HomeMy WebLinkAbout0221 MONOMOY CIRCLE - Health 221 MONOMOY CIRCLE, CENTERVILLE
A= 191219
I
�lf3F.C7�:
UPC 12543 -
No. 53LOR
HASTINGS, ml
I
I
`.....--.'...�� Fps.. ....3 Q.t.O 0....
No. --.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH AV-
TOWN OF BARNSTABLE
Apphratiou for Bivjipuual lVar1w Towitrurtiun remit
Application is hereby made for a Permit to Construct ( ) or Repair kX) an Individual Sewage Disposal
System at:
..... 2A....NiS1I39mOYc1e.-Centerville -••---------•---••-------------•-••-•-------••---•••--•----•---
----
Location-Address or Lot No.
...... ARchie Ha .e,5---•-------------•-•----......-----------•-
.........................
owner Address
a J.P.Macomber Jr...............................
Installer Address
Type of Building Size Lot............................Sq. feet
.a DwellingX—No. of Bedrooms............a-----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons-------2----------------.. Showers ( ) — Cafeteria ( )
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.
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........................
44 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-.---._---_--__--_-----.
0 Description of Soil---------- -•--------
� ........................Sand...&...Gravel -----------------------------•----------------------------------------------------------------------------------•--•-----------•-•--........
W
--------------- - ------ ----------------------------------------------------------------------------------------------------------------------------------•--•----•-•---•-----•--•-----------------•--.
V Nature of Repairs or Alterations—Answer when applicable.Add..-1,1-Q-Q 0.._gal1nn.._le3Ch_--pit....tn...an
.......................existing---tank...&...P-i t-•---------------------------------.......-----..._....----------------------------------------------------•------•--------
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 bee Pi
. sued by the b and of health.
Signed .. r. .. G ...'
------------- --------................... -- _
3 ..28- -95 - ....
�� Date
Application.Approved By
-------------------------------- --- ------- --------------- - ----------
Date
Application Disapproved for the following reafons: ............................................................
- - -------------- -� ............._.......................... - '`.....�.... .._
Permit No. z✓ � ................. Issued :.. ......................................
Date
F 1
TOWN OF BARNSTABLE
f
LOCATION 41 p,y c jd® SEWAGE # -" 'Ft
VILLAGE C If,y I e 2 v iL L P ASSESSOR'S MAP & LOT
INSTALLER'S NAME A PHONE NO. 4 !L . emsmg
SEPTIC TANK CAPACITY 1-2 /f/ r
LEACHING FACILITY:(type) ,vex (size) / a
NO. OF BEDROOMS - PRIVATE WELL OR PUBLIC WATER
R OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: '" ''' 0-•�7
VARIANCE GRANTED: Yes No
.v e&1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(ger#ifirate of Coraptiance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX)
JP.Macomber Jr..
by -- .
-----------------------------------------__ ---- - - - - - - ...... -
"staller
at - ..22.1..._Monomoy .Circle- Centerville -
----------
has been installed in accordance with the provisions of TITLE of he S to Environmental Code as described) T�
the application for Disposal Works Construction Permit No. ., �_..� .- dated �.""..� ._. JGJy7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIILLLFFUNCTIONLSSAATISFACTORY.
DATE ./v �--l - ----- Inspec ..... - ------------- -- ---------------------------- ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� � TOWN OF BARNSTABLE 3.0...00
No........................... FEE . ....
Biqunli.a1 Works Tnno#rudion amit
Permission is hereby granted.--J.P_.-Macomber... r.--------------------------------------------------------------------------------------------
to Construct ) or '
Re airX(X ) a Individual Sewa e Disposal System
21 Mon c�my ircle Centerville
atNo............... ----- - ------------------------------------ --------------------------------------------------------------------------------------------------------------------------
se
as shown on the application for Disposal Works Construction Per `-._... _ Dated-.- --- .. .....--
---------------- ------- , � 4�- --L( ✓
Board of Health
DATE----- -----------------------------------
FORM 36506 HOBBS 6 WARREN.INC..PUBLISHERS
�
No.-•--4FZ-•? ;�7 Fes$. ...D.e.9.0....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH A/ ��9
TOWN OF BARNSTABLE
Appliration for Dijv i!ial Worbi Toustrnrtinn ramit
tApplication is hereby made for a Permit to Construct ( ) or Repair kx) an Individual Sewage Disposal
System at:
221 ------Monomov Circle Centerville
- --------------------•-----••----..... -----------------------------------------------•------------------••--------•--••---...-----------
Location-Address or Lot No.
A-Rchie H2tves
Owner Address
a ........................ _.P.-Macomber..Jr. ---•-- ------------------------------•--•----....-------- --
Installer Address
Type of Building Size Lot............................Sq. feet
Dwellings No. of Bedrooms.---.--.----3-----------------------------Expansion Attic ( ) Garbage Grinder ( )
PL4 Other—Type of Building ---------------------------- No. of persons--------2------------------ Showers ( ) — Cafeteria ( )
a' Other fixtures --------------------------------- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitv------------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-------------------------------•--------
,� Test Pit No. I................minutes per inch Depth of Test Pit-----------------... Depth to ground water.......----.............
(14 Test Pit No. 2................minutes per inch Depth of Test Pit--.--.---...--...... Depth to ground water.....---......--....---.
.....------•-----------------------••-----...............--•---.....--------------•---------•................................................................
ODescription of Soil........................................................................................................................................................................
xSand--- .... ravel----------------------------------•----------------------------------------------- --------
U .
W
--------------------------------------------------------------------------------------------- ••----------......-----------------....---------------------...---------------------•---------•---•------.
V Nature of Repairs or Alterations—Answer when applicable.&M..-1--A Q n Q..-aa.1 011---laacYl---pi_t...t o...a><a
....................... .m.........................................................................................................................
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 bee• issued by the b.and of health.
Signed - - ��r..� � --'/f........ 3/.z 8/.9�`.......
U/f� r� Dale
Application.Approved BY v✓ --- ------------------------- ----- ---------------- ------ram.. ..`,�13---.��
Da[e
Application Disapproved for the following reasons: ............................................... ----------------------------------------------------------------------------
........ ..................---------------------- ---------------------------------------------------------------------------------------------------------------- ---- ..... - ---------------
Permit No- ---------- ------
�;/ Issued `........��. 1� i- --------'----------------
Dare
) 9/
DATE:_1./1.6/96 .
PROPERTY ADDRESS: 221 Monoad-circle n
Centerville , �
Mass . 02632 JAN i 9 1995
.--- -- - - - HEALTH oEPI:
'AKIN OF BMISTABLE
On the above date, I Inspected the s-eptic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank.
2 . 1 -Distribution box.
3 . 2-1000 gallon leaching pits packed in stone .
eased bn my Ing:w.ction, I certify the following conditions:
1 . This is a title five septic system. .' 78 Code )
2 . T4e optic system is in proper working order
at the present time .
3 . No repairs are needed �at this time .
r
SIGNATURr, :
Name : J . P . Macomber Jr.-
Company: J . P .-Macomber & Son '-Inc ..
Address:_-BQ-X-66------ I----.--
Centervill,e LMass__02632
Phone:---
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
ffi •
JOSEPH P. MACOMBER & ,SOD
Tan,zs-CeupoolrLeachfleld:
Pumped Inst"0
Town Sewer Connectlons
P.O. Box 66 ' Centerville, MA 026
775-3338 775-64`12
s
;J Commonv,'eeim of Mlv.;�o,--[ _;sells
Execulive Oii)ce of trt, fon i;enicl ;'-.!l�.,ls
pepartment of Protection
Environmental Pro
Wllllam F.Wold
a w.rnN s
Trudy Coto' •
S+u,r.ry,EOE-A
pavld D. Suuhs.
CormJ,+Ion,r
SUBSURFACE SE1'i:-,CE•DISNOSAL S1'S7EA1 INSPECTION FORA
VART A
CERTIFIC.\TIO.N
Address of O�rncr,
Property Address: 221 Monomoy Circle Centervilleuf dilferrr;t)
Date of Inspection: 1 /1 6/96
Name of lnspectorJose }� R, Mq p r r Jr.
Con an Name, Address Pi Telph0�
J. .l acomber & Son Inc . Box 66 Centerville,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
disposal system at this address and that tile information reponed below is true, accurate
I certih, that I have personally inspected the se.vab' d based on '
rn, training and experience in the proper function and
and complete as of the time of inspection. The inspection w s perr ot11e
maintenance of on-site sewage disposal systems. The system:
zPasses
_ Conditionally Passes ity
Needs Funher Evaluation By the Luca' '\pproving Authu'
Fails
GGf�-'� Date:
Inspector's Signatvre��%
) days Of
lIg
is
The System Inspector shall submit a copy of Lhis anspeCtiOn re, on to rise npA(� �!fg iy'I`o'iti e improorrt and Othe systen, Ownee11Shall lsubmit
inspection. If the systern is a shared system or has a Bert neik ., Ef !0.000e Pj f'rotecuon.
the iepon to the appropriate regional office of the OePa
The original should be sent to the system owner and cco es set to the buyer, ;i a;�pl icable and the approving authonty.
INSPECTION SUMMXRY:
Check A, B, C, or D:
A) SYSTEM PASSES:
--k1— I have not found any Information v;hicit :nd,_ates that the systerir :>
:i ti,�. '.:,i,::e c:�tcria as defined in 31U CnSR 15.303.
Any failure criteria not evaluated are indicates Lelv".
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of detemtination in all instances. If 'not determined", explain why not)
/ } The septic tank is metal, cracked, structurally unsound, sho,,•rs substantial infiltration or ex conforming
or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic wnk as
�J approved by the Board of Health.
t
trcvlscd s/:5/S51
C.9 • T•lophon. (617) 292.5500
On. WIntor Suoot . t3oston, MassachusoCts C''ICU • F (G17) SSG 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 221 Monomoy Circle Centerville ,Mass
Owner: Archie & Patricia. Hayes
Date of Inspection: 1 /16/96
eJ SYSTEM CONDITIONALLY PASSES (continued)
AP 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):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or 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) FUR i Iil.R EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
k Conditions exist which require further evalLation by the Board of Health in order to determine if the system is failing to protect the
public health, safely and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 'THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 'eel of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2)' SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM iS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
p y I 1"" f rfacc pp!y G. tituVtai•j LC a
The ',�51en1 nds d >eUt�l ldlll. JIIU )Uu db)Uf'liull ) SlEll'i ,illu I,i Kii ill's vv 2ci to a SU, u..l 1'�ater SU �
surface water supply.
The wstem has a s?ptjc tank and soil absorption system and is within a Zone I of a public water supply well.
1 ' The sy.tem has a se,;ti; tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a sep:ic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well seater analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollutio;i from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D) SYSTEM FAILS:
/LJ0 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is idel,ti`ied below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
I! Backup of sewage it t) facility or system compone it due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface )f the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/55) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 221 Monomoy Circle Centerville ,MASS . 02632
Owner: Archie & Patricia Hayes
Date of Inspection: 1 /16/96
D) SYSTEM FAILS (continued): o
•
Q� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
m-"Alr�
Liquid depth in cesspool 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
�Q i%ny 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.
1�T Any portion of a cesspool or privy is within 50 feet of a private water supply well.
QZi} 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.
EJ LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
_Q The design flow of system is 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:
the system is within 400 feet of a surface drinking water supply
A 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 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 221 Monomoy Circle Cen'terville ,Mass .
Owner: Archie & Patricia Hayes
Date of Inspection: 1 /1 6/96
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
one 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.
_J/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
ZThe site was inspected for signs 110(breakout.
ynlc�llp+�t�
ZAll system components, e*e144+tthe Soil Absorption System, have been located on the site.
/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
-k/—/The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
/The facility ianj occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 221 Monomoy Circle Centerville ,Mass .
Owner: Archie &- Patricia Hayes
Date of Inspection: 1 /16/9 6
°FLOW CONDITIONS
RESIDENTIAL:
Design flow: 77 V all s.�a'✓�� �
Number of bedrooms: •�
Number of current residents: :2
Garbage grinder(yes or no):
Laundry connected to system (yes or no): gib
Seasonal use (yes or no):ti�0 G �
Water meter readings, if available: 199 �s e r
— 2
Last date of occupancy:
COMMERCIALJINDUSTRIAL:
Type of establishment: Ald
Design flow:k#4 gallons/day
Crease trap present: (yes or no)
_W7
Industrial Waste Holding Tank present: (yes or no)
n-sanitary waste discharged to the Title 5 system: (yes or no)
`,titer meter readings, if available: !L)17L
Last date of occupancy:I_
OTHER: (Describe) R/A
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and�- source o infi� i n: 5
System pumped as part of inspection: (yes or no) Q0
If yes, volume pumped. gallons
Reason for pumping:
TYPE OF YSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
A Overflow cesspool
NP Privy
A!(_') Shared system (yes or no) (if yes, attach previous inspection records, if any)
/L)7 Other(explain)
APPROXIMATE AGE of all compggge nts, date installed if.kno n) an source o fi formation: 1
�.v •.4
gage odors detected when arriving at the site: (yes or no)— � Q�
(revised 8/15/95) 5
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 221 Monomoy Circle Centerville ,Mass .
Owner: Archie & Patricia Hayes
Date of Inspection: 1 /16/96
IiEPTIC TANK:-Le, ID00�r
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _FRP other(explain)
Dimensions:
'Tv' t
Sludge depth: V'
Distance from top o:sludge to bottom of outlet tee or baffle:7-
Scum thickness:�hr'�
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 7Y -(-
Comments:
(•"'ommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
:rity, evidence of leakage, etc.) Septic tank should be pumped every 23 years . The
tees are structurall-v sound N
evel in tt
_sound. No repairs are needed at the present time .
GREASE TRAP:A
(locate on site plan)
Depth below grader
Material of construction:42&oncrete _metal _FRP _other(explain)
f�
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Di tance from bottom - cron, to wttnn' of outle! tee or Uatll('�
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, e(c.i
(revised 8/:5/95) 6
SUBSURFACE SEWAGE DISPOSAL SYS11m INSPLCTION FORM
PART C
SYSILnt INFORMAFION ,cuntinued)
Property Address: 221 Monomoy Circle Centerville ,Mass .
Owner: Archie & Patricia Hayes
Date of Inspection: 1 /1 6/96
a
TIGHT OR HOLDING TANK:.&D
(locate on site plan)
Depth below grader
material of construction: concrete _metal —FRP —uther(explau )
D,rnensiont All?
--------------—.
Capacity — AV gallons
Design ilu" / galluns'd;r,
:�!;inn Ir:irl f]i
Comments
(condition 01 inlet tee, condition of alafm and ilu.it wilchcS, etc.)
AW
-----—--
DISTRIBUTION BOX: E'-j
(locate on site plant
Depth of liquid level above outlet mveri ._
Comments.
Vtuit i ie r: an;i ;1 Ur of box, etc I
Distribution box is level ;No evidence of leakage in or out of the�ox-
The box is structurally-sound__._No repairs.-__are needed at this time.
l'UMP CHAN%BEk:"
:!ocale Un Site plan)
Pumps in working order.lye5 or no;-Am
Comments:
(note condition of pump chamber, cwid;: ;c,r ui ;:.a :(.: .t r,i ,i;2puru'nan0.uS, --
�i(l Cja ------
t:ev.sed 7
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Archie & Patricia Hayes
Owner: 221 Monomoy Circle Centerville ,Mass .
Date of Inspection: 1 /1 6/96
SOIL ABSORPTION SYSTEM (SAS):
Z
Jed 9��'
(locate on site plan, if possible; excavation not required, but y be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, n-jmber._,0V1
leaching cham'uers, number:
leaching galleries, number:
leaching trenches, number,length: (�J
leaching fields, number, dimensions: Z
overflow cesspool, number:Q
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
Sand & gravel to medium sand_DLO S3 LZAS Q-r hydraulic failure or ��nr]; n�
IAll Vegetation nermal _I� repair d a+ the present time
CL. DOLS: '
(locate on site plan)
Number and configuration: AA
Depth-top of liquid to inlet invert: —
Depth of solids layer:
Depth of scum layer: �lA
Dimensions of cesspool: >�� —
Materials of construction: /
indication of groundwater
inflow (cesspool must be pumped as pan of inspection)
Comments: (note condition of soil, signs of hydraulic iailure, level of ponding, condition of vegetation, etc.)
i
PRIVY:
(locate on site plan)
Dimensions:
Materials of constr ctron:
Depth of solids:AM f .
Comments: (note conditidn of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
8
(revised 8/15/95)
IC
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 221 Monomoy Circle Centerville ,Mass .
Owner: Archie & Patricia Hayes
Date of Inspection: 1 /1 6/96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' Centerville Osterville Water.
q 9'
�v
""rb
t
► i � IO
X
1
DEPTH TO GROUNB;Y
Depth to groundwater: eet —
method of determination or approximation: Installed New Leaching j�i_t, 3/3OJ95 _ No Water encountered
at 12 ,, Ori gi nal 1Z1 a n on fi 1 P at the Town of Rarn-,t,ahl a Rnarrj of
health No water PnnnuntPred at. 121 alsn _
(revised 8/15/95) 9
ll
'I.OWN OF Barnstable BOARD OF 11EALT11
S(111S1J1?FACF 9EWA(;E DISPO 9AL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 221 Monomn;z rjrr-1 ,_ Centerville Mass .
ASSESSORS MAP , BLOCK AND, PARCEL #
OWNER' s NAME —Archie & 'Patricia Hayes
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr. .
COMPANY NAME J. P.Macomber & Son Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( Snp ) 77 3338 FAX (508 1 790 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage dispo-saj system at
this address and that the information reported is true , accurate , and
complete as of the time of .iinspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenarrce of on-
site sewage disposal systems .
Check one :
XXXXXXXXX Systeai 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 conducted has found that the system fails to
protect the public health and the environment in accordance with Title
6 , 310 CHR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector 8ignatur �1�14 J� bwl
Date 1 /1.6/96
One copy of this certification must be provided to the OWNER, the BUYER
where applicable ) and the 130ARD OF IMAL'I'll.
the inspection FAILED, the owner ar"'o*P* e'rator shall upgrade I the ayetem
within
wit, one year or the date of the inspection, unless ess allowed or required
otherwise as provided in 310 ChIR 16 - 305'.
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTIOT
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
L
June 8, 1995
Acting Director of the -ion of Water Pollution Contrc