HomeMy WebLinkAbout0167 MAIN STREET (CENT.) - Health (2) 107 Main Street (Cent.)
Centerville P
A = 208 096
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O%rf0rd. O. 1521/3 ORA
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LOT 1
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#1671
Q0 LOT 2
110.
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Charles J. Meyer �o��G'STE�Foc
Richard A. & L #C. 22082 g;E°HEN s.
Judith L. Knowles .4 a J. �
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VT
FLOOD PANEL- 250001_0006 D FLOOD ZONE.- "C___ DATED. 712192
I hereby certify that this mortgage inspection,plan Was prepared for: Plan is For
PLYILfOUTH SA DINGS BANK Bank Use Only
The location of the building shown does NOT fall within a special flood hazard zone. PLAN REF.
Per taped inspection it appears the location of dwelling does conform to the local by-laws „
in effect at the time of construction with respect to horizontal dimensional setback requirements Scale 1 = _ 0 FT.
or is exempt from violation enforcement action under Mass General Laws Ch. 40A -Sec_ 7 Date: -±/
ZI
PLEASE NOTE` The structures on this inspection were located by tape not instrument and are approximate only. An actual survey is necessary
for a precise determination of the building location and encroachments, if any exis4 either way across property lines This inspection must not
be used for recording purposes or for use in preparing deed descriptions and must not be used for variance or building plan purposes. This
inspection must not be used to locate property lines Verification of building locations, property line dimensions, fences or lot configuration can
only be accomplished by an accurate instrument survey which may reflect different information than what is shown hereon. This inspection rs not
to be used for any purposes other than mortgage. Yankee Survey accepts no responsibility for damages resulting from said reliance.
PHONE:- 508-428-0055 VANKEE' SUR VE'Y CONSULT�4NT,S'
FAx 50e-420-5553. UNIT 1, 40 INDUSTRY RD, MARSTONS MILLS; MA 02648 36532 RJB
-tx 1a �
r
DATE : 6/14/03
PROPERTY ADDRESS: 167 Na.in Stzeet ______ r
__Centeay.iiie.Mazzs ------
__ 02632 -----------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
7. 1- 1500 ya.Hon ze/2t.ic tank. FHEALTH
C"IVIED
2. 7-Di.6taigution 9oz.
3. 4-.in/.i.etaato2Lz .in zea.iez. (33'X13'X2' ) 2 0 to�j(
Based on my inspection, I certify the following conditions:
BARNSTAgI�
4. 7h.iz .ih a t.it.ie live use/2tie zyhtem. ( 95 Code ) DEPT.
6. The ze/2t.ic zyetem ins .in /22o/2e2 woakiny oade2
at the gaeaent time.
7. Stone .iz /2aezentiy day a.2.2 aaound the .in/.iitaato ¢z.
SIGNATUR
Name : - J__ P__Macomber_ir ___-_
Corripany :,�g�gph per_ M��4mf�gr 8_ Son, Inc .
Address: .------------
__CejueryLLLe.,_ Ja-_QZ.632-0066
Pnone .- __508- 77S.: ________
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
IOSEPH P. MACOMBER & SON, INC.
Tanks•Cesspools-Leach Ile Ids
Pumped & Installed
Town Sewer Connections
P.O Box 66 Centerville. MA 02632.0066
775.3338 775.6412
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 167 Naia St2get
Cvn}flnui fPP, /1rr.s.s_
Owner's Name: on Mr( Pn. k g1g
Owner's Address: 3 ame
Date of Inspection: 6114103
Name of Inspector: (please print) 10.3el2h P. /7acomPe2 Ia.
Company Name: ;. /• Ilacom en R Son Inc.
Mailing Address:Box 66
Cente2viiie Nas.s. 0263Z
Telephone Number: M-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
r//Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 2A01ftj Date:
The system inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 167 Na-in Staeet
Cen.teay,ii,ee
Owner: _Ke.2en McC eozkey
Date of Inspection: _ 6114103
Inspection Summary: Check A,B,C,D or E 1 ALWAYS complete all of Section D 1
A. �Passes-
-A?�L t
I have not found any information which indicates that any of the failure,cnt�tr))'a desc M
ribed in 310 CR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not'cvaluated are.indicated�below. /
Comments:
7ize .6ep.tic zys-tem .ie in paopea woaking ,oadea
time_
B. System Conditionally Passes:
p 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.
A/P 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:
W-1 6 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:
/)e) The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 167 Nain Staee.t
Cen.te21).i-PPe, M azz.
Owner: lie Qen McC.Pozkeu
Date of Inspection: 6114103
C. Further Evaluation is Required by the Board of Health:
4P 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.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
)b 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:
ND 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.
A),O The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
/0b The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
Na The system has a septic tank and SAS and the SAS is less than 100 feet blut 50 feet or more from a
private water supply well". Method used to determine distance !1,(
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coli form
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
P • 16 7 Na-in
Property Address. S.t`aeet
Cente2v�i.e.Pe, /'lass.
Owner: Keen McUoakey
Date of Inspection: 611410
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No//
_ l� ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
c/ 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 SJ,yu ,tTi'�)'Jr G
_ ✓ squid depth in.cescpeal is less than 6"below invert or available volume is less than ''A day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
- :�zof times pumped .
y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
/water supply.
— y portion of a cesspool or privy is within a Zone I of a public well.
�
�y portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
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.)
(Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes now�
I/ /the system is within 400 feet of a surface drinking water supply
_ v 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 167 Na in Stlteet
en e2vi e, 77ETT
Owner: He-en. McC.2oa ey
Date of Inspection: 611,9103
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
e Pumping information was provided by the owner, occupant, or Board of Health
ZWere any of the system components pumped out in the previous two weeks
�as the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Z_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
�_ Were all system components, luding the SAS, located on site?
_ Were the septic tank manholes uncovered,o ened and the interior
of the baffles or tees, material of construction,dimensions, depth of liquid, depth tof sludge nand depth sected oof scumr the ndition
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) (310 CZAR 15.302(3)(b))
5
Page 6 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:167 Ma-in St2ee.t
en eavi e,
Owner: Heien McC Po.skey
Date of Inspection: 6/14/0 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 1% Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms);
Number of current residents:L
Does residence have a garbage grinder(yes or no): �s
Is laundry on a separate sewage system es or no):,710 (if yes separate inspection required)
Laundry system inspected (yes or no):
Seasonal use: (yes or no): t)d 2000=5 4, 000 ga.P Pons= 147. 9 5 G/1 D
Water meter readings, if available(last 2 years usage(gpd)).
Sump pump(yes or no): 2M 139, 000mga P e o n,3=2 4. 6 6 Gl')D
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): fN gpd
Basis of design flow(seats/person gft,etc.):
Grease trap present(yes or no):a
Industrial waste holding tank present(yes or no):.-,46X
Non-sanitary waste discharged to the Title 5 s s em(yes or no)�1,� )
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records 4
Source of information:/ owe— Aol W6
Was system pumped as part of the inspection(yes or no):e—
If yes, volume pumped: C�gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
,otld Privy
/9Shared 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
tl.,ained from sys a owner)
Tight tank 96P Attach a copy of the DEP approval
/ 2 Other(describe):
A�pplpximje a e of 2alc o mpon nts,date inst fled (if )and sour a of information:
Were sewage odors detected when arriving at the site(yes or no):,4/�
6
i
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 167 Main Staeet
e nt eay.c e, •3.
Owner: Heien McC.Po.sky
Date of Inspection: 6/14/0 3
BUILDING SEWER(locate on site plan)
�!
Depth below grade: �1
Materials of construction: ast iron �0 PVC,Dother(explain): ,t/A
Distance from private water supply well or suction line: Id f
Comments(on condition of joints,venting,evidence of leak e,etc.):
ao.intz anReaa t iGht. No evidence o� .Peakage. The zyatem ih
vented thzough the houze ven z.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 117 /
Material of construction concrete 414 meta Lt�P fiberglass�.Aolyethylene
/Vdother(explain) A;W
If tank is metal list age: D is age confirmed by a Certificate of Compliance(yes or no)A4(attach a copy of
certificate)
Dimensions: d 6n .r
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: � ,
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: m_
Distance from bottom of scum to bottom 9,f outlet tee orbaffle: Z-40rr•e
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Pumped the .6e t.ic tank annua-v2y..GaaPage diz/2o.sa.2 .iz paeeent. ZnPe.
out Pet teen ate ih /2 ace. Yhe tank t,6 ZZauctuaalry 3ound
.6how.3 no evidence o/ Peakage.
GREASE TRAP (locate on site plan)
Depth below grade:42
Material of constructi n:Lconcreteg&metaLt efiiberglasst�olyethylenootii9other
(explain):
Dimensions:
Scum thickness: lelw
Distance from top of scum to top of outlet tee or baffle: 460
Distance from bottom of scum o bottom of outlet tee or baffle:��
Date of last pumping: o0i
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
tea.6e tltaI2 .ih not /1a.e.5en .
7
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: 167 1lain S.t/zee.t
en e2L.e e, asp.
Owner.Ke2en plc -2o.s y
Date of Inspection: 6/14/0 3
TIGHT or HOLDING TANKt41r t4tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: A1,4
Material of construct�� Iconcrete/metal fiberglass polyethylene di0 other(explain):
Dimensions: ota
Capacity: allons
Design Flow: 44 allons/day
Alarm present(yes or no): 4119
Alarm level:_ 4 44 Alarm in working order(yes or no):4JA
Date of last pumping: zlA
Comments(condition of alarm and float switches,etc.):
7igh.t o/z hoidinq .tankz ate not N2ezen
DISTRIBUTION BOX:Zif present must be opened)(locate on site plan)
)
Depth of liquid level above outlet invert: Vd
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage ipto or out of box, etc.):
I)d' silz1Puilon 9Ox has one .Pa.teaa.P No ev-.cLenee o� zo.Ud.6
c rla n)4 n))on Nn o)).rJonro e) .p )ka pP. 1.R.t0 02 Ou.t O� .the 9Ox
PUMP CHAMBEFtke(locate on site plan)
Pumps in working order(yes or no): �A
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
L)1_m2 rhnm0.on i.S o /1/L23on�
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 67 Na-in St2eet
en e2ve e, a.sa.
Owner: ILe.Pen c o.s ey
Date of Inspection:6/1 47-07-
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
�/- in�i�taato2.s ( 33'X13. 2X2' )
If SAS not located explain why:
/-oralpd: .See Rage 10
Ty e
:!!Poaching pits,number:_
aching chambers, number:
8 leaching galleries,number:_Q
leaching trenches,number, length: O
leaching fields, number, dimensions: D
overflow cesspool, number: �-
innovative/alternative system Type/name of technology: �/4, /2-/!/� C9f�t,�
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
LoamU •sand to medium fine •sand No .6.ignz o e ht/d2au&c ,Paiivae
Q2 120nd.ina So.i.eb 9 -stone .s a/te they Vg a 'on .iz noamai
CESSPOOLV) cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: p
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.):
Ce,6zaoo-P.3 ate not Pee,6ent.
PRIVV416Lk(locate on site plan)
Materials of construction:
Dimensions: A
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
no# a2p.�pnt.
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE•DISPOSA•L SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:16 7 Main St zeet
en eay.e e, ¢.��• .
Owocr:ile.�en 17770Z y
Date of lospectloo.
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system Including tics to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 (cet. Locate where publle.�vater supply enters the building.
•
00kr 0 erg
SIDE
r
•• � D�wl;w0��(
A
10
Page I 1 of 11
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 6 7 /lain Stnee.t
en e2v.e e, a76.
Owner: Ile-Pen c oz ey
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
ES Obtained from system design plans on record-if checked,date of design plan reviewed: 6114103
TT Observed site(abutting property/observation hole within ISO feet of SA$)
ye,s Checked with local Board of Healh-explain: O&t a fined a.6 el u.c2.t ea/td.
yam-Checked with local excavators, installers-(attach docume tation)
y Accessed USGSdatabase-exp lain: ht.t/2:ll.town. Taanztag2e. ma, u-s.
You must describe how you established the high ground water elevation:
11.6ed: GahlLetu & (7.i.P.Pen Mode.P. 12176194 92ound waiez e.Peva.tions move zea .Peve.P.
6,3ed: 11SG u e 1992
U,6ed. 11S Pu Uof in 92 000 1 p a P—#2 ganua2u 1992 Annua 2anye.
4- n oOounf it)nA
Jr` I�-;eet
Groundwater/d t=cct Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is 3�
feet.
11
.•rn.nh.-n.r�.•re-• wrnn•nnnrr-wn rrnrnan.r+�wn�w.nr�syn�n�rtwT .ram+T-r-..e..r..,
TOWN OF BOARD OF HEALTH
SUII3URFACE SEWAGE DISPOSAL SYSTEM INSI'RCTION FORM - PART D •- CERTIFICATION I
«•r^ �r••.-•.fie-r..t��..:rr+t.+r111•n.•rn rRRJ�e•rrsR'7m:rt't r"11RR`f wwwrlTRAAI1R.�n�'I�t7 twn 1++rrr-•1�•�. �..A
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 167 Main S.tnee.t Cen•teavi•P.2e, Ma.3b.
ASSESSORS MAP , BLOCK AND PARCEL # �
OWNER' s NAME Helen McCiQakey
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J P Macomber & SoR Ind".`
COMPANY ADDRESSBox 66 Centerville Mass. 02632
Street Town or City State ZIp
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
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 :
t System: PASSED ;
The inspection which I have conducted has not found any information
Which indicates that the system fails to adequately protect public
Ilealtll 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 zcted has found that the system fails to
Protect the ptiblic 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 f 'rm,.
Inspector Signature -1�
Date "may
ne copy of this rtification must be provided to the OWNER, the BUYER
( Where applicable ) and the BOARD OF HEALZ'JI.
* If the inspection FAILED, the owner or"* perator shall upgrade
he syste
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 16 , 306 .
partd .doc
SEWAGE INSPECTIONS
r.
LOCATION 167 Main S.t.eee.t DATE 6114103
F!IILAGE Cen.te2yi-pie, Na-6,. ASSESSOR'S MAP & LOT 208-096
--INSPECTOR a,A,,h 2- !'7n mOy.i_�,z,
SEPTIC TANK CAPACITY 1500 t P o x
• LEACHING FACILITY: (type) 4 In�ii;t2afo2z (size) 1200 gaiion-s
NO. OF BEDROOMS 3
BUILDER OR OWNER fle-en NcUo.6ky
OWNER MAILING ADDRESS
Same
t
I
SIDE
D2W6 vi
8� er, /
No.
�� Fee
TH OMMONWEALTH OF MASSACHUSETTS Entered in computer:
Y�
PUBLIC HEALTH DI ISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpplic tion for Mi$ onl *p$tem C onelruction 3dermit
Application for a Permit to Construct( )Repair( )Upgrade(yy,Abandon( ) VS Complete System ❑Individual Components
Location Address or Lot No.1(0-7 MGt ti/.! 5j Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No.l Designer's Name,Address and Tel.No.
70
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 3_310 gallons per day. Calculated daily flow 3 V!�`I gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank VS7CrV 7 Type of S.A.S.
Description of Soil U-P—swag)
Nature of Repairs or Alterations(Answer when applicable) c, "%OA 1 ��Use , v-v.
V NtAa t�-T""V�`L61C S t U O"J
t{
�4
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 Co t to place the system in operation until a Certifi-
cate of Compliance has b ' sued by this ot eat .
Signed Date
Application Approved by r Date Af
Application Disapproved for the following reasons
Permit No. Date Issued .10�
TOWN OF BARNSTABLE
LOCATION I o 7 m," .5T SEWAGE # ,� - L 7
VILLAGE_r AA ASSESSOR'S MAP & LOTAv J-- D q(�
INSTALLER'S NAME&PHONE NO.�d2� /> L'.d d /J C
SEPTIC TANK CAPACITY / S'd C)
LEACHING FACILITY: (type) (size) _
NO.OF BEDROOMS
BUILDER OR OWNER d,d,.
PERMTT DATE: in - (�_ _COMPLIANCE DATE: 1,0 --1 q
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
rja , c
kd / Fee No. '. ""
TH OMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DI ISION -TOWN OF BARNSTABLES MASSACHUSETTS
ZppYication for Digpogar *pgtem Con5tructiou Permit
App4cation for a Permit to Construct( )Repair( )Upgrade(Abandon( ) ISComplete System ❑Individual Components
Location Address or Lot No.'(c-7 NO UH W,\11 N 51— Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 5P 0g-0 (_ OR.tq,.`(4\
Installer's Name Address,and Tel.No. ICJ Designer's Name,Address and Tel.No.
L
�O 14r=`t r✓ t -y
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 3?U gallons per day. Calculated daily flow 3 yc1 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 15c'v N Type of S.A.S. 0^Ca eck , S lam'
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Co t to place the system in operation until a Certifi-
cate of Compliance has b ssued by this f ealth. q
Signed Date �b <
Application Approved by ' Date
Application Disapproved for the following reasons t
7
Permit No. ' 40,70 Date Issued /0-
a ,
THE COMMONWEALTH OF MASSACHUSETTS /
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewa a Di s osal System Constructed( )Repaired( )Upgraded(V)
Abandoned( )by 1M` C?--G-A 9E_5C
at (.Q-1 tj b(ZN N 0,"—, eJ Sl , G �(10k has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. '� <, dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system A4\1,Lfuriction as designed.
Date �f`?- (1^ - ' Inspector
*%N
No. �°` --------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Digpogal *pgtem (fongtruction Permit
Permission is hereby granted to Construct( )Repair( )U grade(Abandon( )
System located at �� ff� ti �- S 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:Construction must be completed within three years of the date of ermit.
Date: of Approved4 ? ' xi� 7
TOWN OF BARNSTABLE'
LOCATION 162 ffylau , .5T SEWAGE # :28 - 7 a-
VH:LAGE— C-za4 -r `Q, ASSESSOR'S MAP & LOT-2 0 8- 096
'INSTALLER'S NAME&PHONE NO. 42 4 Q CA
d S,P/J C
-SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 141&LZe—d-tO6:� (size) _
NO.OF BEDROOMS .9
BUILDER OR OWNER Jrr, alzdA,
PERMIT DATE: 16 -J� COMPLIANCE DATE: 1,0 =1 y --
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
a. i
//U
� ,,
�, �r�� ��
��4a � 3- -
„� -- 1019/97 I
I
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only:
t
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
�`�'� ,
construction permit signed by me dated �`” concerning the
property located at (�kac` k_ meets all of the
following criteria:
Lr
Th are no wetlands located within 100 feet of the proposed leaching facility
G�
?here are no private wells within 1 S0 feet of the proposed septic system
ere is no increase in flow and/or change in use proposed
4 There are no variances requested or needed.
• f the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of.the
proposed leaching facility will nM be located less than fourteen (14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) r_f
VI
B)Observed Groundwater Table Elevation(according to Health Division well map)
?io 4
DATE:
SIGNED:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
3
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