HomeMy WebLinkAbout0410 NYES NECK ROAD - Health 410 NYE'S NECK R.D.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William Nancy Johnston
Owner Owner's Name
Information is Centerville MA 02632 6-15-18
requlr�ed for every -
page. CityrTown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
�y,�a��' +au,
on the computer. OF ,,,y�1 .....�Gs yiy�
use only the tab 1. Inspector:
key to move your
JAMES a
usecursorthe
•do not James D.Sears M
use the return Name of Inspector to tt` *ZhARS 4
key. Ca ewide Enterprises
Company Name
� 53 Commercial Street
Company Address
Mashpee MA 02649
cftyrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
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 16.340 of
Title 6(310 CMR 15.000).The system:
® 'Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-27-18
pectors Signature Date
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 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.
*"*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 systein will perform In the future under
the same or different conditions of use.
tSms.doc•rev.W16 TWe 5 Official Inspection Form:Subsurtece Savage Disposal system•Page t of t 7
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William&Nancy Johnston
owner Owners Name
inforrnarequired
is Centerville MA 02632 6-15-18
required for every
page. Ckyrrown State Zip Code Date of Inspection
B. Certification (cont)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
The system is a 1000 Gal.Tank D Box and four chamber's
S) 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.
Check the box for"yes","no"or"not determined"(Y,N, ND)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.
❑ Y ❑ N ❑ ND(Explain below):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owner's Name
friformrequir dfotion is Centerville MA 02632 6-15-18
required for every
page. CWTown State 2lp Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Condltlonally Passes(cont.):
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
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.
I. 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 wfthin 50 feet of a bordering vegetated wetland or a salt marsh
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Commonwealth of Massachusetts
moms Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Nbt for Voluntary Assessments
u5l;
s
410 Nyes Neck Road
Property Address
William&Nancy Johnston
owner Owner's Name
information is Centerville MA 02632 B-15-18
required for every
ppge. City/Town Stele Zip code Date of Inspection
B. Certification (cons.)
2. System will fail unless the Board of Health(end 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 1 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 fecal
coliform bacteria indicates absent 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:
0) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for;li inspectlons:
Yes No
® Backup of sewage into facility or system component due to 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
❑ ® Liquid depth in is less than 6"below invert or available volume is less
than'/2 day flow. L£ elmvG
dlmdoc•rev.ens rae s Official Inepeo ian Form Srbsurface sewage Dkposat system-Pace a m 17
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owner's Name
information is required for every Centerville MA 02632 6-15-16
page. Ci yrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 9 Any portion of the SAS,cesspool or privy is below high ground water elevation.
Cl
® Any portion of 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 1 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. [This
system passes tf the well water analysis,performed at a DEP certified
laboratory,for fecal collform bacteria Indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this forma
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,0009pd.
❑ ® The system falls.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 10,600 gpd to 16,000 gpd.
For large systems,you must indicate either'yes"or"no"to each of the following, In addition to the
questions in Section D.
Yes No
❑ ❑ the system Is within 40D 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
If you have answered"yes"to any question in Section E the system is considered a significant threat,
oranswered"yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat unifier 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.
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Commonwealth of Massachusetts
lam Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fort-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owner's Name
information
required for every Centerville MA 02632 6-15-18
page. Ckyaown State Zip Code. Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping Information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has 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 NIA)
® ❑ 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,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered,opened,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?
❑ ® 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:
® ❑ 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 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DBSIGN flow based on 310 CMR 15.203(for example: 110 gpd x*of bedrooms): 440
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road _
Property Address
William&Nancy Johnston
Owner Refs Name
Information is
required for every Centerville MA 02632 6-15-18
page. Citylrown State Zlp Code Date of Inspedion
D. System Information
Description:
1000 Gal.Tank D Box and four chambers.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Well Water
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: PresentDate
CommerciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatstpersonsfsq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-saMtary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
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Commonwealth of Massachusetts
NOME. Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owner's Name
information Is required for every Centerville MA 02632 6-15-18
page. Chyrrown state Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
9 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)
Cl Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
Inspection of the I!A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5lnsAoc-rev.e1r8 Thle 5 Official Inspectlen Form Subsurface Sewage Olepesel System-Pepe 8 of V
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owner's Name
information k Centerville MA 02632 6-15-18
required for every
page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed(if known)and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage, etc.):
Pipeing is 4" PVC SCH-40.
Septic Tank(locate on site plan):
15"
Depth below grade: feet
Material of construction:
®concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal.Precast H-10
Sludge depth: 2
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William A Nancy Johnston
Owner Owner's Name
information is Centerville MA 02632 6-15-18
required for every
page. CltylTown State Zip Code [gate of Inspedion
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 18'
How were dimensions determined? Asbuilt Plan-Tape
'Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank at working level.Tank and covers at 15"below grade.inlet wall baffle wloutlet baffle. No sign
of leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
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: Date
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owner's Name
information Is required for every Centerville MA 02632 B-15-18
page. Citylrovm State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(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: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Dace
Comments(condition of alarm and float switches,etc.):
'Attach copy of current pumping contract(required).is copy attached? ❑ Yes ❑ No
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• I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owner's Ni3me
information is required for every Centerville MA 02632 6.15-18
page. ciyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(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.):
D Box is 16"x18"-21"below grade wlcover at 2". Box is clean and solid wlone line out.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No'
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
•If pumps or alarms are not in working order,system is a conditional pass,
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located,explain why:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owner's Name
Information Is
required for every Centerville MA 02632 6-15-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovativelalternative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failu(e, level of ponding,damp soil,condition of
vegetation,etc.):
Leaching is four flows(6461. Flow's are wet w/no sign of over loading.Flow's at W above G.W..
Cesspools(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 ❑ No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
410 Nyes Neck Road
`l Property Address
William&Nancy Johnston
Owner Owner's Name
information is required for every Centerville MA 02632 6-15-18
page. Cityfrown State Zip Code Date of Inspectlon
D. System Information (cont.)
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(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.):
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Commonwealth of Maseachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.Not for Voluntary Assessments
F
410 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owner's Name
information is required for every Centerville MA 02632 6-15-18
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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.Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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Commonwealth of Massachusetts
1501Title 5 Official Inspection Form
a) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 410 Nyes Neck Road
Property Address
William&Nancy Johnston
owner Owner's Name
information is Centerville MA 02632 6-15-18
required for every
page Citylrown State zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
8'
Estimated depth to WN ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ 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:
G.W.at 8'.Bottom of flow's at 4'above G.W.
Before flling this Inspection Report,please see Report Completeness Checklist on next page.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
00 Nyes Neck Road
Property Address
William&Nancy Johnston
Owner Owners Name
Information is required for every Centerville MA 02632 6-15-18
page. Citylforin State Zip Code Date of Inspection
E. Report Completeness Checklist
® 'Inspection Summary:A,8, C,D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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COMMONWEALTH OF MASSACHUSETTS 9 10
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA1'
DEPARTMENT OF ENVIRONMENTAL PROTEpCTION �rr 4
ONE WINTER STREET, BOSTON MA 02108 (617)292 5500 ` jY •
t% JUL 25 200
11TMDRUDY COXE
Secretaiy
ARGEO PAUL CELLUCCI DAVIDSTRUHS
Governor 1'N Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 410 Ayes Neck Road, Centerville, MA Name of Owner: Dr. William Johnston
Address of Owner: Same
Date of Inspection: July 12, 2000
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 232
Telephone Number: (508)862-9400 Lot. 001
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 Evalua on y the Local Approving Authority
%1fth
Inspector's Signature: V Date: July 1 Z 2000
The System Inspector shallpy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days
of completing this inspectistem 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.
NOTES AND COMMENTS
revised 9/2/98 Page 1of11
j Printed on Recycled Paper
I
f �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 410 Ayes Neck Road, Centerville, MA
P Y ,
Owner: K r Dr. William Johnston
Date of Inspection: July 12, 2000
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
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 complying septic tank as
approved by the Board of Health.
_ 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
revised 9/2/98 Page 2of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 410 Ayes Neck Road, Centerville, MA
Owner: Dr. William Johnston
Date of Inspection: July 12, 2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)
THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SASS`and the SAS is within,100 feet to 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 1 of a public water supply well.
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 (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 410 Ayes Neck Road, Centerville, AM
Owner: Dr. William Johnston
Date of Inspection: July 12, 2000
D. SYSTEM FAILS:
You must indicate either"Yes" or"No" as to each of the following:
_ 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 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.
Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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_.
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 1 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 11 of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 410 Ayes Neck Road, Centerville, MA
Owner: Dr. William Johnston
Date of Inspection: July 12, 2000
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.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ As built plans have been obtained and examined. Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ _ All system components,excluding 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 conditions 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:
✓ 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 owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
SYSTEM INFORMATION
Property Address: 410 Ayes Neck Road, Centerville, MA
Owner: Dr. William Johnston
Date of Inspection: July 12, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 4
Total DESIGN flow n/a
Number of current residents: 3
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no):No; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two year's usage(gpd): Private well
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: wA(Based on 15.203)
Basis of design flow
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: `
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped on March 29199-per treatment plant
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
✓ 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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: Dec 7182-per as built card.
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
5 S ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 410*es Neck Road, Centerville, AM
Owner: Dr. William Johnston
Date of Inspection: July 12, 2000
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 15"
_. Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 1000 gal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 5" -
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How dimensions were determined: Measuring stick
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.) The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None
(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:
(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.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 410 Ayes Neck Road, Centerville, MA
Owner: Dr. William Johnston
Date of Inspection: July 12, 2000
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) A new D-box was installed
(Permit#2000-413) There were no signs of back-up from the leach field
PUMP CHAMBER: None
(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.)
revised 9/2/98 Page 8of11
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 410 Nyes Neck Road, Centerville, MA
Owner: Dr. William Johnston
Date of Inspection: July 12, 2000
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits, number:
leaching chambers,number: 4 flow diffusors w/2'stone(per design Plans&as built card)
leaching galleries, number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
r (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
The flow diffusors were not dug up. There were no signs of back-up in the D-box. The bottom to grade was approximately 38.S".
CESSPOOLS: None
(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(cesspool must be pumped as part of inspection).
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY: None
(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.)
revised 9/2/98 Page 9of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 410 Nyes Neck Road, Centerville, MA
Owner: Dr. William Johnston
Date of Inspection: July 12, 2000
Map: 232
Lot: 001
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house) O
X.
loa
1 o
io oa Al
� 3 Aa-
6a-
p3- 38 '
Q3-
AN - a a"
ray - al "
revised 9/2/98 Page 10of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 410 Ayes Neck Road, Centerville, MA
Owner: Dr. William Johnston
Date of Inspection: July 12, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
✓ Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
✓ Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. Must be completed)
Using a transit for elevations, the bottom of the flow dffwors was 37.33', the lake elevation was 33.92', with a separation
of 3.41'. There is no high groundwater adjustment for this site per the Health Department.
This report has been prepared and the system inspected and passed as of the date of inspection. This repon is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
OL
Q9
R ► T-I:�ctAZ�- Tc
l
TITLE V
SEPTIC INSPECTION
REPORT
Prepared for:
410 Nyes Neck Road
Centerville, MA
James M. Ford P.O. Box 49
D.E.P. Licensed Inspector Osterville, MA 02655
Tel: (508) 862-9400
w
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT ' KNOWN. THAT
Jim Ford
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEMINSPECTOR
as provided in' 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued.by The Department of Environmental Protection.,
June 8, 1995
Acting Director of the •ton 4 Water-Pollution Control
t
University of Massachusetts Cooperative Extension System
Issues in WATER QUALITY
` `YOUR SEPTIC# :S �
Septic System Additives;,Septic Tank cleaners x
and Hazardous Household products
What are septic tank cleaners and Septic System acid and sodium hydroxide may cor-
additives?How useful are they?What rode the concrete in the tank, cesspool
is their impact on the environment? Additives fall into three
p Cate or seepage pit.
OI'IeS:
When properly designed, installed g In concentrated forms,these chemi-
and maintained,on-site septic systems cals should be handled only by profes-
may function trouble-free for many 1. Yeast, bacteria, enzymes sionals.They are very caustic and may
years.Some systems,however,develop Manufacturers of these products usu- lead to personal injury or damage to
problems due to outdated designs, im- ally recommend that you regularly add your septic system.
installation or improper mainte- these products to the septic system via
proper Hydrogen peroxide should be used
nance.The owner of a failing system is the toilet. They are harmless to the only in specific soil conditions.If used
faced with several choices, most of environment and of little value to improperly,it will make leaching prob-
them expensive. your system. Sewage naturally con- lems worse rather than improve soil
tains vast amounts of yeast and bacte- permeability.
ria that maintain themselves without These products bring temporary (a
What do Septic System need for supplements under normal few months)relief from a clogged leach-
Additives claim to do operating conditions.
In fact, use of these products may ing area and do not address the basic
for your septic p y cause of the failure.At best,they should
damage your septic system. Research be used only in emergencies thereby system? has shown that some of these products
re-
Homeowners are often tempted by the may cause the production of methane. allowing more time ss consider the cause o o
f
seemingly low cost of septic tank addi- This gas bubbles through the septic pairs that truly address
tives that claim to be alternatives to tank and refloats sludge particles that the failure.
costly repairs.Some 12,000 septic sys- flow into the leaching area and then Inorganic compounds may::affect
tem additive products on the market may end up clogging the soil. groundwater by increasing the concen-
claim that they save maintenance cost Yeast,enzymes and bacteria are also trations of salts or metals(such as cop-
or prevent failures. They claim to do not required to restart your system after per)in the water that flows out of the
this, for example, by regularly feed- you have had your tank pumped.There septic tank. However, given the total
ing your system with bacteria or yeast, are enough microorganisms in the tank volume of water used in the average
or to fix an already existing problem to perform that role. system,these effects can be considered
by reopening or unclogging your negligible under normal conditions.
leaching facility. 2.Inorganic chemicals
Inorganic septic system additives,such 3. Solvent-based,
Why is there concern as sulfuric acid, sodium hydroxide or non-biodegradable products
about the use of these hydrogen peroxide,are used to restore Compounds, such as methylene chlo
a clogged leaching area, (the rim ride(MC)and trichloroethylene(TCE),
products? cause of septic system failure) These were commonly used as degreasers
There are three concerns connected with additives destroy the excessive organic or drain openers.They are hazardous,
the use of commercial septic system matter that has accumulated around the substances. TCE is a carcinogen.
additives: leaching facility keeping the wastewa- Because of their potential to con-
•using them may harm your system; ter from. getting into the soil. They taminate groundwater, manufactur-
should be applied directly to the leach- ers have removed TCE and MC from
using them may contaminate ground pp y Before products.i her applying
water; ing facility. Application through the t p any
septic tank dilutes the.product and re- product, the user should read the la-
• using them may be ineffective,but will duces its effectiveness. Also, sulfuric bel to ensure that these chlorinated
discourage you from investing in mainte- hydrocarbons are not present.
nance and repair when needed.
University of Massachusetts,United States Department of Agriculture and Massachusetts counties cooperating.
Cooperative Extension offers equal opportunity in programs and employment.CR-0368:1OM-12/94
' Economic Legal Issues however,is quick to point out that this
Considerations connected with Septic does not constitute an endorsement of
�/
Before considering use of an additive, System Additives: the product's effectiveness.
you should compare its price with that As of April 1, 1995 it is illegal to use Additional Information
of regular septic tank pumping.Pump- or recommend septic system additives More information on environmen-
ing every three to five years may be unless they are on a list of state ap- tally safe and cost effective septic
less expensive than using additives proved products. The criteria used system management methods may be
over the same period. Most important, for approval of products is that they obtained by contacting your local Board
pumping has been proven to work by do not harm the system's compo- of Health, your regional DEP office or
extending-the life of your system.Most nents or function and do not adversely nearest UMass Extension Center.
additives make claims that cannot be affect the environment. The state,
substantiated.
c
How doHazardous ,'Household°Products AffectYour.System
� � ,, •a 3 ,,. # �., �F. � .. ''ter:.
e_Howcan fi dispose Uof household Chlorme.bleacK m Salt13
brine fxom water softeners
ch&hical roduets in a:manner that` ' .�
P Research show's that it take''sev, .Dumping the regeneration bnne ;
does nothann the septic system orthe = eralgallons Hof: liquid:household �>from orate'r$softeners:into "your septic s
PleAl
lk
en"vironment� �, g,i,, ach to destroy;all the,bacteria in s'stem should have no adveise effect_�i � i as s '. �` < .xC r 72 r .. Y G,
xMany';xbwners Hof xhomes� with.,}�: erose tic tank,The bacteriapopula on thehfe of iYucrooganisns ui your
�^, Y p 3. . T tin j
n-site wastewater systems�are con-* 1 tion�recovers its:""ongmal, strength tank but may<shorten the,life of your*
°t,.�,"cerA I about�how theirsystems will witYiui 30 hours,of=normah;sephc ;;aeach rig facility if it:�is iri clay soils. '.aTi f r ::3 a k.W 9 r'kk"ems ,„�"Fa' ',,.,g' #i ti<,'Y - >r 2„• +Y
be effected b the use or disposal of fystem'operation. This°ifieans:that a , P �� k
liazardousouseholdproducts such normal use'of"householdbleach'has �Do`not useyourzseptic'system'
asfbleach, aundrydetergents; Left no negative effecton"your system as ahousehold hazardous
�Ickover painttliiniers d am cleaners, 4 :rv
. waste depository .
, tir:pesticdes �D>su�fectants. +� While there is little reason�o woiry�
r ,
. k �� � rSlaily,it takesraboutfive'galaboutnonnalusetof the�above.sub
_, xlohso�Lysol*todestroy,thebactena, stances, you*`do�riot want,`to dumps
� �W it"�About Hor>rae�
.; 1' population;with"a similar recovery leftoverhgaidfloor�,wax, fi nitiue
t GleanerSnd �p .�,�; nine ofra day,and:a half ' �ti , porsh�pesticdes;paint thinner,auto
. Detergents? mouvehquid',suchasantifreeZe,brake
a s,,
,
� -,i Crystallized drain cleaners.
Iif fWt ffects Af ordm house ,fluid o battery acid down your drain r,�.�
�� However,ittaesonlyoriecuprof � Whdettie do�riotharm oussterts �
z �ldehemica ,onsegsystemop , ,crystalized'dram�cleanertordestroy'� v'p�rforina ce; theyrdo," ass right
do area en overempliasi%ed � the bacteria m the se tic tank and the a ` ' '�r °` $
P through it into the groundwater sip
fDome care roduc`designei3 to go ' recove dine is three da s �' .K }.#^ �` -T-5
sry Y °plyland couldt evil up. m' your
WII tll t , I1cUdlllg&Oa �Ssde .F �� �WN� ;�t •F% us � '9 `' rieigllbOr's drii1k1I1�rWell '
Eergents� bleach disnfectantsand . Soaps aiitl�detergents'= " =Toriiaintain oursyste keeepyowr {
drain l eaners, wee used. t the ,� .,: Y .
- 5 � � '1 here substaiibes used in normal ";leach Feld free of brush;and free'YDo�
� xecq� endedl rat77'e,w�vi11 snot ad '� amountsdo'not r harms:your,septic .*' not drive or`park over any part ofywtii;
verselyfectseptic systemperfar stein Powdered deter ents con- + F '
Y g system h�Have ours tanlcpum e
aiatice b the envivnrnent tain"fillersubstancesthat do'no
�y- t P
A'W,�tank,�w eii. ro eTl, si ed snd. = regularly.and do,noi�usek yqur�sys ,
�� P P y -� ,settee out iu your tank`Liquid deg totem as a trash,caii Fgllow the simple '
�rrlamtainedx actsas a;l�ufferagamst d t � _ , , ;x .
t ,. tergents o not burden the tank in, ll'
1#h ' f 4 - ,. maintenance. rxules:=described.tin
os negate giiap�ts A � 4 x` ii''maniiez 5 _ ,
,+ x �r a` other fact slieets� '
, .3t�
�Ly�so!zs air mime or �dtsmfectant used an,the research rlts use°does nvt constitute anendorsement:�
This material is based upon work supported by The Massachusetts Environmental Trust.Issued in furtherance of Cooperative Extension work,Acts
of May 8 and June 30,1914,in cooperation with the United States Department of Agriculture.Robert G.Helgesen,Dean and Director,Cooperative
Extension,University of Massachusetts.The Cooperative Extension System offers equal opportunity in programs and employment.Prepared by
Gisela Walker,Extension Specialist;David Gordon,M.S.;Peter Veneman,Ph.D.
t ,
TOWN OF BARNSTABLE
Or7NET�Ir
OFFICE OF
96vJ�STAEL BOARD OF HEALTH
y MAG& A
039. 367 MAIN STREET
p MAY HYANNIS, MASS.02601
October 6, 2000
Peter Sullivan, P.E.
P. O. Box 659
Osterville, MA 02655
RE: 410 Nyes Neck Road, Centerville
Dear Mr. Sullivan.
You are granted variances on behalf of your client James D. Johnston, to utilize
the existing onsite sewage disposal system at 410 Nyes Neck Road, Centerville.
The variance granted are as follows:
310 CMR 15.211(1): To construct a ``frost wall" foundation only six (6) feet
away from the leaching field, in lieu of the ten (10)
feet minimum setback required.
310 CMR 15.211(1): To construct a "frost wall" foundation only seven (7)
feet away from the septic tank, in lieu of the ten (10)
feet minimum setback required.
These variances are granted with the following conditions:
(1) The applicant shall record a deed restriction at the Barnstable County
Registry of Deeds restricting the number of bedrooms to four (4)
maximum. A properly worded deed restriction shall be prepared at the
owner's expense and shall be signed by the property owner. A copy of
the recorded deed restriction shall be submitted to the Public Health
Division prior to obtaining a building permit.
(2) The applicant shall remove the two doors at the entrance/exit-way to the
lower level "recreation room".
(3) The dwelling must be connected to town sewer as soon as it becomes
available.
nyes
These variances are granted because there will be no increase in sewage flow to
the existing septic system. No additional bedrooms will be constructed
according to the applicant. Also, the applicant has agreed to connect the
dwelling to town sewer when it becomes available. It is hoped that town sewer
will "-:constructed in this area sometime wit" ^ the next seven to ten y€ ar-
Sincerely yours,
tsan4sk, R.S.
Chairperson
Board of Health
Town of Barnstable
SGR/bcs
1
nyes
r
`Apr-,26-00 09:03 BARNSTABLE HEAL-`H-DEP-T 5087906304 P.04,—,
_F
�tw l y. 37ttrtlsn�re zo tier+F DATE
.� 000Z 0 Z d 3 S FEE:
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• BAalvsrAata, •
rb `,,� A �i,13�� 1 REC. BY
Town of Barnstable
SCHED. DATE:T*J/O
o
Board-of-Health
367 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask.R.S.
FAX: 508.790-6304 Sumner Kaufman,M.S.P.H.
Ralph A.Murphy,M.D.
VARIANCE REQUEST FORM
LOCATION ` 1
Property Address: Q I`+ `��S 14ECtt JZO EFS Ei�!t LL �Z�32
Assessor's Map and Parcel Number: 2 32 Zoo I Size of Lot: i Act2a-
Wetlands Within 300 Ft. Yes 1C Business Name:
No Subdivision Name:
APPLICANT'S NAME: 'Oe WILL%Ar''1 `)OttNSTD" Phone 3�2- QS(o6
Did the owner of the property authorize you to represent him or her? Yes No
PROPERTY OWNER'S NAME CONTACT PERSON
Name: JAnnES 0 J044NSTOry ^�QS Name: �L�� �u t-�-�U A►-1 ��'
Address: _ 9\4 ES Ivy C C_K- j 0tl.f( Address: eoX �5� ���tZ`!I Lt_�Mt t 026 5S
Phone: 2"45 (C) Phone: ^�2 33AA
VARIANCE FROM REGULATION(t.ist Rea.) REASON FOR VARIANCE(May attach if morespace needed)
C. T GEItq\4 f�IU i
Checklist(to be completed by ofce staff-person receiving variance request application)
- Four(4)copies of engineered plan submitted(e.g.septic system plans) _
r Four(4)copies of floor plan submitted(e.g.house plans or restaurant kitchen plans)
v Signed letter stating that the property owner authorized you to represent him/her for this request
v Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting
date at applicant's expense(for Title V and/or local sewage regulation variances only)
P-4k Full menu submitted(for grease trap variance requests only)
_ Variance request application fee collected tnar«rori,uauvdr�mmeevonjeneweis.rr<eK stop var;enoerenewsh(same^w^M"ese.0 on"war e
dining variance renewals taame ownerlleaaee ontyl.and vartanea to repair failed sewage ditpmi sysaerm lunly if no expansion to the building proposedl)
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED^ Susan 0. Rask,R.S.,Chairman
Sumner Kaufinan,M.S.P.H.
NOT APPROVED
REASON FOR DISAPPROVAL Ralph A. Murphy,M.D.
C:/wp/VAR1RZQ
i
List of Attachments to Accompany
Variance Request
for
Dr. William Johnston/410 Nye's Neck Road, Centerville
Map 232 Parcel 001
Attachment A-List of Variances Requested
Attachment B-Septic System Evaluation
Attachment C-Septic Inspection Form
Attachment D-Concept Sketch
Attachment E -Letter of Authorization from owner
Plans:
both on one sheet of paper are:
Sheet 1 of 2-Site Plan of Land in Centerville MA for Dr. William G. Johnston
Sheet 2 of 2-"As Built Plan" dated December 1982 by C. R. short Inc.
Johnston Residence Floor Plans dated 2/10/2000 (3 Sheets)
Attachment A
9/15/00
Town Of Barnstable,Board of Health
List of Variances Requested
win Johnston
410 Nyes Neck Road
Centerville
Variances Required
• 310CMR15.211(1):Mmimum Setback Distances from frost wall
10 feet required 6(six)feet provided to leach field and
7 feet to septic tank.
Reason For Variance
• Frost wall to carry loads from deck above,frost wall to be water
proofed,no change in existing grades at the patio.
Sullivan Engineering Inc.
i
ATTACHMENT B
9ULLXVAN
()S17E-:E'_VI L A,:
4 1 o NyEs �iccr, 2D
A IZ-0 12 /29/0Z
Lc G Tk Lo Q -Z60 .S
Ae-a--H = $x36 X 6P0 = 288G
6PO
CZ I m FOYL-O's C�.CPW--r CAI-CO ; -7/ 1-71 ZCo00 C A-) 7PNC-t--1 Eon
OF
PETER
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ATTACHMENT C
UVCOMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
TRUDY CORE
Secretary
DAVID 13.STRUHS
ARGEO PAUL CELLUCCI Commissioner
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Johnston
Property Address: 410 Nyes Neck Road, Centerville, MA Name of Owner: Dr. WilliamAddress of Owner: Same
Date of Inspection: July 12, 2000
Name of Inspector:(Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: ,lames M. Ford Map: 232
Mailing Address: P.O. Box AOsterville 11fA 02655-0049 Lot. 001
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that theinformation eexperience
below is peon and to
and complete as of the time of inspection. The inspection was performed based on my training Pe proper
maintenance of on-site sewage disposal systems. The system:
✓ Passes
_ Conditionally Passes
_ Needs Further Evalua on the Local Approving Authority
_ ails
Date: July 17 2000
Inspector's Signature:
The System Inspector shall submi a y of this inspection report.to the Approving Authority(Board of Health or DEP)within thirty(30)days
of completing this inspection. If th 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.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
Pd nW on Roaydcd Pacer
EXIST. PATIo EX15-T. G1 APIF
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Q LAKE ELfLV. 314.0
SECTION
NOT To SCALE
Concept Sketch F _
For: Will Johnston
410 Nyes Neck Road E
Centerville µ
Sullivan Engineering Inc. `
ATTACHMENT D Osterville Mass
TI- 19 , a-000
U
'~ to
AL
Chu r
OLL
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Received b _ rint Clearly) tp of Deji ry
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you. C. Sign
■ Attach this card to the back of the mailpiece, X ❑Agent
or on the front if space permits. John' Jir,— et I "-14Addressee
D. Is delivery address different from item 1? Ye
1. article Addressed to: If YES,enter delivery address below: ❑ No
12?eerb,✓ry
3. S rvice Type
Certified Mail ❑ Express Mail
Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D. I
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number(Copy from service label)
PS Form 3811.July 1999 Domestic Return Receipt 102595-99-M-1789
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
LISPS
Permit No.G-10
•'Sender: Please print your name, address, and ZIP+4 in this box •
�. Fn 19!rri!�9• '
P.O.,BOX 669
7 PARKER ROAD
CMAVILLE, MA 02M
j
• r.ort.Yr•.
OAS,' III!fit 11!111111111111111t111l11111111111111,1111111df1111111
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for nisspozat *pztem Construction Permit
Application for a Permit to Construct( )Repair 0< Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. q I o YY£11 (/EC� ,��� 0wIv is Name, ddress and TeL No
Assessor's Map/Parcel C ,N-T&K V!I lL 1V �',Q (,�lf'��A�A�J�1�N�����
Installer's N e,Add s,and Tel.No. Designer's Name,Address and Tel.No.
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 W6 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank i000 A-A Type of S.A.S. w
Description of Soil
Nature of Repairs or terations(Answ r when applicable) f��i�//� �(/^—a- w
c� aA Als,W
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 iss=by s Board o lth.
..
Signed Date i O
Application Approved by Date
Application Disapproved for the following reason
QPermit No. Date Issued
as .. -. +1rP'�i.,. .a♦ �. _.. 4°w %9"�'�" •,af '1 s .... ,q „.;av-,.... -.. .. F� y 1 vR ........ ...,r..-. -
a
!` ..-.
No. Fee
r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
.PUBLIC HEALTH DIVISION' — TOWN OF BARNSTABLES MASSACHUSETTS Yes
OfpPYica�t on for Miz ool *pgtem �tConotruct%on. � hermit .
rs
Application for a Permit to Construct( )Repair O Upgrade( )Abandon( ) El Complete System El Individual Components
Location.Address or Lot No. t,/ ��./ ) {� C j j Own is Name, ddress and Te.N o�..
"7 10 r I 1V U #j1A�l� �N
Assessor's Map/Parcel CZ�RV&K U1I�� � �£!$ � �3
Installer's N e,Add Rs,and Tel.Np. -- Designer's Name,Address and Tel.No.
a vy
Type of Building:
Dwelling No.of Bedrooms _ Lot Size: sq.ft. Garbage Grinder( )
'Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures a
Design Flow AM gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date -
Title -
Size of Septic Tank_�/7t 0 FA Type of S.A.S. y-�✓dr� �.0 osr/cs
Description of Soil
Z
t
Nature of Repairs or Alterations(Answ r when applicable)
Ch
Date last inspected:
Agreement: t r
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 by this Board of alth.
Signed' Datei O
> 0 s
Application Approved by Y` Date I -
Application Disapproved for the following reasons '
f
s-.Permit No. 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
at has been constructed in accordance
with the provisi ns of Title 5 and the for Disposal System Construction Permit No.lrxx dated---:?
Installer 'Designer
The issuance of this permit shall not be construed as a guarantee that the sys em will function as designed.
Date_ `7�( '7 °° Inspector
��///%JpJ✓ ---=—__=Fee_.----.
No
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
s* ig o arr *p-5tetn Con.5truction�permit
Permission is�hereby granted to Construct(' )Repair-( )Up rade( )Abandon( )
System located--at i.9 a Ol sr'?r illly L t and as desc"gibed in the above Xpplication for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local gvisions or special conditions.
Provided: Construction rust be co' Meted within three,years of the date of this p it. . 1
Date: Approved by / r
•� -
73
Fps..............................
THE COMMONVVEALTH OF MASSACHUSETTS
s BOAR® OF HEALTH
oOf Taan. .... ..-... o�............:�ax'nst�b�e. ..............................................
for Diipnsal Murkg Ton.5trartinaa Errant
,pplication is hereby made for a Permit to Construct ( ) or Repair (KX) an Individual Sewage Disposal
of #1, Nyes Neck Road, Centerville, MA Lot 31 #1, AM 464/465 pg. 232
.....-•-------------------•-----......--.....-•----------.......----------••......•----•------.... ----_•••-•-•------•------•-•--------•---•-••••-.....-•----......-•--•--•------------...----------
Location-Address or Lot No.
_Dr. & Mrs. William Johnston,_Jr,3L____________________
......................... ........__........_.. ..............
Owne Address
a Gene Silva:_A.C,...Crowell_:Contracting----__.__ West_Dennis.,•-MA------------------------------------------------------------
Installer Address
dType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures -------------------------------- - .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter------.......... Depth................
Disposal Trench—No......1............ Width...-1Q........... Total Length...36............ Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet....--.............. Total leaching area..................sq. ft.
Z Other Distribution box ( 1) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fT Test Pit No. 2................minutes per inch Depth of Test Pit----0............... Depth to ground water........................
P4 --•-----•------------------•- -------••--...----------•---------------------------------•-•••.-_........---------------•........---••---....-----------------
0 Description of Soil....Coarse Sand_& Gravel. some cobbles_______________________________•_______________________________.___...._.__-__--___
...............................................................
W -----•-...... + ..... ---•-:....--'=--------------•--------------...----•-•----------....---.._..---...-•-•-•---•-•--•----------••-•-•----••-----------------
VNature of Repairs or Alterations—Answer when applicable._-Add -- new leach--trench___(see__abo----- ---------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT Li- 5 of the State Sanitary Code—The undersigned further agrees not to place the system.in
operation until a Certificate of Compliance has-been isyjed l t bo rd of health.
Signed- - ---------------------------•-------------------- ......_....-- •- --••--•- �
at
.-.--..... lApplication Approved By- Da�. .....
Date
Application Disapproved for the following reasons---------------------------------------------------------------•------------------------------...--•---------....
.......................................................-.................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
J r
No C 'xa�.....mod,1K y f ' c !1 Fimic .....� ......
.?
THE COMMONWEALTH OF;rASSACHUSETTS
M
BOARD OF HEALTH
Tssazr ..._.....0F............Barmtable.......................... .....................
Appliratiou for Uigpogal Works Tonitrurfioit Vernfit
Application is hereby made for a Permit to Construct ( ) or Repair (X$) an Individual Sewage Disposal
System at: 1
Lot #1, Eyes Neck Road, Centerville, MA Lot 3z #1, AM 464A65 pg. 232
----------------. ......._._.....---------•.........---••-•••... -
Location-Address or Lot No.
`. & hirs. Will am eT 1T1son.!-.!�r, - ...............
.----..... ..........................................
'a O Address
Gene S�vas Crowe l'Contract' �et--D a -••---.... ..Pen- .....
-
Installer Address "
d Type of Building Size Lot............................Sq.-feet
V Dwelling—No, of Bedrooms_._. .....Expansion Attic ( ), Garbage,Grinder ( )�..
aOther—Type of Building ............................ No. of persons___-________-.__-.,-------- Showers ( ) — Cafeteria'}( )
dOther fixtures ---............................................................................... ......-\...................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity............gallons Length________________ Width................ Diameter,................ Depth................
xDisposal Trench—No. .....I.............Width....1.0........... Total Length...36............ Total leaching area....:...............sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching yarea..................sq. ft.
Z Other Distribution box O Dosing tank ( )
Percolation Test Results Performed by.........................................................................
Date......... ...........................
aTest Pit No. 1___-_-___.____minutes per inch Depth of Test Pit____________________ Depth to,ground wate%,_..................__.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to �ground water ._..............__..
a
D Description of Soil....Coase Sand h Gra�lel ..som _.cobbles. ' ,
w �
• - S __•...... ........
U Nature of Repairs or Alterations—Answer when applicable._.Add a new leach trench (lee above a
-------------------------- Y ..
..................................... ••----•--•-••----------•-----------•--•--•--..................----.....----•------•••-••••--------------••••••.._....-----------..._......--•---•--•...........
Agreement: I .Sys'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witl
the provisions of T ITiE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss both b of health. yGC,
Signed------ ..r. ------------------•----------•--•------- ---•-
,�~
Application Approved BY --t.�' � a te._ ..� ; ram/ - -----.
Application Disapproved for the following reasons:........................:•-••--•------••-••------•••-----•----•-•------------•-•-------------•ate--------•---•. }
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstabld
..........................................OF.....................................................................................
CIerfifirate of Toutpliaure
THIS, eTC,5��TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired O
bY-----------------------------------------------------------------------------------------------------------------------------------------
Lot #1, Nyes Neck Road.. Centerville, Ig�aller
at•---•-------•----•---.---•- .. ..............
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No-------&r...a_--�3_ `I......_... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST S GUARANTEE THAT THE
SYSTEM WILL CTION SATISFACTORY.
DATE.. � '- �-•---------------------•-•---•-----.....---•---•-• Inspector---- ----•• •---•••--.............----------------------------------•......••••--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.....................................................................................
No...61i-.-+>_.1 Y' FEE.--- ..............
Disposal Vorko Toni#rudion "permit
Permission is hereby granted...............•--------------•...-----....--.-----------•----•--•----•-----------------•-----•-••••.......------•---.......................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo....................................................................-•-------------------•----.---•-------------•--•••--------------------------•-•-••-•••••-••--------•--•-•............I....
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
��Y. oard of Health
DATE --- •----•----------•----
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
62
TOWN OF BARNSTABLE u �
LOCATION y10 ✓1�lt-S Yle-( k �'� SEWAGE #
VILLAGE (22f tC%/A1- ASSESSOR'S MAP& LOT�3�-ao/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /Q
LEACHING FACILITY: (typAq-1 10 1 ►� f-is 0 rs (size) Tx 3f4�
NO.OF BEDROOMS 1
BUILDER OR OWNER yr W't�►�^^ J 01.1$7 Ord
PERMITDATE: COMPLIANCE PATE:
4 $gyp i f�e� on -7//1� Jeta
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) QcZ Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
A
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M
SEWAGE flfi E CAI AcE N PERMIT NO.
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I N S T A LLER'S NAINF /b A0.0RESS
� i1lILDER AEA �
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DATE PERMIT ISSUED
DATE " COMPLIANCE ISSUED
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