HomeMy WebLinkAbout0292 LONG BEACH ROAD - Health 292 Long Beach Road,
A = 185-025` Centerville
Aff
a
UPC 17534 �? -
No.2-15�3COR
kA8TIN08.MN
1
I
1
I
fC TOWN OF BARNSTABLE
LOCATION .2 Q//6.0C'A C/1 SEWAGE
VILLAGE C e yirr% 1//L L ASSESSOR'S MAP & LOye.-5 a 2,-5-
INSTALLER'S NAME & PHONE NO. m 4 C 0/415 dc i 5®.#
SEPTIC TAN 49
K CAPACITY � O
LEACHING FACILITY:(type)/ L DW*1-7/f I�'V-SO/e (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
B%ItMER OR OWNER
DATE PERMIT ISSUED: �°-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
Para
/ f
i �
g67 Cr;
C' 30 . 00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
XpVtiratiun for Diupwial Worlai Towitrnrtiun Vantit
Application is hereby made for a Permit to Construct ( ) or Kepair XX)o an Individual Sewage Disposal
System at:
292 Longbeach Road Centerville
.................•-----------•----•---------..__.....-•---•---------------------------•...._..--•- •----•------••--•---•••-••---•--•--••-----•--•--••---•-•---••-•••-•-•••---------...._..--------••-
Location-Address or Lot No.
Wallace Gardner
.......-----•------...............•-•-----------..-..------------•---•-------•------••---_--••- -•----•----•--------•--•------••-•-----••-------------•---•-------•...............-----------_....
W J.P.Macomber Jr. Owner Address
Installer Address
UType of Building . Size Lot............................Sq. feet
Dwell
ng XNo. of
04 Other—Type erl Bedrooms
—Type of Building n ildigly--.---------------------- No. of pe s nsnsion Attic-�-----)Showers (Ga)bage Grinder
Cafeter a ( )
Q' Other fixtures --------------------------------------------------------------- • . . ---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width.----.---------- Diameter_............. Depth................
x Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No...................... Diameter----.---.--_-_--.-- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by......... --------- ------------------------------------------------------ Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.---..........--........
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ........................ - -----------------------•---•-•---------••----•-----••-••------•-._...---.........................................................
0 Description of Soil.......................................Sand
x
U --------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------••-
w
Ux Nature of Re > or Alterations—Answer when a lica — 5 0---tank 1—pump chamber light
P P� 1 ----------p--•••-p-•----------•--•--....
& alarm flozT diffussors .
------------ ---- --- ----
Agreement: h
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 Compli ce has b en ' s y the b and f health.
Sign �L��G%�0� : . ...f .............. 9_%2.9./..9 ....
Dare
Application Approved B ------ e - z� .. ........................ .................... . ..... ......
PP PP Y Dater`-... .�%
Application Disapproved for the following reasons- ----------------- -----------------------------------------------------------------------------------------------------------------
--------------------------------------------------------- ------------------------------------------------------------------- -------------------- ..-------------- ----------- .............._.�..........
e
Permit No. ...�4 ` .......... -�''� (. Issued .............................................. ........
Dare
/q67
s f:
q .00 30.00
No... —_�-��C1/.- `� Fmc..............................
THE COMMONWEALTH OF'MASSACHUSETTS
1 BOARD OF HEALTH
P
TOWN OF BARNSTABLE
Apphration for Diirpoottl Nork.i Tomitrurt"inn run it
Application is hereby made for a Permit to Construct ( ) or Repair I(X)j an Individual Sewage Disposal
System at:
292 Longbeach Road Centerville
................................. ........................•-•••-•--••-•---•--•--------..... .....-...........................................................-................................
Location.Address or Lot No.
Wallace Gardner
.... -• .e.--•----------•-...r....................................................... -•--••-•••---•••------•---••---•••-•-•---••••••--••--•--...-•-••-......-----•----.....---...--•-•-
Owner Address
W J.P.Macomber Jr.
Installer Address
Type of Building Size Lot............................Sq. feet
.—I Dwelling-X No. of Bedrooms.........5---------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures .
W Design Flow............................................gallons per person per day. Total daily flow---------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter......---------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.--__-_----_._.-__-- Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter_--_.-_---_---:--. Depth below inlet-..----------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
.a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground- water........................
Gzt Test Pit No. 2................minutes per inch Depth of Test Pit--.................. Depth to ground water------------------------
04 1
----------------------------------------•-----------------••-------•--------•-•-••......-••.................................................................
Descriptionof Soil Sand--------------------•--•-•--•--•-••---•-•-----•----•-•-----.....------•-••--•---•----•-••--------••-••••••••........
x
W
UNature of Repairs or Alterations—Answer when applicable__.._1-1500 tank 1—pump chamber light
& alarm 4f flow diffusors . ,X� OF
. ....-------•• r
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 Complizri ce has ben; s by the b, and of health.
Sign
edy,���/ % .................................. 9./..29./..94
Date
Application Approved By ........ ¢..
Application Disapproved for the following reasons: ........ . .... .......................... . . ... ......_........ .....................
...... .................................... .............................................. . ............. . ...................... ... . . . -- .......... ........... ---- .......
Permit No. _q.......... Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;t TOWN OF BARNSTABLE
C�er#ifirate of Q-1-omplianre
1 IS TO CERTL'Y, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX )
J.T yNacomber or.
by - --------------------------------- ---------------------------------------------------------------- -------- --------------------------------------------- ----------------------------------------------------------------------------
° , Installer -
292 Longbeach Road Centerville
at .--.........................------------------------------_---------------------------------------------....----------------- ------------------- ----..---------------------.--------------.---------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ....._ ...L/..._ 60........... dated ---- ................._..._..--------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F NCTION SATISFACTORY.
DATE-------/-.`......._......._..` 5;�Z _.. Inspector'" .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE $ 30.00
Noly:,.k 0/ FEE........................
�tn�roottl orko �nitotr�rtinn �rrmit
J P Macomber . Jr.
Permission is hereby granted ----
to Constr c ( ) or Repair (XX) an Individual' Sewage Disposal System
21 Longbeach .Road Centerville
atNo. ....... •••........-•--........ •.•.--•. ••--•. . -•---••-•--••.
Street �,w
as shown on the application for Disposal Works Construction Permit No._.�ty_- _.. Dated--___I.L_.��"?.V........
........................•--L .......................... Board of Health
y _ n/
DATE.............. --b--�-l-a'-- ------`---
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA
_ DEPARTMENT OF ENVIRONMENTAL
ONE WINTER STREET. BOSTON, MA 02108 617.2 2 t 00
r
REc"Fr
WILLIANi F WELD CD ,J U L 15 1997 RL DY COXE
Govcmor Sc:rCLif-,
TOWN OF BARNSTABLE
ARGEO PALL CELLLICCI HEALTHDEPT. ID B STRUJ6
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI M Commissioncr
PART A £
(ONE WAC4
CERTIFICATION
Property Address: 292 Longbeach Rd, Centerville P140ress of Owner: 1 791 Mass Ave
Date of Inspection: 1 2 5,((9 (If different) Cambridge, Ma. 02140 .
Name of Inspector: osep�ri �. Macomber Jr .
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Joseph P. Macomber & Son, Tnc .
Mailing Address: BOX 66, Centerville , Ma . 02632-0066
Telephone Number: — — 38
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of 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:
_✓ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature, Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AJ SYSTEM PASSES:
�Q 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Day• 1 of 10
DEP on the World Wide Web: http:ltwww.magnet state.ma usroep
Printed on Recycied Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 292 Longbeach Road, Centerville, Ma. 02632
Owner: Wallace Gardner
Date of Inspection: 6/2 5/9 7
Bj SYSTEM CONDITIONALLY PASSES (continued)
U Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_YJ 0 The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
A)0 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
LP
Cesspool or privy is within 50 feet of a surface water
v Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
�p The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
YVO The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
�j0 The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance hl r't— (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 292 Longbeach Road, Centerville, Ma. 02632
Owner: Wallace Gardner
Date of Inspection: 6/2 5/9 7
DI SYSTEM FAILS:
You must indicate ei;!:er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
✓ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
i=Lo-d,�TNsot,6 �_DRI�)
Liquid depth in Gassryeel is less than 6" below invert or available volume is less than 1/2 day flow.
_✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
l✓ 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 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
✓ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 292 Longbeach Road,Centerville, Ma. 02632
Owner: Wallace Gardner
Date of Inspection: 6/2 5/9 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
✓ _/ Pumping information was provided by the owner, occupant, or Board of Health.
_ t/ None of the system components have been pumped for at least two weeks and'the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
L� As built plans have been obtained and examined. Note if they are not available with N/A.
✓ _ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
_ All system components, e*cluding the Soil Absorption System, have been located on the site.
Z _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
✓ _ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)]
(revised 04/25/97) Pegs 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 292 Longbeach Road, Centerville, Ma. 02632
Owner: Wallace Gardner
Date of Inspection: 6/25/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 550 p.d./bedroom for S.A.S.
Number of bedrooms:j�5-
Number of current residents:0
Garbage grinder (yes or no): ND
Laundry connected to system (yes or no): 'yt-.5
Seasonal use (yes or no):� _
Water meter readings, if available (last two (2) year usage (gpd): 33 vvo )G-S.R'-6
Sump Pump (yes or no):_41L 3�'q 3tz" G.P/J q G J"p
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment: )Vc� _
Design flow: 11;Gk Aallons/day
Grease trap present: (yes or no) p-
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no),LGL
Water meter readings, if available: -%,GL
Last date of occupancy: )V 0.
OTHER: (Describe) W(,_
Last dare of occupancy: ..YIj
GENERAL INFORMATION
PUMPING RECORDS and source of information:
�U rt S ' 1as of-pea
System
System pumped as part of inspection: (yes or no)V0 n
If yes, volume pumped: PJC',gallons GCP_Lir>o�
Reason for pumping: YU Ci..
TYPE OF SYSTEM
),,� Septic tank/distribution box/soil absorption system
VC Single cesspool
Overflow cesspool
INC) Privy
11tC Shared system (yes or no) (if yes, attach previous inspection records, if any)
)!�a, I/A Technology etc. Copy of up to date contract?
Other Y1)(,L
APPROXIMATE AGE of all components, date installed (if known) and source of information: 1 _ [) �C_ lYl)STII I Irrl, (
►° rY�a(vrf)bare t a n, -1:70 C-
Sewage odors detected when arriving at the site: (yes or no)A)Q
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 292 Longbeach Road, Centerville, Ma. 02632
Owner: Wallace Gardner
Date of Inspection: 6/2 5/9 7
BUILDING SEWER:
(Locate on site plan)
1(
Depth below grade:
Material of construction: _ cast iron /40 PVC _ other (explain)
Distance from private water supply well or suction line Y CU
Diameter Li )t)
Comments: (condition of joints, venting, evidence of leakage, etc.)
(�S ti ��)s�`r� ra f2c �[r hT- r►ao �t��t1� n-�- )'�-�Jr��>ine S(1 S7?—o�c, 1� V F'�? rl� ��11?�>>/u h
TSFTE,E 1> K)T
SEPTIC TANK:-A-�50 qc d lO n S
(locate on site plan)
)r
Depth below grader
Material of construction: 1::-_11Concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age &LA, Is age confirmed by Certificate of Compliance �{�Yes/No)
Dimensions: , �Ir LOhG 14, VI W)Ag-- S r /fr hlgh
Sludge depth: M
Distance from top of sludge to bonom of outlet tee or baffle:
Scum thickness: C
Distance from top of scum to top of outlet tee or baffle: d
Distance from bonom of scum to bonom of outlet tee or baffle:
How dimensions were determined: 19�1 MLLL.L2 I C,6
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
Tit-
integrity, evidence of leakage, etc.) C oZ— S • t ]—
i C G
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:�0.concrete Mkmetal V&iberglass /L1CIPolyethyleneV12C er(explain)
11JG
Dimensions: YL
Scum thickness: 4)[A-
Distance from top of scum to top of outlet tee or baffle:�)%1
Distance from bottom of scum to bottom of outlet tee or baffle:,1VU--
Date of last pumping: ZCL-
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.) �
(revimod 04/25/97) P&go 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 292 Longbeach Road, Centerville, Ma. 02632
Owner:
Date of Inspection: Wallace Gardner
6/25/97
TIGHT OR HOLDING TANK: ►2 nC(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:,��
Material of construction:i1jLAt;_oncrete ,metal Fiberglass Polyethylene &Uother(explain)
YVC�
Dimensions: Y1�11.
Capacity: i\) CZ_ gallons
Design flow: 0. gallons/day
Alarm level:__ Alarm in working order'A&_Yes;1� o
Date of previous pumping: nGx-
Comments.
(condition of inlet tee, condition of alarm.and float switches, etc.)
7 n 1- Y 07 p kF2 Sc-rOl—
DISTRIBUTION BOX:
(locate on site plan) rrl1
Depth of liquid level above outlet inverl:NV
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
c
� V
e_
PUMP CHAMBER:—L)DYIC
(locate on site plan)
Pumps in working order: (Yes or No)—1
Alarms in working order (Yes or No)_AkL
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
'01 0 my)n"C'0�nT pjp r-Sri A)L
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 292 Longbeach Road, Centerville, Ma. 02632
Owner: Wallace Gardner
Date of Inspection: 6/2 5/9 7
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: 0 _ (r )
leaching chambers, number:5 F— _g 0.1 -�'/-tf.S,0e S 5�dC Tb b�&M AC) ,
X }�
leaching galleries, number:_)
leaching trenches, number,length: 0
leaching fields, number, dimensions: 0
overflow cesspool, number:
Alternative system: (7
Name of Technology: h) Y�-
Comments:
(note condition of soil, signs of hydraulic failure, level f ponding, condition of vegetation, etc.)(
C CC11
CESSPOOLS: YVe
(locate on site plan)
Number and configuration: MA
Depth-top of liquid to inlet invert: YUCL
Depth of solids layer: y))[
Depth of scum layer: YI)G(,
Dimensions of cesspool: ")DL
Materials of construction:4_)0.
Indication of groundwater: YUGL-
inflow (cesspool must be pumped as part of inspection) t11n
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CCk C t1�t�T" �YZ� Pw
PRIVY: Y10lUc--
(locate on site plan)
Materials of construction: CA-- Dimensions:VU (A_
Depth of solids:YKt_
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
t�
vI�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 292 Longbeach Road, Centerville, Ma. 02632
Owner: Wallace Gardner
Date of Inspection: 6/25/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
nciude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
16
r p -
a
Ao
(r•v�..0 0�/29/97) P•g• 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 292 Longbeach Road, Centerville, Ma. 02632
Owner: Wallace Gardner
Date of Inspection: 6/2 5/9 7
Depth to Groundwate ' �' be1oW �)o-d.� Cif�Dr2 5
r Feet L.) ' >�
Please indicate all the methods used to determine High Groundwater Elevation:
NO Obtained from Design Plans on record
yc Observation of Site (Abutting property, observation hole, basement sump etc.)
�e5 Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
—Check local excavators, installers
Use USGS Data
Describe in your own words how- you established the High Groundwater Elevation. (Must be completed)
�5. P �acovy)be &on ,TnC_ )yvC'-M(1cd sysjrr , cl
14CL , Cnl-fie"Di ) P`N�-MT- # 9y -&oI
'Titre o+ �V)e crown bf-s)dct-
U -j (-Pf(.d )oca t�--8 GJT-
(revised O4/25/97) Page 10 of 10
'.r.•r+ nr rr--rr-•r.f.-mr'n..-rrs�+r+rerrrrn:•.�rr-�s.r:.rr•+•rrtrn rsr-tau rvrmkro-.+ ma.s�ru-rrs�rrr�TT-�- _. .- r
TOWN OF Rarnstab1 HOARD OF HEALTH
SU;ISURFACF 9FWAGE DISPOSAL SYSTEM INSPFCTION FORM - PART D - CERTIFICATION I
�- �•...-.- r .--.rrr---+rt.-:-T•rt:mrs+:r.�mrrT-.+-r�-r--•.rt�mr-�snnsr'-rw.rr.am�m�mm�w�s�a mnn�nm+rr�rrtrrr�r.r,:—.r r.- r.-. _. .�
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 292 Longbeach Road, Centerville, Ma. 02632
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Wallace Gardner
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAME Joseph P. Macomber & `ffcn, Inc .
COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066
Strvvt Town or City Stat• 11P
COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certifyv that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of oil-
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
ItealLh or- Lhe environment as defined in 310 CMR 15r303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have c .acted has found that the system fails to
Protect the })itblic health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature l Date
One copy of this certification must be provided to the OWNER , the BUYER
( where applicable ) and the DOARD OF HEAL'I`II.
• If the inspection FAILED , the owner or"'oparator shall upgrade the eyetem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 15 . 305 ,
partd . dcc
<<
w
ti
- Sb'lY 3171
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws- Issued by P The Department of Environmental Protection.
June 8. 1995
Acung Director of the ion of Water Pollution Control