector's Signaturer ►'n Date: 11/7/06
r /?T�Fi�• 02�.�
//iF5/NSPEG;����`��
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healt�i di I till,
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: Leaching system has no standing water or evidence of saturation.System designed for
three bedrooms and house Has four bedroo-rsi�*,
****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.
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D
A. System Passes:
_XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
— —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
—X— Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X Any portion of a cesspool or privy is within a Zone 1 of a public well.
— _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
— _X_ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
— _ 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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D'above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
— _X_ Has the system received normal flows in the previous two week period?
_ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X_ _ Were as built plans of the system obtained and examined?(1f.they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out
_X_ — Were all system components,excluding the SAS,located on site?
_X_ — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the bafflers or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
_X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
_X_ — Existing information. For example,a plan at the Board of Health.
_X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIA:L INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Two years total: 18,000 gal.=24 gpd.
Sump pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:.
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
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):
Water meter readings., if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: None
Source of information:
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_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:
Compliance date: 7/28/95
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 2'
Materials of construction:_cast iron X_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: XX (locate on site plan)
Depth below grade: 2'
Material of construction:_X_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: 10.5'long x 5.8'wide—1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees are intact and clear,liquid level at bottom of outlet invert
GREASE TRAP: No (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain).
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: dal Ions
Design Flow: gallons/day
Alarm present(yes or,no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches etc.):
DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
Liquid level at bottom of both outlet nines
PUMP CHAMBER: No (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 appurtenances,etc.):
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:.32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
_X_leaching chambers,number: 8 Infiltrators
leaching galleries,number:
leaching trenches,number, length:
leaching 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.): Installed insmection port as hart of inspection found no standing water or evidence of surcharge
CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
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.
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Page 1 I of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 Linden Ave,Centerville
Owner: Mary Kay Heath
Date of Inspection: November 7,2006
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 25 feet
Please indicate(check))all methods used to determine the g
high round 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)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el.20 and topo map shows property at el.50.
it
RE+CE IED
Z S 3 NOV 2 2004
TOWN OF BARNSTABLE
HEALTH DEPT.
DATE 10128104
PROPERTY ADDRESS 32 L.iaden Qve.
(SAP 20�
PARCEL
02632 LOT
On the above date, the.deptic system at the address above was
Inspected.
This system consists of the following:
1. 1-1500 gaiion 3ept.ic tank
2.- I-d.ist2-igut.ion fox.,
3. 1-1000 gaiion eeach.ing p.it.•
4. 8-.in�iit,zato/t.6 with 2'htone on .3 idez 2%' on endh.
Based on inspection, I certify the following conditions:
5.�7h.i.z .is a t.i.tee /.ive zept.ic zyztem
6. The 3ept.ic .system .i.6 .in /2a0/2e2 wo2k.ing o2de2 at the /2�cehent time.
7. The ieach.ing pit and .in/.ietnato/ta ate d&y. ,
SIGNATURE
Name: Robert A. Paolini
Company: Joseph P. Macomber & Son Inc .
Address: P. O. Box 66
Centerville, Mass 02632
Phone: 508-775-3338 or 508-775-6412
JOSEPH P. MACOMBER & SO N, INC..
Tan ks-Cesspools-Leachf ields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
o �
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRerNM'ENTAL AFFAIRS
ul; DEPARTMENT OFE+NVIRONMENTAI,IPROTMION
A TITLE 5
OFFICIAL INSPECTION FORM—.NOT-FORVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART-A
CERTIFICATION
Property Address: .32 Linden Rve
Cent e2v i U, . Mn
Owner's Name: lame.a heath
Owner's Address: 3 a m e
Date of Inspection: 10128104
Name of Inspector: (please print) i2o ke2.t u o e cni
Company Name: n Zc.
Mailing Address:
Cgn 22v a •02632
Telephone Number: 5 0 8—7 7 :3 3 3 8
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system.at this address and that the reported
ime of the inspection.The inspection-was performed based on.my
below is true;accurate and complete as of the t
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to-Section.15:340.of Title 5(316 C•MR i5:000). The system:
XXX Passes
-Conditionally Passes
Needs Further Evaluation,by the Local Approving Authority
ail
Inspectors Signature. A .•' Dater/V� C�
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,shazed system or has a design flow of 10,000
gpd or greater, the inspector and the system own er.shall.submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owmi and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
""This report only describes conditions at the time of inspectiote 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.
r;.le c 7"L"Pr+4;nn Fnrm 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NO.T FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:3 2 Lindeq 4 v e
en envy e Na
Owner• aame_3 Heath
Date of Inspection: 7 O/2 8/0 4
Inspection Summary: Chick A,B;C,D or.E/AL_WAVSycomplete.all of Section
A. System Passes:
NO I have not found any information which indie'ates`thatany of the failure criteria described in 310 CMR
15.303.or in 310 CMR 15.304 exist.,Any failure criteria not evaluated are indicated below.
Comments:
septic burtem i.6 LR yn,,pnon wan klny nadaa of ihn nnn ennf' f
B. System Conditionally Passes:
NO 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.
r
Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
NO - The septic tank is metal and over 20 years old*or the septic tank(whether meta l.or not)is.structurally
unsound,exhibits substantial.infiltration or exfiltration.or tank failure is Imminent System will pass inspection if the
existing tank is replaced with'a complying septic tank-as approved by the:Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken.pipe(s)are replaced. .
obstruction is removed
distribution box is leveled or replaced
ND explain:
NO The system required pumping-more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL MP-ECTION FORM-NOT!OR VOLUNTARY ASSESSMENTS
SUBStW ACE SEWAGE�SFOSAL SYSTEM INSPECTION FORM
PART A . .
CERTIFICAIION•(6ontinued)
Property Address:3 Z Linden Ave.
Cen.te2v �i
Owner:IcLme13 Keath
Date of Inspection: 0 28-704
C. Further Evaluation-is.Required by the Board of Health:
NO Conditions.exist whichxequire ftnther.•evaluation•by•theBoard:ofHealth;in•order.to;determine ifthe system
is failing to protect public,health,.safety or the environment.
1. System will;pass unless Board of Health determinesdii accordance with 310.CMR 15:303(1)(b)that the
system is-not functioning in.a•mariner which-will.protect public health,safety=0•tbe..environment:
na Cesspool or privy is withinr50 feet of azurface water
2a Cesspool or privy is within 50.feet of-a bordering vegetated wetland or a salt marsh.
2. System wi
ll fail unless the Board-of Health{and Public Water Supplier;•if any),determines:that the
system is functioning in a manner that protects thepttblic Health,safety and environment:
La The system has aseptic tank and soil absorption system{SA•S).:and the SAS is within 100 fe.et.ofa
surface water supply or.-tributary to a•surface water supply.
no The system has-a.septic tank and SAS and thefSAS is�within a Zone 1 of a-public watensupply.
n o The system has aseptic tank and.SAS and the-SAS is within-.50 feet of a private water supply well.
n o The system has a septic tank and SAS and the-SAS is less than 100 feet..but 50 feet or.niore from a
private water supply well" Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,,for coliform
bacteria and volatile organic corhpounds indicates that the well is free from-pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other
failure criteria are triggered.'A copy of the analysis must be attached to-this form.
3. Other:
Page 4 of 11
OFFICIAL,INSPECTION FORM-NOT'FOR;VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:3 2 L.i n d e n 4 v e
Cente2y.iiie Ma 02632
Owner: 7amez Keath
Date of Inspection:
1
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to.each.of the:following..for all;inspections:
Yes No
_ . X Backup of sewage.:into-faAity.:or system component due to overloaded.or clogged SAS.or cesspool
X '.Discharge:or-ponding of effluent to the surface of the;ground or..surface:waters due to an-overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool '
X Liquid depth in-cesspool is less than.6"below invert or available volume is less than May flow
X Required pumping more-than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of.the SAS;cesspool or privy is below high ground water elevation.
Ahy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ X Any portion.:of a cesspooFor privy is within a-Zone I of a:public.well..
7— Any portion of a cesspool or privy is within.50 feet of a private water supply well.
X Any portion of a,cesspool orprivy 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 coliform bacteria and volatile organic.compounds
indicates:that the well is.free from pollutioq:fr..omAbatfacility 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 niust be attached.to this forte.]
NO (Yes/No)The system fails.I have determined that one or.more,ofthe:above.failure:criteria exist as
described in 310 CNM 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:systiem must.serve.a.facility,with a design flow of 10100.0 gpd to 15,000.
gpd•
You must indicate either"yes"or"no"to.each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the-system is within 400 feet of a surface drinking water supply
X the syste m.is within 200 feet of a tributary,to a surface drinking water supply
_ X. the:system is located in a nitrogen sensitive area Qnterim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional.office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS
gjUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:32 Linden Rve
Centon»apio Na
owner: lame-6 Reath1
Date of Inspection: " ..74)128104
Check if the following have been done You must indicate"yes"or"no"as to each.of the following:
Yes No -� f
X Pumping information was provided by the Owner,occupant, or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as-part of this inspection?
X Were as built plans of the system'obtained and examined?(If they were not available hote as N/A)
X Was the facility.or•dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
X • Were all system components,oxcludung the SAS;located on site
X _ Were the septic tank manholes uncovered;,Dpened,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?
X — Was.the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS).on the site.has been detern�itted based on:
Yes no
X Existing information:For example,a plan at the Board of.Health.
_ X Determined in the field(if any of the failure criteria related to Part C is at issue approximetionof distance
is unacceptable)[310 CMR 15.302(3)(b)'J
• 5
Page 6 of 11
OFFICIAL>rNSPECTIO°A1:IFORK-NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE ST'-WAGE I)ISAOSAJ,:;:SYSTUM>INSPEETION FORM
PART.0
SYSTEM INFORMATION
Property Address: 32 Lir�cl n aye
en e,zv.iiie Na
Owneraame.e Heath
Date of Inspection:10/2 8.1_(14_ ,
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):::, .4.. Number of bedrooms(actual):4
DESIGN`:flow based on 3l0 C1Vil 15. 03(for example:1 I0 gpd z#oi'bedrooms)4 4
Number of current residents:.:2
Does•residence have a garbage grinder(yes or no):_
Is laundry on a separate sewage.system.(yes or.no):.� [if yes separa te inspection required]
Laundry system inspected(yes or no): ri o
Seasonal use?(yes or no): no 20.02=21,. 000gaiioaz G.,�.,D.- 57. 53
Water meter readings,if available(last 2 years usage(gpd)):2 0 0 3=14. 0 0 0 as e.P o n [7. =3 8. 3 5
Sump pum (yes or no)n o
Last date of occupancy: a 2 e,3 e n t
COMMERCIALIJ DUSTRIAL
Type of estab : ;aat: NA
Design flow '"', on 310 CMR 15.203)%N,4 apd
Basis.of d�igo#1 ow(seats/persons/sgft,etc.):, NA
Grease trappresent(yes or no):
Industrial waste holding tank present•(yes or no):I& �
Non-sanitary waste discharged to the Title 5 system-(yes or no):_44
Water-meter readings,if available: A14
Last date of occupancy/use: Aug
OTHER(describe):.
GENERAL INFORMATION
Pumping Records
Source of information: 9/2 3/9 7 P u m I2 may M a r n m f e 2
Was system pumped as part of the inspection(yes or no): n o
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for.p..=. ping:
TYPE OF SYSTEM ,
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
— ivy
_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
ob_tained 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:
In.6taiiecl 7126195 ! Nacom aa gvnmif #95- 1AM
Were sewage odors detected when arriving at.the site(yes or no): n oo
6 -
Page 7 of 11 .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM
INSPECT
ION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address 32 L-i.nden Ave
e T ne2v.c e a
Owner:17ames Heath
Date of Inspection: 1 0/2 8/0 4
BUILDING SEWER(locate on site plan)
Depth below grade:7 9"
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supplyyej or suction line: 0 0 f
Comments(on condition of joints,venting,evidence of leaks e,etc.):
_lo.int6' appea.¢ tight. �3 No ign.6 Q� �eakage., Vented
ih¢ough hou.6e vent.
SEPTIC TANK ee-3 (locate on site plaT)5 0 0 ga i e o n tank.-
Depth below grade:1 2"
Material of construction:X 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:7 0' 6" X 5' 8" X 5 ' 7"
Sludge depth: i 2 a c e
Distance from top of.sludge to bottom of outlet tee or baffle:
Scum thickness:t a a c e
Distance from top of scum to top of outlet tee or baffle:t/c a c e
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined;m e a,3 u 2 e d
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Pump nk . eve2 2 ea2-s. et t eeA ate .in /a Pace.-
ank ins zt2uctunaih4/ zound no zignz o ea A,ye
GREASE TRAP:N Q (locate on site plan)
Depth below grade:N,4
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain): 41ri
Dimensions: N A
Scum thickness: N 4
Distance from top of scum to top of outlet tee or baffle:N A
Distance from bottom of scum to bottom of outlet tee or-baffle: Na
Date of last NR
pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
1�/Leaze t2ap .iz not /22ezent. .
Title 7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS
S0,VVRVW:A,CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:32 Linden 4ve
en e2vii e a U2632
Owner;garrcez flea.th '
Date of I•uspection; 10/28/•04
T.
TIGHT or YIO'I,DING TANK: NO (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:NA
Materiat of construction: concrete metal fiberglass___polyethylene other(explain):
NA
Dimensions: NA
Capacity: NR gallons
Design Flow: N,4 gallons/day
Alarm present(yes or no): N4
Alarm level: Alarm in working.order(yes or no):
Dote of last pumping: NA
Comments(condition of alarm and float-switches,etc,):
7igh.t o2 hoCding tarzkz ate not /22e�3en.t.'
DISTRIBUTION BOX: y e-z(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc,):'
Bo'z ha,3 3 iateaaiz., no zignz o/ 30iid ca/"zY ove2.'
No evidence of Leakage.
PUMP CHAMBER: NO (locate on sife.plan)
Pumps in working order(yes or.no): NA
Alarms in working order(yes or no):_.
Comments(note condition of pump chamber*condition of pumps and appurtenances, etc.):
ohnm0oa nnf �Z'AQpf - -
8 .
Page 9 of 11
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
f . SUBSURFACE SEWAGE DISPOSAL SYSTEM INNSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 Linden 4 ve
en e2vz e. Na
Owner•. lame-3 ea
Date of Inspection: 70128104
x w
SOIL ABSORPTION SYSTEM(SAS):_.(locate on site plan,excavation not-required)
If SAS not located explain why:
Located bee /2aje 10
Type
X leaching pits,number:
leaching chambers,number:
leachinggalleries,number:
leaching trenches,number,length:
X leaching fields,number,dimensions: 8 .i n e i e t 2 a t o 2-6 3 0'X 7'
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.):
oa fo me -ium Annrl No AignA oe enitulze an Panr/iny
CESSPOOLS: NO (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
indication of groundwater.inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
C
PRIVY: NO (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids: -
onding,condition of vegetation,etc.):
Comments(note condition of soil,signs of hydraulic failure,level of p
Pltivy -iz not ne.6ent
9 .
Page 10 of 11
.0MC A.L INSPF.CT''ION'FORM—,NOT FORVOLUNTA Y ASSESSMENTS
S SI�F:RA:CE'SEWAGE:DISI?.QSAL SYSTEM,.INSPECTION:FORM ,—
PART C"
SYSTEM INFOR ATI.ON(Ontihued)'
Property. Address: 32 Linden—Ave
NZ Cent e2v.ii ie Na 02632
ti /AO + jy
SKETCH OF SEWAGE.DISPOSA,L SYSTEM
Provide a sketch of the sewage disposal system inclu ing tie to at.least two jermanent r ference lan ..arks or
benchmarks.Locate all wells within 100 feet.Locate. he blic water supply enters. building.
y &.4
F:
ypu ....
10
Page 11 of 11
FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS FORM SMENTS
O�, .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 e_Lin d._�e Ma
Owner�amez flea
Date of Inspection: 0 1 2 8/U:4 ,,,
SITE EXAM
Slope
Surface water
Check cellar.
Shallow wells s
t:
Estimated depth to ground water 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 rMviewed:
Observed site(abutting property/observation hole within 150 feet of.SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database:explain:
You must describe how you established the high ground water elevation:
used;Gahert & Miller model 12 1
used•USGS observation we
11
used- Technical bull — —
wa er a eva ions.
Leaching
Pit Beet
Groundwater: feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per JiLinsptel Method
Therefore,the.vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet.
:,•,mnnrf—rtt•rar—•rrarnrmrrr+n�crs•+inasrrrrrarrnrr:rssrrt+�**+•r*+*+�T^ "Ply
a f
F
'I'UNN OF 1; ! 130ARD OF 11EALT11
S1)1)SU4FACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CE{l'CIFICATIUN
Irsfnts>Ttfrrn+rrtfa•.rtrrr•r.•-tr•_!.�
••••f!:•t-T•:•::f��.tlf.�.T.TTT.•.t'R:TTI TRT.'CM1T.1'SR'•�1r-!•'T T.1tT{C"i STR1RrT�T�n� W4V"
—TYPE OR PRINT CLEARLY—
PROPERTY INSPECTED
STREET ADDRESS 32 Linden Ave Cente2viiie Na
208-016
ASSESSORS MAP , IILOgK AND PARCEL # ,
jam ez Heath
OwNER' s NAME
PART D - CERTIFICATION
NAME OF INSPECTOR
COMPANY NAMEJoseph P. Macomber & ''ion
COMPANY ADDRESS Box 66 Cent Town or city state LIP
Street
COMPANY TELEPHONE ( 508 } 775 - 3338 FAX 508 -} 790 1 578
,R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that t)i.e information reported i•s true , accurate, and
omplete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my 't'raining and experience in the proper function and maintenance of on
sitesewage disposal systems .
Check one:
XXXX gystesi 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 which I have con treted has found that the system fails to
Protect the public health and the environment in accordance with Title
6 , 310 CMR 15 , 303 , and as specifically noted on PART�C -„FAILURE
CRITERIA of this ' nspecti form .
Inspector Signature Date /®
e copy of this certification must be provided to the OWNER, the BUYER
On
where applicable ) and the BOARD OF HEALTH .
t,.
* If the inspection FAILED, the owner or operator eh.all upgrade ' the system.
within o'ne year of the date of the inspection, unless allowed or requi..red
otherwise as provided in 3.40 CM.R 15 . 306 . partd .doc
i
Town of Barnstable
I AM Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kaufman,MSPH
Wayne Miller,M.D.
May 24, 2004
Mr. James Heath
32 Linden Avenue
Centerville, MA 02648
Dear Mr. Heath,
You are granted a conditional variance to construct an addition to the home in
close proximity to the septic tank at 32 Linden Avenue, Centerville.
The variance granted is as follows:
310 CMR 15.211 (1 . The septic tank will be located four (4) feet away from the
foundation wall, in lieu of the ten (10) feet minimum separation
distance required.
This variance is granted with the following conditions:
• A polyethelene liner shall be properly installed in the ground in
between the septic tank and the new foundation wall.
This variance is granted because the Board is of the opinion that maintaining the
existing septic tank in it's present location along with the installation of a
polyethylene liner should not adversely affect the health or safety of the
occupants in the home.
Sin rely your ,
aynEypiller, M.D.
Chair an
HeatliVariance
TOWN OF BARNSTABLE
LOCATION Lin jQ✓e—
VILLAGE (?,"`tXr L) tf— ASSESSOR'S MAP&PARCEL 4o? D/6
INSqWtq5�NAME&PHONE NO�Gn r i c,k—�� o yt of rr7
SEPTIC TANK CAPACITY f SOD
LEACHING FACILITY:
(type) -4-(size)
NO. OF BEDROOMS
OWNER
PERMIT DATE: DATE: l �1 0Co
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 any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
Unden Ave T
D l;vevay,
25
,4 17
(;kiAWL A OS r
No._Z ore �/�j�}�/� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for Mgw6al *p6tem Construction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. M "40 U4 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel (3A„� �� �QgYk . ,
Installer's Name,Address,and Tel.No. Lsozj J 7 Designer's Name,Address and Tel.No.
Cild 3Jn, rlc
Na ,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Natu a"off or Alteratio s(Answer when applicable) 4 e U
+IDAP
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 Certifi-
cate of Compliance has been issue B 00 a h.
Signed Date / d
Application Approved byq��� Date
Application Disapproved for the following reas
Permit No. Date Issued
It
U6g
HE COMMONWEALTH OF MASSACHUSETTS
6 w BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CEJ�IFY, that the O site Sewa a Disposal aSstern Constructed( )Repaired ( )Upgraded( )
Abandoned >
at s ha constructed in accordance
with the provisions of Title 5 and the for Disposal,System Construction Permit N dated
Installer l�n 6P_N+ Pma LL Q Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
����;'*,... -r-� �.s.4 �. .,-.. ..�.. ...,, ..-"•s' _.i .��.v8r�,�.T.-._."N.._f,. ... ..r ^h'^'sb1.r-✓'r'*.i.rr.t sr,(a s` .. -- i...y .�••..:'.er"-s.:, .p-.. .. .. i ,, ,:. r.<, .__ .`. ...r
No. ' _ l)v o- Fee
i' THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
i
;t 01pprication for Miopozaf �&potem Con.5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot 3� ss ne;'nAd and Tel.No.
Assessor's Map/Parcel � JQa7i��� A ITY��JV`� L
Inst le's Name,A dre s +d a No. �� Designer's Name,Address and Tel.No.
.Flacon-1 oe�- 11 Xinc
zcpk 40(0 (Qrc"IL
i
Type of Building:
Dwelling No.of Bedrooms .Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
r Size of Septic Tank Type of S.A.S.
Description of Soil
_ s
s
Natu a of Repairs or Alteratio s(An wer when applicable) zn4a 'O� e LXl e- Ln qro U r
#��wP—M rC l�
IIXL� f 1 GUJ Form (wr1 Lkla)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and rpaintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued-, its
d BB, d H alth, #
Signe 1 11 ` %' l"' Date
Application Approved by r�� U l� %!�/ Date
Application Disapproved for the following reas n
� v
Permit No Date Issued
HE COMMONWEALTH OF MASSACHUSETTS
. 6Ej BARNSTABLE, MASSACHUSETTS
Certificate of Compliance �
THIS IS TO CER- IFY t at the On-site Sewage Disposal Ustem Constructed( ),Repaired ( )Upgraded( )
Abandoned , )by > ,5,6n A-ri C
at ` — ,x • U�- + l/ bden constructed in accordance
with the pr-visions of Tid 5 ands the for Disposal System Construction Permit N dated
Installer RoaQ UV t 1 Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as'designed.'
Date Inspector
No. Fee
�a
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
3igpozal *pztem Construction Permit
Permission is hereb ranted to onstruct, )Repair( Upgr e( bandon( )
Alm Gn. tit
System located at ��� l 1
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construct* �t b- ompleted within three years of the date of this :er;mi .
Date:_� �t/ Approved by
TOWN OF BARNSTABLE DATE:
FEE:
' '"MAW. ` 2004 APR 12 PM 2: 50
t�
es EMC. BY
s� �
Town of Barnstable,,. .. DATE:
Ba9bf Health
200v Mairt-Street,HyamisMA-02601
Office: 50946246a4 Susm.G.:Rask R.S.
FAX. 508-7-90-6304 Sumnee.Kaufman:1VFS.P_H.
Wayne A.Miller,M.D.
VAPIANCE:PJ-OUF,&T-FARM
LOCATION
Property Address: 3 Z LI&DR.N A'fz CE jl 7 /Z.'it L L l-?L , MA 0 2 6 3 2-
Assessor's Map and.Parcel Number:..AIAA LO — 6 Size of Late D. 36 ACA iZ
Wetlands-Within-300 Ft. Yes Business Name:
No_ Subdivision Name:
APPLIcANrs=NAME:-J,g AA CZ S a, H 321,4T. Phone 70 3 I i -513'70
Did the owner of the property authorize yoti to represent.him:or.her? Yes. No.
PROPERTY OWNER'S NAME_ CONTACT PERSON
Name:-JAr^115 71, }-f' A I_^ Name: AAA A-t etonRMr RX O
Aar-ar�i7r��)Z
Address: 3 00 Q 144 R ) II A 2Z d 0 3 Address:
Phone: 7 U 3 /61 9 -Y 3 I o Phone:
�Q
VARIANCE FROM-REGfiII ArION It t.gcg} REASON-FOR.VARIANCE(May attach if mote.spac€-needed)
/S, Zl1 SLAB Foot-DP?lVe--� U Aq-nA.(- Hou,5E (G927 AM/L6-
o=Co&- S13-P7e— TAr-(C - /c7 G(ZrtAT- 2opk- ON lzr.A2 AND IZ r -
01 L-D)A,fr Ct 006-- 7a 3 iF, t" c enrGY,1AA4F_
NATURE OF WORK House:Addition-IK House-Renovation Z Repair of Failed Septic Systm 0
Checkl t(to be completed by qa ce.stal)tperson receiving variance request:appucatioo
_ Four-(4)copies of the completed variance request form-
_ F6ur(4)copies.of cugiiff plan-sttbmit[ed(e.g..septic-systemptans)
_ Four(4)copies of labeled dimensional floor plans submitted(e.g_house plans or restaurant kitchen plans)=
Signed letter stating that the property owner-authorized you to represent him/her for this request
Applicant understands that the abutters,must be notified by certified mail at:least-tendays prior to meeting date at applicant's.expense
(for Tide V and/or toed sewage regulation variances only)
_ full menu submitted(for grease trap-variance requests only)
_ Variance request application fee.collected-(no fee for lifeguard modification renewals, grease•trap variance renewals [same
owner/leasee.only),outside dining variance.renewals-[same owner/leasee onlyl,and variances to repair failed=sewage.disposaf.sAtems
[only if no expansion to the building proposed]) .
Variance request submitted at least I5 days prior-to-meeting date-
VARLANCI APPROVED Susan G.flask ILS.;Chairman
NOT APPROVED Sumner Kaufman,M S.P.EL
REASON FOP-DISAPPROVAL - Wayne A,Millers KID.
C.\boauments and 9ett-ings\deco3.Ii-k\Local gettinga\-Temporary f.nternet Files\OLI �CV11R$RS�.1)6C
TOWN OF BARNSTABLE
LOCATION 1 tiJth SEWAGE # 9
VMLAGEC'en4eP%/t (( ASSESSOR'S MAP & LOT24:f>
INSTALLER'S NAME&PHONE NO. l-MA' Wm Ar/ Oh 1:(,l C-
SEPTIC TANK CAPACITY /S'o D
LEACHING FACILITY: (type)
NO.OF BEDROOMS q
BUILDER O OWNS
PERMIT DATE: 7 r Z/"�COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�y
�07ut ,
y�
39 //
T
DATE;__
PROPERTY ADDRESS;_•,,---- -------------------
32_Linden Avgnyg_______
Centerv_i l le,,_,IM,j,,_Q�,(, _
On the above date, I Inspected the septic system at the above address.
This system consists of the following;
1 . 1 -1500 gallon septic tank
2. -1 -1000 gallon leaching pit Q ��
3. 8-Infiltrators
4 . 1 -distribbutio bo
Based on my Inspecton, l certify the following condltlonat
5. This is a title five septic system. ( 95 Code )
6. The septic system is in proper working order
at the present time.
7 . The system was upgraded 7/26/95
8 . The leaching pit is presently dry.
SIGN-ATURE: 449
Company: Joae.h_P ,. Hacomber_b Son , Inc .
Address;__Box___66_____________
Centerville ` Ha _02632-0066
Phone:...508 775_)398______—
THIS CERTIFICATION oOeS NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC,
Tinks•Ce&spools•LeichfIsIds
PUmped Z, Instilled
Town Sewer Connections
P.O. sox 6776.333 tery77, 1026g2-0066
I�ECE.
JUN � 12000
N OF BARNSTA3LE
T�WV,F -TH DEPT.
T
y ' COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVE B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CERTIFICATION
Property Addrw: 32 Linden Avenue Name of owner Archie Anthony
Centerville Address of own«:
Dsu of Inspection: 7
rt Naw of kmp*ctor: Joseph P. Macomber Jr.
I am a DEP approved syswn 4tspector pursuant to Section 16.340 of This 5(310 CMR 15.000)
Comp,rryNaime: Joseph P. Macomber & Son, Inc.
Mai'vtg Addr"s: SoxCenterville, Ma. k2632-0066
T@l'ephon@ Numbw: — —
CERT1F11CAT10N STATEMEM
I ctrtiry that I have personally Inspected the #@wage disposal system at this address and that the Information reported befow 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:
l/Passes
_ Conditionally Passes
Needs Further Evalustlon Sy the Local A proving Authority
_ Fails
Inspector s Signature: r: f Data:
The System Inspector all submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wttNn thirty (30) days of
completing this Inspsction. If the system Is a shared system or has a design flow of 10,000 gpd or greater, the Inspector and the system owner
fish submit the report to the appropriate regional office of the Department oK-nvlronmentsd f ortactlon. The original should be sent io Vw
system owner and copies sent to the buyer. If applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 PagtIorll
C� PnM[W on R"kE P,psr
SUMURFACE SEWAGE DISPOSAL SYiTDd IN3KCnON FORM
PART A �. .•
> > CERT JiCATtON (oorslinued) t
Propemr Addr o": 32 Linden Avenue, Centerville
Owr' '. Archie Anthony
D.a or Mup.ct : 6/7/0 0
NSPECMN VU&AMARY: Chock Al B, C, w P.
t A. SYSTEU PAS SES:
I haw not found any Information wNch(ndicatas that any of the f4ure oond)dona doacribod In 310 CMR 14,303 exist. Any talk
utUria not ovaJusted are Ind(calod below,
CO itJ,iFN7 3: '
S. SYSTDJ CONDMONALLY ►ASSES:
•P_ One w more system sompononu s+a dosortbed In the 'CondV"►saa' seodon need to be replaced or ropslrod. The syeta+n. wp
completion of the roplaoement w ropaU, so approved by the board of Health, wW pews.
tndcete yes, no, or not dotermJned(Y, N, ce NO). Ooacr(be baals of dotwnJrwtiwt In all Uutsawes. If 'not dotsrminod', explain why not.
A4 The ►spds tank la metal, urJesa the owner Of opsrstw has provided the system Inspector whh a copy of o Cordllute o
CompUance (attached)1"codnp that the uM wea InataLod wlWn twenty(20) yout pdw to the date of Uw tnap+cvon
the septic tank, whether or not metal,Is stocked, svuettuaUy unsound, shows eubstandai tnlVvadon a erNvedon, w 1
failure Is Imminent. The system wW pass Irupoction If the oxJstinp soptle tank is roplaood whh a complytnp ospdc tans
approved by the $card of Health.
Sewage backup or brookovi or Nph sutio wetor level observed in the dJstrlbutJon box is duo to broken Or Obstrvctad plc
of due to a broken, settiod or unevon dlovibvtion box. The system wW pass IrupootJon If (whtt spprovaJ of the 60aro of
Health),
broken pipe(&) we replaced
obswcdon Is removed
dlovlbudon box is levelled w replaced
The sMsm required pumpinp•mon tttanivur-dmse tiryoarduo%a broWvnw vbsovoted pipo(s). The vyvtsm wV-psar--
Irupocoon If(with opprov.d of the 1oard of Health),
broken plpe(s) we replaced
obstruction Is removed
revised 9/2/98 nceserIt
s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA
PART A
CERTIFICATION (cort*uod)
PropertyAd&*": 32 Linden Avenue, Centerville
Owner: Archie Anthony
Dou of kupection. 6/7/0 0
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
AJ15 Conditions exist which require further evaluation by the Board of Health in order to determins If the system Is WUng to protect the
public health, safety and the environment.
1) SYSTEM Will PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTE)A
IS NOT FUNCTIONING IN A MANNER WH)C)1.WILL.PRQTECT THE PUBLIC HEALTR AND SAFETY AMD THE BC080MiMEAiT
22d Cesspool or privy Is within 60 test of surface water
D Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTDA WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETER&UkES THAT THE SYSTBA IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE BiMONMENT:
The system has a septic tank and soil absorption system(SAS) and the SAS Is within 100 lest of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a pubUc water supply w".
The system has a septic tank and Boll absorption system and the SAS Is within 60 foot of a private water supply wall.
The system has a septic tank and soil absorption system and the SAS Is less than 100 foot but 60 foot or more hom a
private water supply well, unless a well water analysis for collform bacteria and volatile organic compounds Indicates that the
wall Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nlvogen Is equal to or less
than 5 ppm. Method used to determine distance -Ad (approximstion not vaUd)•-
3) OTHER
revised 9/2/98 Page 3of11
i
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A t
CERTIFICATION (cor*wad)
PropwtyAddress: 32 Linden Avenue, Centerville
Own«: Archie Anthony
Date of aapectim: 6/7/0 0
D. SYSTEM FAILS:
You must Indicate either "Yes" or"No" to each of the following:
_�LLL I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this
determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure
Yes No
Backup o+sewage irrt 4ecIH "er-r/etern compone mduego an overloaded ormlagged SAS-orcesspool. j-
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 Jevel p �he distribution bpve�out; inver�du�t9 pn�overloaded or clogged SAS or cesspool.
Liquid depth in leeeepeel Is less than 8' be�loywJinvertt or available volume Is less than 1/2 day flow.
Required pumping more th 4 times in the last year NOT due to clogged or obstructed pipe(*).
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 Isss•than 100 feet but greater then 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.
E. LARGE SYSTEM FAILS:
You must Indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
NThe system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to put
health and safety and the environment because one or more of the following conditions exist:
Yes No/
�( the system Is within 400 test of a surface drinking water supply
the system•Is-whin 200 feet ot+irib+►tery to o wrfaoe drk wq weNr+u'ply
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 upgrade the system in accordance with 310 CMR 16.304(2). Please consult the local region+
office of the Department for further inforgnstion.
I
revised 9/2/98 Page 4orII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B t
CHECKLIST
Property Address: 32 Linden Avenue, Centerville
Owrww: Archie Anthony
Data of Inspection: 6/7/0 0
Check if the following have been done: You must indicate either"Yes" or "No" as to each of the following:
Yes No,f
1/ Pumping Information was provided by the owner, occupant, or Board of Health.
f� None of the systsmcors*oaw►ts hawsiman pusnped4opal-Joasttwo-%voWwaad-tha'aystem hasbwavqsceitiwgwnd 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.
Y _ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or Industrial waste flow.
_ The she was Inspected for signs of breakout.
_ All system components,*=Iuding 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 toss, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
_ Existing Information. For example, 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))
The facility owow land.occupaau,Jf difiwaat frouu=uaw).war&4uavtdad with iaiauzuWoaan*►L pry ar--in:a ^f
SubSurface Disposal Systems.
revised 9/2/98 Page Sof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
PART C
SYSTEM INFORMATION
Property Address: 32 Linden Avenue, Centerville
D1MT1w: Archie Anthony
Dow of kwpoct w: 6/7/0 0
FLOW CONDITIONS
RESIDENTIAL:
Design flow:—j�d_g.p.d./badro m.
Number of bedrooms( sly Number of bedrooms(actual): 'l
Total DESIGN flow � D'�-U
Number of current residents:
Garbage grinder(yes or no):115
Laundry(separate system) (Y44 o no ._; If yea, sopauta.Inspectlon.roqulred
Laundry system Inspectedor not
Seasonal use (yes or.no):
Water meter readings,If av liable (lost two year's usage(gpd): ��'•` ��� �� N
Sump Pump(yes or no):
Last date of occupancy: '�r3'"r�
COMMEACtALIINDUSTRIAL:
Type of establishment AA
Design flow: A ood ( Based.on 16.203)
Basis of deslgn flow
Grease trap present: (yes or no)
Industrial West# Holding Tank present: (yes or no)_a
Non-sanitary waste discharged to the Tide 6 syjtsm: (yes or no).,&
Water meter readings,If ava able: A/�
Last date of occupancy:
OTHER:(Describe) 1
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECOR arise,sourc of,�pfor on•
Alew)
System pumped as port,,off�ol-n-�ection: (yes or-no)" ��((✓✓
If yes, volume pumped: gallons
Reason for pumping:
T
YSTEM
eptic tank/dlatribution box/soil absorption system
ingle cesspool
verflow cesspool
rivy
hared system(yes or no) (If yes, attach previous Inspection records,If any)
IA Technology etc. Attsch copy of up to date operation and maintenance contract
ight Tank NM Copy of DEP Approval
Other �
OXWATE EE of all components, date Inotallod4lf known)-and souraa of4eformation: -•-
S-ow"odors detected when-arriving at the site: (yes or no)_
revised 9/2/98 Page 6ofII
Macomber Customer History Screen 6/7/2000
r
Customer number 54
Company Name `yx3
Customer Name Archie.AnI n,y. � �� '
JobAddress ��den Ave
J o b S to to {
JobZlp 02632 *4 ��
Tel
Fax
Blliing Address
BIIIIngClty
BIIIIngState ...................................................................................................................................
BIIIIngZlp
Notes -
.7/.81.9.5-pump.LP....145aQQ...........9/.1./.9.5.............................................................................................................
...........................................................................................................................................................................................................
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contirsusd)
Prop"Addrsss: 32 Linden Avenue, Centerville
Owrw: ArchleAnthony
Dau of Inspection: 6/7/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade:,
Material of construction: {' test iron Z'40 PVC Alpother(explain)
Distance fro grivate water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of Jaak"o'-etc.)
Joints appear tight No eyident-P of 1PAkAgP
S s
SEPTIC K:z1ae-d917A4,4,05
9 ,
(locate on site plan)
Depth below grade:
Materiel of construction: ncrete"metal/t/dMberglassA)6Polyethylene?&ther(explain)
If tank is motel, list age � Js.aggs.confirmed�bry Certificate of Compliance (Yes/No)
Dimensions.-
Sludge depth:
Distance from top�at.sludge to bottom of outlet tee or baffle
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of tl t t e or baffle:E
How dimensions were determined: .f>S
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level In relation to outlet invert, structuralwintegrity,
evidence of leaks er etc.) Pump septic tank annual(
,present.Liquid levelat the outletQc
ily
Tn tl1Pt tPPC Ariz in „1 CF A S rU ura
s Inc
�71� i e�fi cez o1 1 a a e.
GREASE TRAP: NG'
(locate on site plan)
Depth below grade:A)�
Material of construction JJ concretsAJr9metal�✓�1Fiberglass Polyethylenoj &ther(explsin)
ti14
Dimensions: AM
Scum thickness: d--1/9
Distance from top of scum to top of outlet tee or baffle:_'Lld
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: 411f
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
revised 9/2/98 Page 7orit
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA
PART C , '.
SYSTEM INFORMATION(continued)
PTopw y Addro": 32 Linden Avenue, Centerville
Cownw: Archie Anthony
Darts of Inspection: 6/7/0 0
TIGHT OR MOLDING TANK:.A&,(Tank mutt be pumped prior to, or at time of, Inspection)
llocate on slit plan)
Depth below grads:si/[l
Meterial of construction. concret�metal&FiberglassliPolyethyleneA,gother(explsln)
fl�,
AM
AM
Dimensions: AN
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: AW Alarm In working order:Yes 10 NoAA
Date of previous pumping:A7
Comments:
(condition of Inlet tee, condition of alarm and float switches, etc.)
Ti ht Or
DISTRIBUTION BOX:,Z
(locate on site plan)
Depth of liquid level above outist Invert:,�(Z_
Comments: e�� qq
(note If Isvel and distribution Is equal, evident of solids carryover, "doo$o o evidence ofout of
f SOl1dS
D1V
bag-
carryo evi n .
PUMP CHAMBER: °i
(locsts on site plan)
Pumps In working order:IYes or No)
Alarms In working order(Yes or No),ra
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
'PITY p�cham nnt- nrcccnf
I
revised 9/2/98 of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �
' PART C '
SYSTEM INFORMATION(continued)
ProgenyAdaess: 32 Linden Avenue, Centerville
Owner: Arche Anthony
Date of kopection: 6/7/0 0
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan, If possible;excavation not mqulred,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number: ox f &n
leaching chambers, number: ��r�r^S
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dim Ions:
overflow cesspool,number:V
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to medium fine Ganrl No signs of hydraulic failnre nr
F?4Z1d3.ng- Sni I s arA ary y=gg+-a igii J6 ;! Qr-;I1& pit +9 dry the
�T�eat? i}g
Jnfiltrratefs are working properly .
CESSPOOLS:
(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: 14
Indication of groundwater:
inflow (cesspool must be pumped as part of Inspection)
Cesspools are nni- prolcen+- -
Comments:
(note condition of soil, signs of hydraulic failure,level of pending,condition of,vegetation, etc.)
Cesspools are not present -
PRIVY: )
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:A19—
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
Privy is not prp--Pnt-
revised 9/2/98 Page 9of11
SV93VAPACt SEWAGE 01it OSAL iYiTtAI WS►ECTION►ORJA
.,
PART C
iYSTEaA WF0RJ.tAT101ti(oond+-'44
piop✓tyAddw: 32 Linden Avenue, Centerville
0~: Archie Anthony
Doti. of In.p+cson: 6/7/0 0
SKETCH Of SEWAGE DISPOSAL SYSTEM:
Inc vdo too to &t Issst two pgrmsnsnt referents lsndmuks or bsnchmsrks
locate ul wells wltNn 100' (locate where publlo wets,supply Domes Into house)
1
C. �
t7
I
�srn
_. AV_
revised 9/2/96 ntetoottl
SUBSURFACE SEWAGE D13P93AL SYSTEM INSPECTION FORM
PART C '
SYSTE)A y4FORMAT1ON (eorr*ijed) e
Prop•rtyAd&&": 32 Linden Avenue, Centerville
Owr„r: Archie Anthony
oat,of Inapect)on: 6/7/0 0
NRCS Report name
Soil Type_
Typical depth to groundwater
uSOS Date websits visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Collar
Shallow wells
Estimated Depth to Groundwaterb I Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
20btained from Design Plans on record
Observed Slt• (Abutting property, observetion hole, basement sump etc.)
Determined from local conditions
Chocked with local Board of health
Chocked FEMA Maps
hocked pumping records
� Checked local excavators, Installers
Used USOS Data
Describe how you established the High Groundwater Elevs0on, (M.ylS be completed)
Used water contours map.
Gahrety & Miller Model
12/16/94
revised 9/2/98 PagoitofIt
•n►•nrw.-nl•r�*-T- fnrJen•n.swTTrti7nrlArr.T+n�n�.R�.m RR+1^atf�-'w►.rlwT *'w•RT-fir-w:•m- . r•.•'
TOWN OF BARNSTABLE BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
•••TI'1^T".••.:.-T,III.^.T:TTA.I'.11•Rl.TI TIRIItf7lpw..T•r^.\'iT1VTn1't�l'Rfr�TA��I�t'fR\ AIR •.�'IPT'►^^�.-..^
-TYPO OR PRIHT CLEARLY-
PROPERTY INSPECTED
STREET A MES$ 32 Linden Avenue , Centerville '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Archie Ahthony
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr,
COMPANY NAME Joseph P. Macomber &''`Son, Inc.
COMPANY ADDRESS Box 66 Centerville MA. 02632-0066
Street Town or City state LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (��) ��� - l✓ ��
-
w
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 - 303 . Any failure
criteria not evaluated are As stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have con Meted has found that the system fails to
Protect thej)ublic health and the environment in accordance with Title
5 , 3.10 CMR`vl5 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA oV'this inspection form .
1 - /
Inspector Signature4 Date
>
ne copy of this rtification must be p ovided to the OWNER, the BUYER
( where applicable ) and thekBOARD OF HEALTII.
.0
* If the inspection FAILED, the owner or operator shall upgrade ' the eyetem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CMR 16 . 306 .
partd .doc
� •�� ��'',, TOWN OF BARNSTABLE
SEWAGE #
VILLAGE � �� ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ( f
LEACHING FACILITY: (type) f� ���������
NO. OF BEDROOMS
BUILDER OR OWNED
PERMTTDA COMPLLANCE 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 6i withir..'200 feet of leaching facility) '—
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of a An acility) Feet
Furnished by '
�•w
NGtJS�
1 I -
�k, y
I G,4Rdji
V
.. Fss�.....�C•,Qn
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
, pplirativit for Di5pwial WArkS Cnowitrurtion ttermit
Application is hereby made for a Permit to Construct ( ) or Repair �X) an Individual Sewage Disposal
System at:
32 Linden Ave Centerviliv
----•........................•-..........--•---....-----•-•------------•---------......-----•--••- --•---•••-••--------•-•••-----••••------------•----------••---...........---...---•-•-•••-•-••---.
Location-Address or Lot No.
..................An tiiUn !
W .f. P .I:IacoinbeOr wnerJr .. Address
------------------------------------------•............•---------------------------------..-----
Installer Address
UType of Building Size Lot_.........................Sq. feet
►-� DwellingY-- No. of Bedrooms------------- _____________________________Expansion Attic ( ) Garbage Grinder to )
a Other!—Type of"Building .% f_ ___________________ No. of persons...._2..................... Showers
Cafeteria
C>a ( ) — ( )
Q Otherfixtures
W Design Flow..._..;,t '. ..:.................gallons per person per day. Total daily flow_.____33 ......._._..__..._.....,.__...gallons.
Gd Septic Tanko�--Liquid capa6ty__,1�50l allots Length1-0:"._6"___ Widths_`.......... Diameter---- Denth------ 6
_ ."
�
Disposal Trench—No. -------.. .......... Width....1`----------- Total Length_54__`.....__.____ Total leaching area_3 T_�:..........sq. ft.
3 Seepage Pit No--------ill.......... Diameter..........Q._ ..... Depth below inlet-----fl............ Total leaching area......(?..........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
W
Test Pit No. !................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_-....______-___-____
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O9 .......................•----....--••._..............__...---.._.....-----•------•--•---------•--------------........---•---------•-•--• ......----------....
Description of Soil.................................................................................................................................................... ..................
x ---•--------------------------••------....Sand Gravel_
U
W
UNature of Repairs or Alterations—Answer when applicable._.()-m_i.t... e.s �Q s�.ls__...�ztu.G. l 1---1-....................
o-i�--.tip nk....d—. n.x--s.--iaf.i.1.tx>a-t.Q.x�a---------------------------------------•---------------------------------............--••-•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce has be iced the boar o ealth.
Signe .... r.. 7_/J..7.19.5:-----
...........er---..... Dace
Application,Approved By .... --- ........... ... .. ... --------------- ---------...... ..... .. Dare
Application Disapproved for the following reasonr: ............. -------------------------- ......... ..........................................
----------------------------------------------------- -------------
6----- .. ----------------------------------------------------------*..... - -'
Date
Permit No. .......... Issued
ac
fNo.................
THE COMMONWEALTH OF MASSACHUSETTS a3
•� BOARD OF HEALTH
' TOWN OF BARNSTABLE r
Appliratinit for Uiv nnttl nrk> (fungtrurtinrt ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at: � -- -
a ........ ........32 Linden Ave Centerville
- ----------------------------------------------------•-----•...------•.
•------------------------------•------------•----•"------....-----•----...--------•---•------•--•--
Location-Address or Lot No.
Anthony
OwnW J.P.Ma C o m b e r C7J r. Address
--•-••...............•----•-•.........---•--•-----••-•-••---••-----
............Installer Address
U =Type of Building ' 3 r Size Lot................... Sq feet`
Dwelling X No. of Bedrooms______________________________________ ____Expansion Attic ( ) Garbage Grinder (q0)
aOther Type of"Building _Res _____-_..___ No. of persons-----2------------------ Showers ( ) — Cafeteria ( )
d Other fixtures ------------------------
Design Flow:_...1 k --------------------------gallons per person per day. Total daily.flow_._...33Q
W -� P P P Y Y - gallons.
rr r ------- Diameter.___ ..._..__ Depth_....�:_:b_.
Disposal Trench—No. ....a.?......... Width....®:_.�,__..... Total Length_.`1.............J.0tal leachng area.370..........sq. ft.
3 ; Seepage Pit No...-Io.....n--- Diameter---------- ---__-�_ Depth below inlet...... ..._.._..... Total leaching area......QL.........sq. ft.
i`z.l Other Distribution box ( ) Dosingptank ( )
aPercolation Test Results Performed bY-----------------------------•-.._.....----------------•---------...-_---- Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2.......:........minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
i ..:..----••---------------------------•----------.......----...------•--•-•-•---•--•-----•-•-....---.........................................................
D Description of Soil s
x.. ;
v Sa:nd & Gravel
W
x -------------------------------------------•---------------------------------•--
U Nature of Repairs or Alterations_=Answer when applicable---Om_i-t:.... Pa. n.c�ta�_l..g. s ]. .•---1_-...................
L.1.0L---n-11-gin.. ��+�k _�-1'�� �� tn£��t_�r�tt�axs------ '-•- --- ----- --•--••. -------- -•--•-•---.
Agreement'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has be is. , ed by the board ol?health.
,.
Signe ..---.C�.. . . ............................. .......A--- -- ---------7../.1.7./95:.
Due
Application.Approved By ._--- .-
,.,,,�- ..-s-e--1....,.. -e.... ... ....... _ _._. ... .... .. ...._ --- ----- -----
J, r v,ra--- Dale
Application Disapproved for the following reasons: . o,J----------- --------------------------------------------.... .
' � -.--............... ._............._..........__- .- 1, ...................... D.a.t.e... ..........
............................................. ................... ---- ----- --.............. --------------------------------
No.
. �Permit .. ------- -------------
6
\ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T(O��WN OF BARl!..��NSTABLE
0-wrtifi ate of �10ra lianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX)�
by ---i-------------.L...p.e.Mc G.e.m.li.e.�C. .Jx., ------------,...._--------------------------...---------------------------------------------------------------------------------------------
1nsr.Jler
at -..------------3.2....IAn-d-en.. AYe----C.e.n.te.r.v.1lle------------------------- ---------------------------------------- ----------._------------ -------------------------------------
has been installed in accordance with the provisions of TITLE 5 T e Sta e Environmental Code as described in
- the application for Disposal Works Construction Permit No. ...--- -. . . . dated ____......_.:...._........_.._....._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE 6 NSTRUEA AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. - w
DATE ------- ....._----------------------------------------.. Inspect r .....-- -
• `——— r. —y! '—---a—^—
THE COMMONWEALTH OF MASSACHUSETTS
J BOARD OF HEALTH
TOWN OF BARNSTABLE
.
FEE...............30...000
......
�in�n��tl nrk� �laa�ntr�.cti�an �rrmit
Permission is hereby granted.....'I R--,Mac.0M1ar....1r ---------------------- ------------"-------------------------------------•--................
to Construct ( ) or Repair 4(. ) an Individual Sewage Disposal System
at No.....3.2-_•U n d e n--A v e........ n.t 4 r v i-11e....................................
street
as shown on the appli Zion f"r Disposal Works Construct'o"f�yi-e No. . `__._ +ated.. 4! .................. ......
. . ,�
�,,� • Boar dff Health
DATE................ �}'?n .... ---------- --------------_-_--- \
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS -
a D 4
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, J.P.Macomber J r . , hereby certify that the application for disposal works
construction permit signed by me dated 7/17/9 5 , concerning the
property located at 32 Linden Ave Centerville meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED DATE: 7/17/9 5
a
LICE SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 9
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
' J TOWN OF BARNSTABLE
LOCATION %3a 4d°C01 SEWAGE # 96 :- �4
VIILLAGE CV_v►aeP 't d( ASSESSOR'S MAP & LOTS"
INSTALLER'S NAME&PHONE NO. -� 7 VYIACc�rvt�i�rOh 77O C
SEPTIC TANK CAPACITY /s'O 0
LEACHING FACILITY: (type) .�11t=t OT&X402 s (size)
NO.OF BEDROOMS
BUILDER O OWNE
PERMITDATE: ZA� ` �r_COMPLIANCE DATE: 7- ;;?
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
y
Matra f� '
39 1/
- re
•
/rT—^ A r
1i�d
0
I
�1 1.500 gallon tank
! W
�1:,tribution box
�--infiltrators
No...._..5..'L...... FRs.......�r. -..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Lv. . ....... ........OF......� �'�r./�5 `�� -------------.....----------------
App iration for Disposal Works Tnnstrnrtinn rantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...... ��--._ l..!?. /-e . _e,,,...��'.t2. [�Y//.1e----•................•--------•------ ---- --...----•--- ------------------------
'rw
Locatio A ss j �?t�h v ►s or 1Lot No.
il111. ......._. rj a_e,r-•--------•-•....... .E-------------�--�----}-------------------------p-------
O r -Address
- _�
.... ......A' SQnvL'. �
Installer Address
i
QType of Building Size Lot........:...................Sq. feet
aDwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
pa Other-- pe of Building ............................ No. of persons_....s,`J-.-.-.............. Showers ( ) — Cafeteria ( )
Pa .:ether fixtures ..........................................................
W Design Flow_._,_.:_,...........................•.....___gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal '' ?;nch—No..................... Width_......_._..._._.__. Total Length_____........._..... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.................. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground_ water-___--_-_____-._.__--_.-
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ra' ...........................I.....•. ..........................................................................................
Description of Soil--- f'�Gl_�1 ..........
.. a.YI.C....-•---•---------
- ------- ----- -- —
ature o Re airs or Alterations—Answer when aPP licable_:, /,SfI/l.n�{........O1�_ _. ._._. X!- _ d[C�Z!$'L1fI /
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage.Disposal System in accordance with
the provisions of iIT L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a=Certificate of Compliance has been issue yth board health.
. 1. V
gned a. _
t4' „' ' Date
-A l cation Approved BY = -•L." ...... ...... ......��
Date
Application Disapproved for the following reasons:................................................................................................................
----- ----------- - -----------........
> Date
--._...__. Issued. C� oc'
w0 Date
4
a
No.f_ .r ...... YmB...................* 0-...
} THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ar&� ? ................OF..... ..................................
Appliration for ,Disposal Works Tonstrnrtion rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System
r at:
Locatio d ress or Lot No.
....... ` P' _. ;�......._. .... . a.alt.....•................ ...................... ?.......................................................
O ner Address ,
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms-------- ............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............... . No. of ersons__...
QI Other—Type g --•---•-•--• P --------------•---- Showers ( ) — Cafeteria ( )
a' Other fixtures ............................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter__----_---_____- Depth................
xDisposal Trench—No. .................... Width..........::....__:_Total Len gth.................... Total leaching area_...................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below`inlet............._.._... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutts per inch Depth of Test Pit....._.............. Depth to ground water__-_--__.._-_-__--___--.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth:to ground.water........................
e .... ......... ...............•-•----••-•--•-•---•--•-•---•-...•-••-•--•--•.....----•••--•.....•-••.........•-••...•---
0
Descriptionof Soil.._.V. ..tz� - -•-• .... � ,t'$------------------------------------------------------------•-----------------•-----------...-----------
x
c., ••-••-••---•-----•••----•••...............•----.........-----------------•-----•---•-----------••••-•-•-------------•------------•-•----••-•----••....................................................
---------------------------------------------------------------------------------------------------•- -- ---- ---- ---
U Nature o Repairs or Alterations—Answer when applicable—a'., / �f ? : -..._ aY9 ?
oe-R-an.---•-• s- ''ne..Y---- - -: ? ..••••0!1c.t a. • -------- --------•---------------------............. .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been;issu y the b _health.
q
igne .•..... ------------------------------•- m
Application Approved By-•---. a� Lv
Date
Application Disapproved for the following reasons----------------------------•--•-----------------------------------------------------------------•-....-•--•-•.
..---•---------------------------------•-----------------------------. ......................................................---------------------------------------------...-••--•----•---..._....•....
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
low, ..........OF........ � . ........ .............
Trrtifirtttr of T o mplianrr
THIS I 0 CBIFY, t the Individua ewage Disposal System constructed ( ) or Repaired
M-
by.. t..... -- . ...
- I�rs 1 er
..
has been installed in accordance with the provisions of T - F 5 of The State Sanitary C de as described in the
P y J3
application for Disp sal Works Construction Permit No..._ _..:__ !. ................. dated___. ._.' " ..�- *
--....._
THE ISSUANCE OF THIS C- RTIFICATE SHALL. NOT,BE CONST E® A A GU NTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY._
DATE. l Inspector__... G . ' .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ® • HEALTH
No........................ FEE... ...............
Disposal Nork %-11, o#rnr#ion rrntit
Permission is hereby grant -•-:,,, •••••. .: ---• -- ----•...................•-------
to Con§tru py.Repaii an Indio' I S age Dis sal System
Street• A /+
as shown on the application foi Disposal Works Construction Per ' o......... ..... ... ed..Gr- _'- ... _
....................
Yeard of Health
DATE-- •-f.... ----..... "".-•--------•.................................•--
FORM 1255 HOB9S a WARREN, 'INC.. PUBLISHERS ,3
L0''C A T`10N SEWAGE PERMIT NO. '
VILLAGE
I N S T A LLER'S NAME i ADDRESS
B U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
��
` --
I
a9 `�
1 1
��
C
/ � �
� tN
�_
AIM 208-22 CENTER GILLE LOCUS
�0
STAKE & NAIL AIM 208-19
FO UND
4 BACON
2'
LOT 2
m�
AIM 208-16 `y
15831.t S.F.
0.36 ACRE
IT APPEARS
THE SEPTIC TANKCOULD E 7VO �� BEACH
CLOSE 7V B77IE ADD. p u'NG CENTERVILLE HARBOR
0
° LOCUS MAP
o° o O
LOT 3 14) O PLAN REF` 20-139, 21-133
AIM 208-13 LOT CLOSURE.- 0.08'
*-- ASSESSOR'S MAP- 008-16
1 SEPTIC SYSTEM t\5 ZONING: "RD-1"
DRA WN FROM ORIGINAL SETBACKS: 30-10-10
os O INSPECTION CARD o CURRENT SETBBACKS.• 30-10-10
�t p FLOOD ZONE.- "C"
O PANEL NUMBER- 250001—0016—D
PROPOSED DATED: 7-2—92
00,%•' 2 NEW ADDITION
GARAGE20.13 2'S�o GA RA�N; & GARAGE
(M BE RE.YOVEv) �♦
b.5 0
N ♦ 9 ♦ 0 3
CB DH
FOUND i ,, 20 �
�' 1 0. c LOT I
♦o coHcs ogCH>��� 35.8 o AIM 208-17
♦ PA770
11.B P
♦5,0
LOT 4A o. .
AIM 208-15
34.0.
-`: HOUSE.
= '�'o'
11 o' 32 o'g
LV
Y E C, y
126.00
ST P HEN G�
N
E DOYLE
80
,,E � . 375 9
ss
p �o ~ �
6,0 � �
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PROPOSED ADDITION PLAN
GENERAL NOTES LOCATED AT
32 LINDEN A VENUE
1) ALL WORKMANSHIP AND MATERIALS SHALL CONFURM 719 CENTER VILLE, MA
THE TOWN OF -- BARNSTABLE _— RULES AND
REGULATIONS FOR THE CONSTRUCTION OF AN ADDITION.
2) NO DETERMINATION HAS BEEN MADE AS T 9 COMPLIANCE WITH
DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO PREPARED FOR:
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
3) UTILITIES ARE NOT SHOWN, EXCA VATION CONTRAC710R JAMES J. HEATH
IS TO CALL "DIG-SAFE" AT 1-888-322-4844 AT LEAST 72 HOURS
PRIOR TO COMMENCING WORK ON SITE. NO VEMBER 6, 2003
4) CONTRACTOR IS M VERIFY GRADES AND ELEVATIONS AS WELL AS
SITE CONDITIONS PRIOR 719 COMMENCING WORK ON SITE
GRAPHIC SCALE YANKEE SURVEY CONSULTANTS
20 0 10 20 40 so UNIT 1, 4 0B INDUSTRY ROAD
P. 0. BOX 265
MARSTONS MILLS, MASS. 02648
( IN FEET ) TEL- 428—0055 FAX 420—5553
1 inch = 20 it. JOB 53487A SDS
SYSTEM PROFILE NOTES
TOP FNDN. AT EL. 47.3'
ACCESS Route 28
COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SE)CAL
ACCESS COVER TO WITHIN 3" OF FIN. GRADE 1. DATUM IS APPROXIMATE NGVD
ACCESS COVER (WATERTIGHT) TO
42.0' MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING
2% SLOPE REQUIRED OVER SYSTEM
'+ 40.4' RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
*EXISTING FOR FIRST 2 OR GEOTEXTILE FABRIC,
EXISTING 1500 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO LOCUS
H- 10
*EXISTING GALLON SEPTIC L39. 39.32' eo 0
TANK (H- 10 ) a �\�
''. BAFFLE 38.94 �� 38.77' 0 0 0 0 O p 0 0 0 5. PIPE JOINTS TO BE MADE WATERTIGHT.
0 38.52 0000 0 0000 0
s" CRUSHED STONE OR MECHANICAL p 0 0 0 0 0 0 0 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH
4' COMPACTION. (15.221 (21) 2' p ED O 0 O 0 0 0 0 36.52' MASS. ENVIRONMENTAL „ODE TITLE V. 'o
DEPTH OF FLOW o
7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED S+ONE
INLET DEPTH - 10" BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
n z Horseshoe Ln
OUTLET DEPTH = 14" ( 1 SLOPE) ( 1 X SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
' LEACHING 7.52' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
FOUNDATION EXISTING SEPTIC TANK 6 D BOX 27, FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION LOCUS MAP
OBTAINED FROM BOARD OF HEALTH.
SCALE: 1" = 2,000'f
10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION ASSESSORS MAP 208 PARCEL 16
BOTTOM TH-1 EL. 29.0' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO LOCUS IS WITHIN THE AP OVERLAY DISTRICT
COMMENCEMENT OF WORK.
LEGEND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
5'7 REMOVED 5' BENEATH AND AROUND THE PROPOSED
100.0 PROPOSED SPOT ELEVATION 0 2' LEACHING FACILITY.
'�
16,g' It 10
+100.00 EXISTING SPOT ELEVATION $ T'H `r gREq
100 PROPOSED CONTOUR 19.4 a :; o. SYSTEM DESIGN:
{
GARBAGE DISPOSER IS NOT ALLOWED
100 EXISTING CONTOUR .T' APPROXIMATE AREA
OF EXISTING SAS DESIGN FLOW: 4 BEDROOMS 0 110 GPD = 440 GPD
a USE A 440 GPD DESIGN FLOW
5' REMOVAL OF"UNSUITABLE
SOIL REQUIRED AROUND
PERIMETER OF LEACHING 41 SEPTIC TANK: 440 GPD (2) = 880
FACILITY, DOWN TO SUITABLE
En!L LAYER. RFYLACE WITH �2 RE--USE EXISTING 1500 GAL. SEPTIC„TANK
TEST HOLE LOGS CLEAN MEDIUM IN SANDPECT ENGINEER
OR BOH TO INSPECT REMOVAL 0 � EXISTING 3 BR LEACHING: BY OTHERS
BENCH MARK - GAR. SLAB AT
°` PVC CLEAN OUT CENTER OF DOOR EL. = 43.8
ENGINEER: DAVID FLAHERTY, R.S. LEACHING:
SIDES: 2 (9.83 + 10) 2 (.74) 58.7 GPD
WITNESS: DON DESMARAIS, R.S. o
DATE: JANUARY 18, 2007 GARAGE BOTTOM 9.83 x 10 (.74 _ 72.7 GPD
PERC. RATE _ < 2 MIN/INCH (ON SLAB)
TOTAL: 177 S.F. 131 GPD
iV 44 Q
CLASS I SOILS P# 11581 OVER ai GRAVEL DRIVE USE (1) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
NFq� e N WITH 0.75' STONE AT ENDS AND 2.5' AT SIDES
ELEV. ELEV. C�CrR/C 4s
0" 41.0' p" 41.0'
I 4S
MA
EXISTING 4;BR APPROVED DATE BOARD OF HEALTH
30" FILL 38.5' 31" FILL 38.4' DWELLING lOP OF
A A
FNDN = 47.3' `` TITLE 5 SITE PLAN
LS LS / of
10YR 4/2 10YR 4/2
36" 38.0 36" 38.0' e 32 LDEN AVE.
B B � (CENTERVILLE) BARNSTABLE, MA
LS LS
1 OYR 5/6 1 OYR 5/6 \ \ PREPARED FOR
60" 36.0 57" 36.2
^ BORTOLOTTI CONSTRUCTION/
C C MARY KAY HEATH
PERC _ LOT 2
MS MS 3 15,815 SF f DATE: JANUARY 19, 2007
1OYR 7/4 1OYR 7/4 12n
(n Ails off 508-362-4541
144" 29.0' 120" 31.0' \ �� ���,JH OFr4,gssq fax 508 362-9880
(N Q M
t� I
NO GROUNDWATER ENCOUNTERED z �n � ARNE ��H. m ono AOJaLA yG� down cape en gln eerin q, in c.
UO � C�' OJALA " CIVIL� �
„ No. ALA N 92 4 Cl VIL ENGINEERS
Scale:1 = 20 o LAND SURVEYORS
T
qN ss\ 939 Main Street - 'YARMOUTHPORT, MASS.
DATE °suP H. OJALA, N .L.S.
DICE #06-299 0 10 20 30 40 50 FEET 06-299 BORTOLOTTI-HEATH.DWG (DDF)
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