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HomeMy WebLinkAbout0084 OCEAN AVENUE - Health $4 Ocean Ave Centerville F A=226-058 - 8 i Omrford, NO. 1521/3 ORA 10% k r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town 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: A. General Information When filling out I 'I forms on the computer, use 1. Inspector: //y1 only the tab key to move your Sean M. Jones cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 �rwn City/Town State Zip Code (508)477-8877 S14522 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 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails r 4 ❑ Needs Further Evaluation by the Local Approving Authority CM co �» 7/5/2011 ccInspecior's Signature Date G They system inspector shall submit a copy of this inspection report to the Approving Authority(Board of ealth or DEP) within 30 days of completing this inspection. If the system is a shared system or a E5 ha atdesign flow of 10,000 gpd or greater, the inspector and the system owner shall submit the ~ e 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 system will perform in the future under the same or different conditions of use. I , 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage D osal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town 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: ® 1 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: System consists of a 1500 gallon septic tank, distribution box and a 20'x25' 3 line leaching field. At the time of inspection the soil absorption system was functioning with no signs of past failure. B) System Conditionally Passes: 1 ❑ 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M ,•'' 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally 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): t ❑ 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is Centerville Ma 02632 7/5/2011 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: 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 cesspool is less than 6" below invert or available volume is less than 1/2 day flow 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. CityTrown 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 N/A) ® ❑ 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 gpd t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,••''V 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: t 4' Does residence have a garbage grinder? ❑ Yes .® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? f ❑ Yes ® No Water meter readings, if available last 2 ears usage (gpd)): yes 9 ( Y g Detail 2009=23,000 total = 63 gpd 2010= 10,000 total = 27 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow-(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;H 84 Ocean Ave. Property Address Nelson &Joanne Hartunian ' Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: I Date Other (describe below): 1 General Information Pumping Records: Source of information: 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: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 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: system repaired 5/21/1999 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No i Building Sewer (locate on site plan): Depth below grade: 1.5 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.): Joints ok, no leakage, vented through roof Septic Tank (locate on site plan): Depth below grade: '5 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: 1500 gallons Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 3.5' V. Scum thickness Distance from top of scum to top of outlet tee or baffle 6" 11 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? opned covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Water level in tank at bottom of outlet invert, tank not leaking and was structurally sound. Inlet and outlet tees intact and in good condition. Tank should be cleaned soon and again every 2 years as maintenance. I 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town 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.): l 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): I Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town 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 was functioning as intended, no solids carr"yover, no signs of past hydraulic overloading. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 25'x20' ❑ overflow cesspool t number: ❑ innovative/alternative system Type/name of technology: , Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil and stone in and around leaching field was probed in various locations and was found to be dry with no indications of past saturation. Vegetation was normal. 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Ocean Ave. M Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town State Zip Code Date of Inspection 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is Centerville Ma 02632 7/5/2011 required for every page. City/Town 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 I A-f ._ Z fIG t t t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Ocean Ave. Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 5+ 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) r ❑ 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: The location on the property where the soil absorption system is located is elevated compared to surounding areas. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Ocean Ave. �M Property Address Nelson &Joanne Hartunian Owner Owner's Name information is required for Centerville Ma 02632 7/5/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, 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 { i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 84 Ocean Ave. Property Address Mary Balsamo Owner• Owner's Name information is required for Craigville L Q r vl Ma. 02636 6/28/2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered r way. i ; 'T Important:When filling out A. General Information forms on the _G�Q computer,use ` (X °2' v 1. Inspector: only the tab key to-move your Robert Paolini cursor-do not use the return Name of Inspector key. Capewide Enterprises,LLC Company Name /aa P.O.Box 763 Company Address Centerville I Ma. 02632 City/Town State Zip Code (508)428-4028 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 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority } f 6/28/2007 YA Inspector's Signature Date - ti l The system inspector shall.submit a copy of this inspection report to the Approving Authty(Board of Health or DEP)within 30 days of completing this inspection. If the system is,-ai shared�rstemyor has a design flow of 10,000 gpd or greater,the inspector and the system ow 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. .. w ****This report only describes conditions at the time of inspection and under he con,d,itionFpf use at that time. This inspection does not address how the system will perfor in the future under the same or different conditions of use. 1/ 84 ocean ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form . _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Crai9 yille Ma. 02636 6/28/2007 every page. City/Town 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: ® 1 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 septic system is in proper working order at the present time. B) System Conditionally Passes: I ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank!is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts 921 W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a ,M 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Craig yille Ma. 02636 6/28/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): distribution box is leveled or replaced ND Explain: , ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by'the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh M1 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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. 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is Crai yille Ma. 02636 6/28/2007 \ required for g , every page. City/Town State Zip Code ' Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: 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 El ® 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 Y2 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Craig yille Ma. 02636 6/28/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® 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 if the well water analysis, performed at a DEP certified laboratory,for fecal coliform-bacteriaindicates 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a.surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered .'yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Craig yille Ma. 02636 6/28/2007 every page. City/Town 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? 1:1 . ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) . ® ❑ 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)] 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Craig yille Ma. 02636 6/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ` ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available. last 2 ears usage 2005:85,000 g ( y g �9pd))' 2006:30,000 Sump pump? ❑ Yes ® No Last date of occupancy: Date 007 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 84 ocean ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 84 Ocean Ave. ' Property Address Mary Balsamo Owner Owner's Name information is required for Craig yille Ma. 02636 6/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? measured Maintenance Reason for pumping: L Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool + ❑ Overflow cesspool 1 ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): ' Approximate age of all components, date installed (if known)and source of information: System installed in 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Crai9 yille Ma. 02636 6/28/2007 _ every page. City/Town State Zip Code Date of Inspection a D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): 10'+ Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): t 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 ------------------------------------------------------------------------------------------- ------------------------------ J Dimensions: 10'6"x5'8"x57' Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness 0 Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? tank empty 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Craig yille Ma. . 02636 6/28/2007 every page. City/Town 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.): Pump tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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 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): 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•'Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Craig yille Ma. . 02636 6/28/2007 . every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: ' gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: ` Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert no 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.): Box is Ievel.Box has three laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order:. ❑ Yes ❑ No 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Craig yille Ma. -02636 6/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site pian,'excavation not required): ' If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 20'x25'x1' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil. 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts u• W Title 5 Official Inspection Form -,Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM '" 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name requinform r ori is Crai ville Ma. 02636 6/28/2007 requiredd for g every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Crai9 yille Ma. 02636 6/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply'enters the building. 1 d.* t4 84 ocean ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 84 Ocean Ave. Property Address Mary Balsamo Owner Owner's Name information is required for Craig vllle Ma. 02636 6/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 8'to water bottom of leaching field. 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you.established the high ground water elevation: Used:Gaherty& Miller Model 12/16/94 groundwatewr elevations.Used:USGS Observation Well Data June 1992.Used:Technical Bulletin 92-000-01 Plate#2 annual ranges of ground water elevations. 84 ocean ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 No. �1'�' 3 73 s. ; Fee $ 5 0 .0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for Oigonl *p5tem Construction Perron Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) XXComplete System El Individual Components Location Address or Lot No. 84 Ocean Ave Owner's Name,Address and Tel.No. 7 81 —8 2 8—7 2 6 0 Craigville,Mass. 02636 Mary E. Balsamo 535 Washington St. Assessor's Map/Parcel A / U L Canton,Ma s s. 02021 Installer's Name,Address,and Tel.No.7 7 5—3 3 3 8 Designer's Name,Address and Tel.No 5 0 8-7 7 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass . 02632 Type of Building: Dwelling XX No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building RES No. of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 4 4 0 gallons per day. Calculated daily flow 4 x 1 1 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 500 Type of S.A.S. 3-500 gallon chambers Description of Soil Loamy sand to medium fine sand Nature of Repairs or Alterations(Answer when applicable)O-mitting two cesspools. Installing 1 -1500 gallon septic tank.1 -Distribution box & 3-500 gallon chambers packed in four feet of stone. . Date last inspected: 6/1 5/9 8 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y this Board f al Signed ► Date 6/1 9/9 8 Application Approved by e Date Application Disapproved for the following reasons Permit No. 1 —3 73 Date Issued i� —/?- _ lam.. ,. .,. �. • Fee $ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYicatfon for Migoar *pgtem Con6truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) XX Complete System ❑Individual Components Location Address or Lot No.84 Ocean Ave Owner's Name,Address and Tel.No. 7 8 1 —8 2 8—7 2 6 0 Craigville,Mass. 02636 Mary E. Balsamo 535 Washington St. Assessor's Map/Parcel 9 pf / ( �+F Canton,Mass. 02021 Installer's Name,Address,and Tel.No?7 5't—,3 3 3 8 Designer's Name,Address and Tel.Nos 0 8—7 7 5---3-3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building:_., Dwelling XX No.of Bedrooms 4 Lot Size sq. ft. Garbage Grinder VO) Other Type of Building RES No. of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 4 4 0 gallons per day. Calculated daily flow 4 x 110 gallons. Plan Date , .r»- Number of sheets Revision Date Title Size of Septic Tank 1500 Type of S.A.S. 3-500 gallon' chambers Description of Soil Loamy sand to medium fine sand. Nature of Repairs or Alterations(Answer when applicable)Omitting two cesspools. Installing 1 -1500 gallon septic tank.1-Distribution box & 3-500 gallon chambers packed in four feet of stone. . Date last inspected: 6/15/9 8 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 issuedjby this Board fal Signed . Date 6/1 9./9.8 Application Approved by Date 9 90 Application Disapproved for the following reasons Permit No. 9F 3 73 Date Issued C —/7- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired( )Upgraded�X) Abandoned( )by J.P.Macomber & Son Inc. at 84 Ocean Ave Craigville,Mass. has been constructed in accor ance with the provisions of Title 5 and the for Disposal System Construction Permit No. "'_I r 37 3 dated 40 Installer J.P.Macomber & Son Inc. Designer J."P.Macomber & Son Inc The issuance of this permit shall not be construed as a guarantee that the system willfunction as designed. Date_ S - 11 •/"!9 Inspector `w 0 r r ——————————————————————————— No. % - '7 3 ————— Fee$ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS M!6pozal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )UpgradAXX)Abandon( ) System located at 84 Ocean Abe Craigville,Mass. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ' Provided: Construction must be completed within three years of the date of this Permit. Date: Approved by (-I- �� 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) 1, Joseph P.Macomber Jr_, hereby certify that the application for disposal works construction permit signed by me dated 6/18/98 , concerning the property located at 84 Ocean Ave Craictville,Mass meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will a.4t be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) /Q f i B)Observed Groundwater Table Elevation(according to Health Division well map) low, SIGN DATE: 4GLlp—,57F LIC ED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). q:hcalth folder:cen 3-500 gallon chambers packed in four feet of stone. n 1 -Distribution box Q 1 -1500 gallon septic tank. We are omitting two cesspools. TOWN OF BARNSTABLE LOCATION ,T �P/4 AZ I/ SEWAGE# _I � VILLAGE C IV A/ ,V f -p�-�e ASSESSOR'S MAP& LOT fib'®-S INSTALLER'S NAME&PHONE NO. ✓ - MA C 014 /9 @X 4 SO.V SEPTIC TANK CAPACITY /,,L2 LEACHING FACII=: (type) .` L • (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: A' I I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching-Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist, on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I �, �.) / r �z �F� `. ` � � �� /q��� � � f ` . � � � O � '��., � �- --- � S'- . - z TOWN OF BARNSTABLE , c— c LOCATION C CA Al ✓ SEWAGE # 7 D" -3 Z3 VILLAGE G 9 A l A'y i ll e ASSESSOR'S MAP & LOT fib'0 S7 INSTALLER'S NAME&PHONE NO. 120, A C 0 M IS elf S©•'V SEPTIC TANK CAPACITY ^,�:G2 0 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER fl1 40•' PERMTTDATE: 1& 9 q COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by vo ell ` 6 .