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Home My WebLink About0143 OLD STAGE ROAD UNIT #A - Health 143 OLD STAGE RD., CENTERVILLE A= Sllh ® 01 !!!! g Z UPC 12534 No. 2,..� 153LOR �°GSr•C0�c0�� HA$TINQ$, MN D ATE:-11 /11 /00 _-- PROPERTY ADDRESS- 1 43_Old_Stage _Road____ -Cen.t�ex u i.J-1-e.,m a s r------- 02632 ------------------------ On the above date, I Inspected the eeptio systern at the above address, Thls system conslsts of the following; 1 . 1 -1000 gallon septic tank. 2 . 1 -6 ' x4 ' precast leaching pit packed in 3 ' of 11" stone. Based on my fnspectlon, I certlfy the following condltionv 3 . This is a title five septic system. ( 78 Code ) 4 . The septic system is in proper working order at the present time. 5 . The leaching pit is presently dry. SIGNATURE:., Company Joa•,Qh_P Hacomber_6 Son , Inc , Address :— Box-6 6----------___ CencervilleL. Ha-_02632-0066 Phone:___ ------- THIS CERTIFICATION DOES NOT CONSTITUTE A OVARANTY OA WARRANTY J6SEPH P. MACOMBER & SON, INC, T�nks•C�ssPools•LI"hfl41ds Pumped l• Instsllod Town Sswor Connootlons P.0. Box 66 ClnterYI111, MA 02632.0066 776.3330 775.6412 [RECEIVED 0N OBLEHEA COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON M.A 02108 (617) 292.6600 TRLTDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECT{ON FORM PART A CERTIFICATION NpwtyA�,:143 Old Stage Road of o Todd Walker Centervi I le as Address of Own«: one Dau of inspection: 1 1 1 6� e way, ass. Nan„@ of inspector: (Pt.a„Prir3t) aS e P. Macomber J r. I am a DEP approved system k►spector pursuant to Section 15.340 of Tale 5(310 CMR 15.000) c,mpwyyK,,,w:jose h P. Macomber & Son Inc. fr,&ngAddeeas: B ox en erv1 e Ma . 02632-0066 Telep+1Of1e Kwnb« — CERTIRCATION STATEMENT i cerdty that I have personally Inspected the *@wage disposal system at this address and that the Information reported below Is true, accurate and complete as of the dme of Inspection. The Inspection was performed based on my training end experience In the prop@r function and mainisnance of on•3ite sewage disposal systems. The system: �Y Ya33@3 _ Conditionally Posses _ Needs Further Evaluation By the Local Approving Authority _ Fails 2� tnspecZor's Sipnatun: Date: r The System Inspect shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)wftNn thirty 00) days of completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner fhall submit the report to the appropriate regional oMc@ of the Department oKnvlronmerusd fsratection. The original should be sent tovw system owner and copies sent to the buyer, If applicable, and the approving authority, NOTES AND CONIMENTS revised 9/2/98 page IorII `� Printed on Recycled Paper SU53UR.FAtx SEWA09 DLSPOSAL SYSTEM 1N3rECT$0N FOR).1 PART A mgw1 c no N (oondrn+e4 143 Old Stage Road. Centerville,Mass. o.�r..r Todd Walker ofr"I' 11 /11 /00 µs►ecTsow SUsdMAAYt ch.ak A, B, C, cw Dt A. SYSTFSI f ASSES• AM I have not found any tnlormadon wNch Ind)cats& that any of the f&uurs con4dons described In 310 CMR 14.303 or1+t Any ra: crttsrt&NONE stud are In�cated below. COW-WDM: 1, SysTF3d CONDmON.A1.).Y PASSES: —All or more system somponenu N described In the 'C"%fo" ►Sao' aaodon need to be ropleoed w ropairod, rew oystam, compredon of No roprocomont w ropalr, ns approved by the Sowd of Health, Will Paws, tnacoto yes. no. or not doterminod(Y• N, w ND). De+crtbe beads of dotorm1n.6don In W Wtanaos. If 'not dotsrmJned', azpraL+ why rwc. 9[V The o•pdc t" Is moW, arias#the owner a operates ha+ P+ovtded the eysNm 4upsotw whh a sopy of s Cor""ts compuence (artached) Indcadno that the UAk wes 4utauod wlWn twenty (20) Years Prior to the date of vie wp.coc the sepdc tank, whether or not metal, Is orockod, ►woturaey unwound, ohowo ►ubst.andal Inftttredon w o- fallvre Is ImrNnont. The system will pass kupeotlon If the exJsdno sopde tank Is ropl000d with a 0omptytn9 aoogc un approved by No Board of Ho& h, Ar(/(o Sewsoe backup or bro►kout or Noh #Ledo water level observed In the distribution box Is due to b+okon w obwtn+cud P or dvo to a broken, serdod or uneven dj#ulbutlon box, The system will Pass lnapootlon If (with ►pproval of VW 80-uo c HI&Ahl, broken pipes) ere replaced obawcdon Is removed disvtbudon box Is levoued or replaced The sMom roq,.rod pump)rto-man d►an'fow-*nos v"&,-due to brol(ema obsovotod pipe(s). Th vyvtir^ wv-vg3w- Inapsctlon If (with approved of the {oard of Hodth)t broken pips(►) are roplacid obswcdon Is removed ed 9 2/96 hce3ofll revis / SUBSURFACE SEWAGE DISPOSAL 3YSTCM INSPECTION FORM � PART A CERTIFICATION (oortdn+ed) P,op.rtyAdar"s: 143 Old Stage Road Centerville,Mass. owns: Todd Walker 001:6 of r»,°"ts°"`1 1 /1 1 /0 0 - C. FURTHER EVALUATION IS REOUIRED BY THE BOARD OF HEALTH: kConadont exist which require Nrthet eva)usdon by the Board of Hselth In order to determine It tits system Is faJUnp to protect ttw Public health, safety and the environment. 1) SYSTEM W%LL PASS UNLESS BOARD OF HEALTH DETOWINES W ACCORDANCE WITH 310 CLLR 16.303 (1)(b)THAT THE SYSTEM IS NOT FUNCTIONWO IN A h ANNER WFUCKWUJ..PR03ECT THE PUBUC dEAILTH.AND&AFYTY AMD THa B �0NM.9tfL C@IapooI or prlvy Is within 60 feet of surface water Ces►pool or privy Is within 60 feet of a bordering vegetated wedand or a salt marsh, 2) SYSTF]d WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,tF ANY)DETVUAVa3 THAT THE SYSTEW CS FVNCTIONINO IN A WANNEA THAT PROTECTS THE PUBLIC HEAL Pi AND BAFETY AND THE ENV1RON&LEWT: A,LO The system has a sspoc tank and soil absorption system (SA31 and the SAS Is within 100 het of a wrface water wppiy or Itibutsry to a suriece waist 1uPP1Y- The system has a sepUc tank and loll ob►orptJon system end the SAS Is within a Zone I of a pWAC water wpplY weU. The system hex a sepUc tank and &oil abaorptlon aystem end the SAS I• within 60 foot of a private water wpp+Y w" lJ The system has a sepUc tank and soil absorption system and the SAS la leas than 100 het but 60 feet or more hom a prlvall waist wpply well, unleas a well wetar analysis for colllorm bacteria and volatile orpaNc Compounds lydWcsta6 trot us well is Its@ hom polluUon from that facility and the presence of•mmonla Ntvopen and nitrate rJVogen Is eQue1 to or 1061 than 6 ppm. Method used to determine dlstonce .,VA (a4,pro4.%Ion not valid).- 71 OTHER revised 9/2/98 Pale)of 11 D SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECnoN FORM PART A CERTIFICATION (continued) PropeM Addyo": 143 Old Stage Road Centerville,Mass. °w^ef1 Todd Walker 1 1 /1 1 /0 0 0• SYSTEM FAILS: You must Indicate either 'Yes' or e or to each of the following: At I have determined the t one or more of he tBoardhe lof Health owing ishouldure nbeticontacted to dsteons exist as rlminelwhat will be necessary to t:orr*ct Vw twl determintion Is Identified below, Yss No / oornponertt•doeto an overloaded or�Ie99� 1;41J"s or t es+fool• �..-• - ` �/ Backup o4*•wage IRW * INhror�/t1+r^ ed SAS or Discharge or ponding of stfluent to the surface of the ground or surface water*due to an overloaded a dogg — cesspool. Static liquid level In ho. Istf utlq�t box ab ryuU7 Invert Spran overloaded or clogged SAS or eeseDoo+ Liquid depth In citaP�Is less than 6' below Invert or available volume Is lea*than 112 day flow. In more than 4 times In the last Year h1 due to clogged or obstructed DJD•(si Required pumping Number of times pumped?) • Any portion of the Soil Absorption System, cesspool or privy Is below the Ngh groundwater elevation. feet of a wrface water supply or tributary to a surface water wDWy Any Donlon of a cesspool or privy Is within 100 Any portion of a ces+pool or privy Is•witNn a Zone I of a public well. / n ortlon of s cesspool or privy Is within 60 feet of a Private water supply well. tJ Any D well wiV� Any portion of s cesspool or privy Is les*•thon 100 feet but greater then 60 feet from a Driv*te water wpprY acceptable puDle water quality anslysls. If the well has been analyzed to be accepteWe, attach copy of weu water ►name's ...colllorm bacteria, volatile organlocompound+. ammonia nluogen•and nlvate nitrogen• E. LARGE SYSTEM FAILS: You must Indicate either 'Yes' or 'No' large ,+systems ha"mi ^°�ddiUon to the criteria above: The following criteria apply g y rJilcar+t trveat t The system serves a facility with a design flow of 10,000 gpd or greater(large System) and the system Is a sJg health end solely and the envtronmem because one or more of the following conditions exist: Yes N? . l� the system Is within 400 feet of a surface drinking water .uDDIY -0 eurfeoe dslnklw4+�'asec eu►1slY..., /the sy*tem•Is-witJdn 200 Feetol+ t Y Zone n of the system is located In a nitrogen sensitive ores (interim Wellhead Protection An m Area•IWPA) or * apped �- water supply wall) any such System shall upgrade the system In accordance with 310 CMR 1 S.30412). Please con"" Ow The owner or operator water otltcs of the Deportment for turther Inforrnstion. Psgr 4 of 11 revised 9/2/98 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, � PART 5 ' CHECKLIST Pw,TyAd&.a,:143 old Stage Road Centerville,Mass. own«: Todd Walker oeu vl v,apecdon: 1 /o o Check 11 the following have been done: You must Indicate either 'Yes' or 'No' as to each of the following: Yes No , Pumping Informadon was provided by the owner, occupant, of Board of He _ � .Nona of the+yat+mcore�o+arus Maa,aba.+n paw►p�d+beaatJeaat�wo•weaJca awdtha7yst.ssss haabaaowc•J.ts.Q....d r+ rates during that period. Large volumes of water have not been Introduced Into the system recently or sa pint of ws 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 backup, The system does not receive non•sanitary or Industrial waste now, _ The ske was Inspected for signs of breakout. All system componenis.4-cluding the Soil Absorption System, have been located on the all*, 1 _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inspected for con6hion of bee or tee+, material of construction, dimensions, depth of UQuld, depth of sludge, depth of scum. The site and location of the Soil Absorption System onthe slit has been determined based on:- _ Existing Information. For example, Plan at B.C.H. 1 criteria related • 1 I approximation_ Determined In the field (11 any of the failure c Ite r ted to Part C t •t awe, aggro m•tlon of distance Is VMCceDUD 116.30217)1b11 The faclUty owrw dltlwant froaLza i aarl.wus.pcauldad with W r,r,.rfofLon th.A^. SubSurt+cs Dlspos►i Systems. revised 9/2/98 of It SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PTogarcyA6d.eea: 143 Old Stage Road Centerville,Mass. Owrw: Todd Walker Dane of Vu4xKti0n: 1 1 /1 1 /0 0 FLOW CONDITIONS RE VNTTIAL., Deslgn flow:_A4_9.p.d.roodrSom. Number of bedrooms (dss n) r/ Number of bedrooms(actusl):k Tots) DESIGN Aow.NLkLX Number of current rssidents: Garbage grinder lyai or no): Laundry (separate system) ea o61:,_) If yes, sepaiaw.lrupacdon.required Laundry system Inspected or no) Seasonal use (yes or nol: Q Wets( meter readings,If TI able (last two year's wage �' Sump Pump (yes or no):_NO f ✓ / Esc �j,� Last date of occupaney:t2 �� dC�? �d��Q+IV Jj�, f�OI.IMEAC1AllINDVSTRUIL: Type of establishment: Abt Design flow: T Based on 16,203) Basis of design flow 0rssss trap present: (yes or no) , Industrial Waste Molding Tank present: (yes or no)Ay Non•sanitary waste discharged to the Tide 6 system: (yes or no) Water motor readings, If evsll ble: Last dote of occupancy:_ OTHER:fDescribs) Last date of occupancy: GIJJf?R/1L INFORMATION PVM PIN O RE ORDS and oar f Information: P ) System pumped as part of Inspection: (yes or no) If yes, volume pumped: A gallons Reason for pumping: TYPE 0 SYSTEM Septic tankldietrfbt �soil absorption system Singis cesspool Owrllow cesspool Privy Shared system(yes or no) (If yes, attsch 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 ZOYAA j)E com o d at 1 talledilfltnown)•end sours.@ o 4oforTnadon: _Zj Saw"odor detected when arriving at the site: (yes or no) revised 9/2/98 Psgr6of11 SUBSURFACE SEWAGE DISPOSAL•SYSTEM INSPECTION FORMA .� .. PART C SYSTEM INFORMAKnON It:ondrx+.d) PropertyAddrsaa: 143 Old Stage Road Centerville,Mass. ownw: Todd Walker oau of k�:1 1 /1 1 /0 0 BUILDING SEWER: (Locate on site plan) Depth below grsda: e Material of con wcdon: �is ronA040 PVC Bother (explain) Distance hon privets Ater supply well or auction line Diameter y Comments: (condition of Joints, venting, evidence of fsak"c-stc.) Joints a ear -System is ven SE771C TANK: (locsis on she plan) rI Depth below grade* / Material of construction: it concrete4?Ametal/V6iberglassA�•Polyethylen*kVother(explaln) If tank Is metal. Ilst-ago 1s.ags.conRrmed by Certificate of Compliance dffi (Yes/No) Dimensions: Sludge depth: Distance from top of cadge to bottom of outlet tee orbsfflr.'&&b Scum tNckness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bo�j m of oud t It a or baffle: Mow dimensions were determined: Comments: (rscommendation for pumpin , condition of Inlet and outlet tees or•batfias, depth of liquid level In relation to outlet invert, •tructurM-w+cegritr, evidence of leakage, sic.) I'Um the . no evi ence of leakage. GREASE TRAP: (locate on site plan) Depth below grade:A- Material of construcdon:4)4concrat9A) rnetsI4 Flb9rglaas4�APolyethylene1✓yother(axpl&In) Dimensions: Scum thickness: Distance hom top of scum to top of outlet tee or bsffls:-AL4 Distance from bottom of scum to bottom of outlet tee or.baffle: Oslo of last pumping: Comments: Irecommendatlon for pumping, condition of Inlet and outlet tee$ or baffles, depth of liquid level In relation to outlet Invert, air mrsi Integrtry evidence of leakage. etc.) Gr . revised 9/2/98 Psge7of 11 f - $Vi3VRfACt IFEWAOE DUPOSAL SYSTEU tNSrECMN FORJA ,J /AAT C , fiy3TuA WFORwAnON (corrtlnu•Q) PW.MA66res.e:143 Old Stage Road Centerville,Mass. OWT..•: Todd Walker 710►fT OA HOLDWO TANX IT•nk must be pumped prior to, or of Um• of, Inepocdon) (194$1e on slit plan) Depth below ondo:J M$tor1N of conlWtUon:,fr�Aconcr.t��m•t+1r1�Flb�rpl��.�4_Idy�chyl�n�,(',oth�r(�xpl►ln) r i Olmen$lon$: C$peclty: gallon$ 0•ii9n Row: •r p►Ilon$ldey Alarm prosenl Alarm level:��Alarm In o(klnp order.Yee No�� 0ete el previovr pvmpinpl AA Commenu: Icondloon of Wel lee, vondltlon of •lerm end noet switches, etc.) RO 04STRI&I ON IOX:-4fv- noceie on Nte plenl 0cplh of lipvld love, sbove ovdei Invon:�� Comments: I .q Iflevel end distrlbvuon I, tgveJ, •v1d•nw of solids c•rryov•r, r,AdMaa of ieek•p•into or out •I le"' etc. stribution how is nc,4 Present. pvmp f;}{A►Asm.X tt llocete on $110 plenl lumps In working order.(Yes or NO). Alarms In wolklnp order lye$ or NO- ' Comment$: mote condltlon of pump chamber, condition of pumps end •ppuMn•nws. •td.l EE��a re ' ' n{e I of 11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con*%jed) Prop«tyAd&*": 143 Old Stage Road Centerville,Mass. Dwt*: Todd Walker Data I lnw'ctso":BS 1 1 /1 1 /0 SOIL ABSORPTION SYSTEM(SAS),—el (locate on sit•plan, it possible: excavation not required,location may be approximated by non-Intrusive methods) If not located, explain: Type: leaching pits, number: leeching chambers, number: Q leeching galleries, number:= leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: ��( i Name of Technology: Comments: Inot• condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Lo Faliure or Don q I-p—hing pit is dry. CESSPOOLS: (locate on sit• plan) Number and configuration: Depth-top of liquid to mist 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) esspoo S are nest =raSr�ntr Commanu: (note condition of soil, signs of hydraulic failure, level of ponding,condition of.vegetation, etc.) eSSD00J S arp not nrr:lcon te PftJ1/Y �� (locals on site plan) Msterials of construction: � Dimensions: .✓L'i7 Depth of solids:, Commenu: (note condition of soli, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) is not present revised 9/2/98 Pegg 9of11 3U&3UR►ACt ItWAOI DanSAL 3YiTVA W3►tCT10N POR1A PART C SY3TVA INFOP.AAT10N (oomctr 61 1 4 3 Old Stage Road Centerville,Mass . Dwrm.: Todd Walker Date of V4P*G-do -'1 1 /1 1 /0 0 SU7CH Of SEWAGE DISPOSAL SYSTEM: InCAWd1 to# to &t lq&4I two p#rmanent reference Iandmukl or benchmarks Iocott NI wells wlUdn 100' ILOWI when public water►apply Comes Into hour) �Z f* to AP � %b i i revised 9/2/98 r.�� 10of11 I ' SVI.3URFACE SEWAOE OLSP93AL 3Y3TOA 1,1413PECT10N FORIA PART C 3Y3TEM WFORMAMN (continu-411 P, Ada&": 143 Old Stage Road Centerville Mass. ow�ty g � Owner: Todd Walker °"' of 104p.c'60n: 1 1 /1 1 /0 0 MRCS Report name 50 Type_ Typical depth to groundwater V$05 Oate webslte visited Observstlon Weill checked Qrovndwater depth: Shallow Moderate Deep — SITE EXAM Slope Surface weter Check Cellar Shallow wells Erumated Depth to O(ovndwetef Feet /letre Indicate ail the methods vied to detarrNne Mlph Orovndwatar EJevatlon: ��///pppotaJned from Design Pions on record o�(Abvttlnq obaarvadon hole, baaemeot eump etc.) Os Checked with local losrd of health Chocked FEMA Maps necked pvmpinp records -,Z/C hecked local escavators. Installus Used U503 Oats Oescrioe how yov established the Mlph Oroundwater Elrv/tlon. (M!j be completedl Installed system. 10/5/79 Permit # 79-649 Used; Water Contours Map. Gahrety & Miller Model 12/16/94 neellarll revised 9/2/98 I •. 'M1 rr--n�1r+'r Jrr.'nts-ra�e+r.as.r.rrr.:-.•m••Torr:TTe+n++rfrrly*.a�rrsr.r+1+ Tn-rT•T- s—r--..-..s_...F WY) Barnstable TOWN OF BOARD OF HEALTH SUI)SURFACF SEWAGE DISPOSAL ,SYSTEM INSPECTION FORM - PART D •- CERTIFICATION 1 •••�•••.•T•"'.'.ter.:.:--T.T.T.ft•n:TTtTT.T.TTi#`1"rY1:r'-•.•I*•5'T�'f\1'nlvr`1'RTCOIn♦'.�'..tRnlT.'ICT7 mnn7mTR.sforTrr*rer.—.rrrr-- • •-..� -TYPE OR PRINT CI.EARL1•- PROPERTY INSPECTED STREET ADDRESS 143 Old Stage Road Centerville,Mass. ' ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Todd Walker PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Soff"Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 street Town or City Stat• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 790 _ 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at )r1ecoinmenda his address and that the information reported is true , accurate , and omplete as of the time of :inspection . The inspection was performed and any tions regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check ne ; • System PASSED The inspection lihich I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe. environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have con 'voted has found that the system fails to Protect the public health and the environment in accordance with Title ,5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date _ lf��.G)d Ycopy of this certification must be provided to the OWNER, the ➢UYER re applicable ) and the 130ARD OF HEAL711. * If the inspection FAILED, the owner or""operator shall upgrade ' the eyetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .doc DATE; 11 /1 .1 /00 PROPERTY ADDRESS: 143_Old-Stage_E2ad____ ---Cen.tnxv ------ 02632 on the above data, I Inspected the 6eptic ,system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2.. 1 -6 ' x4 ' precast leaching pit packed in 3 of 1 ' stone. ` �O, 0 Based on my fnspectlon, I certify the following condltfons; 3 . This is a title five septic system. ( 78 Code 4 . The septic system s in proper working order at the present time. order 5. The leaching pit is presently dry. / SIGNATURE Name ;_,j,� •1{DS.Qatt.L.JjL ------ Company: Joae�h_P . _ Nacomber & Son , Inc , Address :_ Box_66 __centerY1118 L Ha__02632-0066 Phone: 508_775_3338_______ THIS CERTIFICATION ODES NOT CONSTITUTE A GUARANTY OR WARRANTY J6SEPH P, MACOMBER & SON, INC. Tinks•Cesspools•l eichllelds Pumped 4 Instilled Town Sewer Connections P.O. Box 6775•3338e�775.64122632-0066 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON M.A 02108 (617) 292.5500 TRUDYCOXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION Property Addr"0 43 Old Stage Road Haase of ovqs�t Todd Walker Centerville as$ Address of owner: ,3 / Daywoud�ne Dvu of litspection: 1 1 1 /0�0 e way, ass. Noma of Inspector: (Ptse Print) o s e p h P. Macomber Jr. I am a DEP approved systarn Inspects pursuant to Section 16.340 of Ttde 5 (310 CMR 15.000) Corn—yN,TM; Joseph P. Macomber & Son Inc. µ,A.;gAdd,.zs; Ox , es - ervi e_, Ma. 02632-0066 Taieptsone Nurr6w: — —3 3 3 CERTIFICATION STATEMENT I cerdty, 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 dme of Inspection. The Inspection was performed based on my training and experience In the proper function and maintenance of On-Sill sewage disposal systems. The system: 2 Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails 4upector's Signature: �lrii`� Date: �� The System Inspect shall submit a copy of this InspWIon report to the Approving Authority (Board of Health or DEP)wftNn thirty (30) days of completing this inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater, the Inspector and the.system owner shall submit the report to the appropriate regional oMce of the Department ciKEnWonmenzal Protection. The original should be sent%o Vw system owner and copies sent to the buyer, If applicable, and the approving authority, NOTES AND COMMENTS revised 9/2/98 page IorII %, Printed on R"Ied Paper SUBSURFACE SEWAGE DISPOSAL SYSTDA U43P£C=N FORJA PART A CV"ViCAMN (oon� 143 Old Stage Road. Centerville,Mass. o.rnK Todd Walker ,r *,ar£t TTON SUTAMAAY: CT+.ck A< B, t:, O/ A. sYSTt7J PASSES R I have not found any information wNch L-4cat•s that any of the faUuro con&} ortx described In 310 CIAR 14.303 oslat. Any fut crfuris NONE ated us Indicstsd below. Cow-u0m: s. SYSTE3AI CONDmONALLY PA.Ssf3: , �5E 0" a more system sompononta ss dosoribod In the 'Conditions! /aaa' sootion Mod to be ropJaood or repaired. The syetam. compledon of the replacement w repair, as approved by the solid of Health, w{U Paas. t^acste yes, no, or not detorm)nsd (Y. N, a NO). Describe basis of dstumJnadort In all Matut000. If 'not determined', expiain why mat. The sepdc tank Is metal, urJ•sa the owr4t a operator has provided the system Inspector with a dopy of a CantAute compusncs (stteched) Indicating that the tank was inat"od within twenty(20)Years prior to thO data.of Vw trupectc the septic tank, whethsr or not meta), Is oraokod, swewra.Uy unaound, shows substantial Inftrtradon or exfUVotion.. o+ f.11ure Is Imminent. The system ww pass Inspection If the existing sopda tank Is replaced whh a compiytng sopdc tA^ approved by the Board of Health. Sews9e backup or bro►kout or N9h stado water level observed In the dJstributJon box Ia due to broken or obrwcud P. or due to a broken. settled or uneven dlstrIWUon box. The system wUl page Impaction If(wtth approval of tha Board c Health). broken plpe(s) we replaced obswction Is removed disvibudon box Is levelled w replaced The system regtrkod pump q—rrary d-.an fourtmes Vryeu-due Lo brovettvs obstructed plpo(s). the rrrssr^ wfir Inspscdon If(with approved of the loud of Health): broken plpe(al wo replaced obswcdon Is removed r . revised 9/2/98 nte3oril I SUBSURFACE SEWAGE DLSPOSAL 3YSTEJ61 INSPECTION FORLA PART A CERTIFICATION (c00drx»d) NoqrtyAd&"4: 143 Old Stage Road Centerville,Mass. OWTW: Todd Walker C. FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: ,lsjJ Condrtlons exist which require further waluatlon by the Board of Health In order to determine If the system Is faMn9 to protect the public health, safety end the environment. it SYSTE34 WILL PASS UNLESS BOARD OF HEALTH DETUtMINES W ACCORDANCE WTTH 310 CUR 16.303 (1)(b)THAT THE SYSTEM L5 NOT F>1NCTIONWG W A A4AIINFA WHJC}i WILL.PAt1TF.CT THE PUBUC 8LkLT1•LAND SAFM AkD THE E>tM80aLBCL• Cesspool or privy Is within 60 feet of surface water Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a tali marsh. 21 SYSTDA WILL FAIL UNLESS THE BOARD OF HEALTH(WD PUBUC WATER SUPPUFR,V A)M DETERUDa3 THAT THE SYSTraj is FUNCTIONWO W A wANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIROe MDiT: ;0 The system has a septic tank and loll absorption system (SAS1 end the SAS Is wl%Nn 100 feet of a wrtace water wpply or tributary to a surface water wpply. The system Ms a septic tank and soil abaorptlon system and the SAS Is within a Zone I of a pubUc water wpplY well. The system has a septic lank and soil absorption system and the 3A3 Is within 60 lest of a private wets( wpplY wou. The system has a septic tank and toll absorption system and the SAS Is less then 100 feet but 60 feet a more hom a private water supply wall, urJass a well water analysis for collform bacteria and volatile org"c cornpounds Indicates U I tree well 11 flat hom pollution from that facility and the presence of ammonia nitrogen and nitrate Nvogsn le equal to or lets than 5 ppm. Method used to determine distance iL�lQ (approxlmstlon not vaLd)." 31 OTHER dd `j 6 revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE OLSPOSAL SYSTEM INSPECTION FORM PART A v CERTIFICATION (cortdr"d) pTopertyAddrass: 143 Old Stage Road Centerville,Mass. Ownan Todd Walker D" afVOPOC-d—: 11 /11 /00 D. SYSTEM FAILS: a exist as dsscHbod You must Indiw* either 'Yes' or 'No' to each of the following: LPi I hays determined that one o or T of he the following allure condIlJohould be ntacled to detsrn l oiwhatt will be n casauY to correct ttw fail determinadon Is Identifled below Y++ N0� oomporwrtt'daeto an over4o.d+d or-ciegg+d BASorcessrod. 1.- - Backup o4txwege Ir.to¢sclUtY-oreT*t+^t Discharge or ponding of stfiuent to the surface of the ground or surface water due to an overloaded a Clogged SAS or cesspool. Static Ilquld level n�the, 11 %ribu ti ,box abov outlet Invert d�!�pran overloaded or clogged SAS or ceaapod. ery liable volume is less than ill day flow Liquid depth In cia.s.Pj0-W Is less than 6' below Invert or ava . Requlred pumping more than 4 times In the last year o due to clogged or obstructed Pipe($)• Number of times pumped Any portion of the Soil Absorption System. cesspool or privy Is below the high groundwater elevation. rface water supply or trlbutary to a surface water auPPIY• Any portion of a cesspool or privy Is within 100 feet of a su Any portion of a cssspooi or privy Is•wl%Nn a Zone I of a public well. Any Portlon of a cesspool or privy Is within 60 1}01 of a private water supply well. portion of a cesspool or privy is Isss•than 100 feet but greater then 60 feet , at • private water water bn& wls .� Any p p of weU water anaiys+s � acceptable water quality analysis. If thew well has been Nuo9�`o be nitrogen.attach copy -coiiform.bacterla, volatile organio-compo E LARGE SYSTEM FAILS: You must Indicate either 'Yas' or 'No, Ito each of the following: n to the criteria above: The following criteria apply e nMcant ttvest t th a design flow of 10.000 gpd or greater(Large Sy The sys tem serves a facility wit+teml and the system Is • slg health and safety and the environment because one or more of the following conditions exist: Yes No/ the system Is within 400 teat of a surface drinking water supply . er �o�wr/awdslnklw4"M''eNrsu►flY•..• / the system I,-wIvi4A 200 {eetoh+e +t Y Zone II of a the system Is located In a Ntrogen sensitive area(Interim Wellhead Protection Area IWPA) or a m � aPP wets( supply well) The owner or oper$tor of any such system shell upgrade the system In accordance with 310 CNIR 15.304(2). Maass cortau►t tN iota( r offlce of the Department for further Inforinadon. . Ps te 4 of 11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTE)d INSPECTION FORM PART f ' CHECKLIST PropertyAd&ft":143 Old Stage Road Centerville,Mass. Dwnof: Todd walker oa* or tnavc 1 1 /1 1 /0 0 Check li the following have been done: You mutt Indicate either 'Yet' 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 c orr4w&&ru.s wd•tke-ystam hss bwa wcslaaq go.ol r rates during that period. Large volumes of water have not been Introduced Into the system reeendy or as pan of ws Inspection, _ As built plant have been obtained and examined. Note If they are not available with N/A. The facility or dwelling wai Inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The ske was Inspected for signs of breakout. All system componenis.4.v4luding 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 condition of bat or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The site and location of the Soil Absorption System orrihe site has been determined based on: Existing Information. For example, Plan at B.O.H. _ 0etermined In the field fit any of the failure criteria related to Part C Is at Issue, approximation of distance Is unocceptao. 115.302(3)(b)l The facility owrw (and.^r—p`f=.Jf dltfuaot ptavIdAd yvLth infarmirlon on rk,ptaguir main, SubSurfacs Disposal Systems. revised 9/2/98 rage 5of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ProgertyAddrs13: 143 Old Stage Road Centerville,Mass. Ownw: Todd Walker Du of h`pecton: 1 1 /1 1 /0 0 " FLOW coNDmorJs RESOOiT1AL: DesJgn flow: aO q.D.•d./badr9om. Number of bedrooms (des!pn) ✓ Number of bedrooms (actual): Total DESIGN flow Number of current residents: Garbagl grinder(yes or no):A Laundry (separate system) ve+ oA) If yes, aopacsialrtapectlon•requlred Laundry system Inspected_ or no) Seasonal use (yes or nol: ? `i��/► Water meter readings, If av�llsbit (last two year's usage(gpd): 6'"' Sump Pump (yes or no): /U_ /)� / r44 Last date of occupancy: 1/�a� �y]�y �r� l 5404r (Lj COMMERCLALIINPVSTRIAL: Type of establlahment•�7�, I✓,f Design flow:_A2& fled I Based on 16.203) Basis of design flow AJA Grease trap present: (yes or no) to industrial West$ Molding Tank present: (yes or no)A Non•s&M&ry waste discharged to the Title 6 system: lyes or not - Water meter readings, If ovallible: �l� Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RE ORDS and oar f Information: System pumped as part of Inspection: (yes or no)Aff If yes, volume pumped: gallons Reason for pumping: — TYPE 0 SYSTEM Septic tank/dletdbtr3hZ-bQAl$011 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 l t �^sue J ��— •-��/Y OXIMATE A . Qf al combo nU, date 1 taYed•iaf known)•and source o(Jwlotffw : A 11+��'.�• �k�� sow"odors detected when-arriving at the site: (yes or no) revised 9/2/98 Paes6orII SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corrdnuod) PropertyAdareas: 143 Old Stage Road Centerville,Mass. Dwrw: Todd Walker _ D"t"of w.a°":1 1 /1 1 /0 0 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of con vuctlon: 'cas ronA_e.�40 PVC iir other (explain) Distance horn rivals wits( supply wall or auction Ilne J.• •t Diameter �:r� Comments: (condition of)olnts, venting, evidence of h►ak+ge,etc.) Joints aDDear _ Of System is ven ed SEPTIC TANK:_ (locate on she plan) r/ Depth below grade: / Material of construction: t concrote.f)met&IA/alberglassA:d PolysthylenotiVothsr(explaln) If tank Is fnetal, Ilst age is.age.conRrmed by Certificate of Compliance (Yes/No) I r Dimensions: Sludge depth: d-A_@_ _. Distance from top of udge to bottom of outlet its ortr%M4rzdA 6 Scum tNckness:rG Distance from top of scum to top of outlet tee or baMe: � Distance from bottom of scum to bo pj� of outlet t a or battle-': aAd� Mow dimensions were determined: Comments: (recommendation for pumply, condition of Inlet and outlet tees or-baffles, depth of liquid level In relation to outlet 'Invert, atructurb"iritegrity. evidence of leakage, etc.) 1�Um the L ' no evi he of leakage. GREASE TRAP: +V, (locate on alte plan) Depth below grade: Material of construct]on:A/ concreteill�metoi/AFlbergl Sea Akpolyethyienej,�other(*xplain) Dimensions: f Scum tNckness:--A_r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or.batfle: Date of last pumping: 21 Comments: (recommendation for pumping, condition of Inlet and outlet tees or boMes, depth of liquid level In relation to*"at Invert, structural Inte9rftY. evidence of leakage, etc.) Gr revised 9/2/98 Psae7orII SUBSURFACE SEWAGE 01.3I03AL SYTTEM W31•fCTION FOFUA ►ART C SYSTE3d WFORuArow (comvti+ di ft p.MA6,y-,&':143 Old Stage Road Centerville,Mass. 0..r..r: Todd Walker D— °' r�: 1 1 /1 1 /0 0 nGKT Olt NOLDWG TANK' to (Tank musl be pumped prior to, or at time of, Inapecdon) poet• on I,II@ plan) Oeptn below grade:. Material of cons trVc ,isiQconcretery metal,{ Flberptua. 4►olYethyleno otherloxplxJnl 01men4lonr: CapacltY: pallona Oesign flow: .,,s p►Ilonald►y Alum present Alarm level: _Alarm In worklnp order;Yet No!6? Oete of previous pumpinpl Comments: Icond)oon of Inlet tee, eondldon of ►Isrm and float ewltchea, $to.) or iold OtSTltlsvnoN BOX: Iioc+te.on Wo plan) Oeptn of lipvld level above ovdet Invert: Comments: T1StrlbUt tribvtlon Is equal, evldenoe of sotlds carryover, ►vldence of leakage into or out 1�1 loon. etc. PjWF CHA1dBEA: f pocale on site Pan) Ivmp► In working order.(Yes or No)A Alums In working order iYes or NO), 4 Comments: rtenancee, etc.) mote condition of pump chamber, condition of pvmpa and appv res revised 9/2/96 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA r PART C SYSTEM INFORMATION Icon nuod) PropwtyAddrw: 143 Old Stage Road Centerville,Mass. Owr*: Todd Walker D`t'01 IP—Cl : 1 1 /1 1 /0 0 / SOIL ABSORPTION SYSTEM(SAS):J_/ (locate on alto plan, It possible; excavation not required,location may be approximated by non-Intrualve madhods) If not located, explain: Type: leaching plts, number: �t leeching chambers, number: V leaching galleries, number:= leaching trenches, number, length: leaching fields, number, dlmenslons: overflow cesspool, number: Alternative system: F 7_1F Name of Technology: 7 (.��, Comments: Inote condition of soil, signs of hydraulic failure, level of ponding, damp toll, condition of vegetation, etc.) Loa ai ure or pon " CFSSPOOLS: L (locate on site plan) Number and configuration: Depth top of liquid to Inlet Invert:_ k 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) esspoolS are not�LeSent . Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of.vegetation, etc.) eSSA001S arP not nrocoF}%;a PRIVY et (locate on site plan) Materials of construction: /r�/9 Dimensions: Depth of sollds:� Comments: (note.condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) is not pre sent, revised 9/2/98 Post 9of11 SU&SURFACi SEWAGE DISPOSAL SYSTEM WSPECnON FO" PART C SYSTEM WFOR"TION (wn*W*4 P,0qm A6&--: 1 43 Old Stage Road Centerville,Mass. Own«: Todd Walker 11 /11 /00 SKETCH OF SEWAGE DISPOSAL SYSTEM: Indudf dj, to +t least two parm&nent refsrsnc•Iandmuks or bsnchmuks lout) ell well, wlthln 100' (Locate where publlo wstsr supply comes Into house) F.0j, / / w� / Y21--- --g Q ' revised 9/2/98 PSI#10of II SU&SURFACE SEWAGE DL3P9SAL SY3T0A INSPECTION FORA FART C SYSTUA WFORJ.IATION (condrx�ed) f W.nyAdaaas: 143 Old Stage Road Ceniterville,Mass. • own«: Todd Walker Det+ or lnap.cdon: 1 1 /1 1 /0 0 NRCS Report name Soll Type_ TyplcaJ depth to proundwaler USOS Date web►Ite Asllod Obstrvstlon Wells checked Orovndwater depthff' Shallow Moderate Deep SITE EXAM Slop; Svrtace water Check Cellar Shallow wells Ettimatsd Depth to Orovndwater/��Fell 7lease Indicate ail the methods v►ed to delorn-Jne Hlph Oroundwater Elevation: otained hom Design Plane on record �,%bjsrvod She (Abutting property, observation hole, bassmeot lump etc.) Oetermined trom loc►l conditions Checked with tocaJ solid of health _ Checked FEMA Maps + Checked pvmpinp records .ZChecked lots; excevatort, Initallen Used USOS Data Describe how you established the Hlph Oroundweter E)eveVon. (Hyv be completed) Installed system. 10/5/79 Permit # 79-649 Used; Water Contours Map. Gahrety & Miller Model 12/16'/94 revised. 9/2/98 race ttortt `-•rr.-rn^tst.r. ..-n—Tre. err.nr..rrsz+r..r...rr..r...�r-erurr:-rnrzr-rm m�v*rsr'er.rz:1 TOWN OF Barnstable BOARD OF HEALTH I SIIIISUIrFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••-•••_T•'".'.T-�.t t��.T.T.T".t'If.YT11TC TTTTTTTTI-•.•1 T'••5t.-.��t T.T11fr"f'TT1TR'CAT 19'i"STTi'i1r'TiT{ .. iTrttR'nRTTTRip�Tlrr.Tt-TT,•.�.-."T'T•1• •-• —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 143 Old Stage Road Centerville,Mass. ASSESSORS MAP , DLOCK AND PARCEL # OWNER' s NAME Todd Walker PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sow Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City Stat• E I P COMPANY TELEPHONE ( 508 ) 775 _ 3338 FAX ( 508 790 _ 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Chec', I-ne : • System PASSED The inspection «hick I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or tile. environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have cony acted has found that the system fails to protect the pud is 'health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signatur Date ne copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTJI. * If the inspection FAILED , the owner ort��operator shall upgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CHR 15 . 305 . partd .doc -d S W SbjY ��1 THE 'COMMONWEALTH WEALTH OF MASSA.CHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT ]KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CNM 15.340 and Section 13 of Chapter 21A. of the General Laws. Issued by The Department of Environmental. Protection_ I JUDO 8. 1995 \ Acting Dircaor of the -ion of Watcr Pollution Control . '8/ D AT ;;96/2 9 8 PROPERTY ADDRESS: 143A -Old Staga -Road f7C Centerville,Mass. fiT 0 2 6 3 2 �TyoEPTrge199g e�l On the above date, I Inspected the "ptic system at the above a-dd reas. This system consists of the following: 1 . 1 -1 000. gallop septic tank. 2 1 -1.000. gallon precast leaching pit. eased bn my Ine-Ccction. I certify the following conditions: 3 . This is a title five septic 'systein':"'(='78* Code- ) 4 . The septic system is - in proper' working order at the present time. 8IGNATUR!7: p Name J P Macomber Jr� • i - - ------- Company:_J. P_Macomber— &— Son_Tnc . Address: Cente�rviI1e Ae sj,;_02b32 '` Phone: ' THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY SOSEPH P. MACOMBER & SON, INC. Tanks-C•upool&-Lea'hfI Id: PumPtd 11 Ins411ed ' Town Sewor Connections P.O. Box 66 Centerville, MA 02632.0066 77.5.3338 775-6412 aw COMMONWEALTH OF M,ASSACHUSETTS EXECUTIVE OFFICE OF L.NrVIRONMENTAL AFFAIRS DEPARTMENT OF ENV'i'ONMENTAL PROTECTION ONE WINTER STREET, BOSTO!�, NIA 02108 617.292.5500 WILLIANi F.WELD TRUDY CO) Govcmor Secret; ARGEO PAUL CELLUCCI DAVID B.STRUI Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL YSTEM INSPECTION FORM Commissior PART CERTIFICA1!0N Property Address:1 43A Old Stage Road Centervill(`ddress of Owner: 143 Centerboard Lane Date of Inspection: 9/28/98 Mass. If different) Hyannis,Mass . Name of Inspector: 02601 I am a DEP approve system inspector pu suant td Section 15.;. .0 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: BOX 66 Centervi 1 1 P.,Macq" 02632 Telephone Number: S t1 R_7 7 5_3 3 3 2 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this. : ddress and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed ...::>ed on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ,Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving . ..,thority Fails Inspector's Signature?all ; Date: The System Inspectorubmit a copy of this inspecti n report to the A;;!)roving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,00( .pd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environn.._ ,ial Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 8, C, or D: A) SYSTEM PASSES: —Y.=2 1 have not found any information which indicates that the system; _,lates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: .1-116 One or more system components as described in the "Condition.- ?ass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Boar: of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of deter: s.,ation in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator h.. provided the system inspector with a copy of a Certificate of 'a. Compliance (attached) indicating that the tank was insta within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structu 'iy unsound, shows substantial infiltration or exhitration, or tank failure is imminent. The system will pass inspection if t_ : existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of DEP on the World Wide Web: http:14v .aQn0t.$Late.ma.u$JdeP Printed on Recy ?aper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 143A Old Stage Road Centerville,Mass. Owner, Doris Walker Date of Inspection: 9/28/98 el SYSTEM CONDITIONALLY PASSES tcontinued) .ale, Sewage backup or breakout or high static water level observed in the dis ribution box s due to broken or obstructed pipets) or due to a broken, senled or uneven distribution box, The system will pass Inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box Is levelled or replaced 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 pipets) are replaced obstruction is removed n FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: AV Conditions exist which require further evaluation by the Board of Health In order to determine if the system is failing to procett the public health, wfery and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENTi 40 Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within So feet of a bordering vegetated wetland or a sate marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THA1 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 (SAS) 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 I of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 50 feel 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 wale( analysis for colifo(m 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 equ4I to or less than 5 ppm. Method used to determine distance (approximation not valid). )) OTHER 69 Aar AIA (r•vl••d Os/af/f7) )&0• 3 of 10 i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 43A Old Stage Road Centerville,Mass. Owner: Doris Walker Date of Inspection: 9/28/98 D) SYSTEM FAILS: You must indicate ei:%.er 'Yes' or 'No' as to each of the following: I have determined that the system violates one The o rn of Health should ore of the gbe lcontactedlure rlto detera as mine m'a(what will be 1 ece The °yea for this determination is identified below. the failure. Yes No / Backup of sewage into facility or system t:omponent 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 a distr• cati�Ioy. bove 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of limes pumped. Any ponion 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 ponion of a cesspool or privy is within a Zone I of a public well. L/ Any ponion 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 SO feet from a private water supply well w4h 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 feel of surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply i 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please.consult the local regional office of the Depanment for further information. (r•v1••d Ol/1S/Sl) D•9• l of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:143A Old Stage Road Centerville,Mass. owner, Doris Walker Date of Inspection: 9/28/9 8 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 wale( have not been Introduced into the system recently or as pan 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,eluding 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 condition of baffles or tees, material of construction, dimensions; depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. ZExisting information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) lr.vs..d Ot/as/77) ?&go 4 of 10 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 43A Old Stage Road Centerville,Mass. Owner: Doris Walker Date of Inspection: 9/2 8/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.dJbedroom for S.A.S. Number of bedrooms: V- Number of current residents:j" Garbage grinder (yes or no):_ Laundry connected to system (yes or no): Seasonal use (yes or no): 42 n Water meter readings, if available (last two (2) year usage (gpd): (o Sump Pump (yes or no):-&& ' sd" Last date of occupancy:,a(g COMMERCIAUINDUSTRIAL: Type of establishment: .vie Design flow:_dLallons/day Grease trap present: (yes or no),& Industrial Waste Holding Tank present: (yes or no)ALA Non-sanitary waste discharged to the Title 5 system: (yes or no)" Water meter readings, if available: A2I4 AIA Last date of occupancy:_&A OTHER: (Describe) 9A Last date of occupancy: AIR GENERAL INFORMATION PUMPING RECORR S and source of information: YumO Taos _ q---A-98- hgy0 c" System pumped as part of ins ction: (yes or no)-4Z If yes, volume pumped: Fallons Reason for pumping: TYPE OF SYSTEM Septic tankZdjRi6v"ffr_}vz/soil absorption system Single cesspool AIT Overflow cesspool _)D Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc py of up to date contract? Other , APP OXIMATE AGE of all components, date installed (if known) and source of information: z-1 f�dy 4- /j o � a� Sewage odors detected when arriving at the site: (yes or no)y0 (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143A Old Stage Road Centerville,Mass. Owner: Doris Walker Date of Inspection: 9/2 g/9 g BUILDING SEWER: (Locate on site plan) Depth below grad _Material of constr% t iron I'40 PVC other (explain) Distance fro private water supply well or suction line a .�� Diameter y Comments: (condition of joints, venting, evidence of leakage, etc.) Joints appear tight;No evidence of leakage; gygtpm i c vpntpH thrniigh the hn17cP vent SEPTIC TANK:IP7.- (locate on site plan) Depth below grader Material of construction: Zoncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age dL4 Is age confirmed by Certificate of Compliance.i/dl (Yes/No) Dimensions: Sludge depth:_ Distance from top Judge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom f outlet tee r baffle How dimensions were determined: 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.) Pumped tank every 2-3 years;Inlet & outlet tees are in pl ace; 1 iaru,i d 1 Pyp] at outlet i nyprt iG f i fty one_ i nrhps _ The tank i q ctriiCi-lira( 1 c_� iinrl and shows no extir1l3nr'a Of 1 Gakiagz GREASE TRAP:AAXf(1 (locate-on site plan) Depth below grade: Material of construction concrete lei metal-V.AFiberg1assU4_Polyethylene i other(exptain) A1. Dimensions: Scum thickness: AW Distance from top of scum to top of outlet tee or baffle:_,d Distance from bottom of scum to bottom of outlet tee or baffle:_&J Date of last pumping: 4 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.) Grease trap is not presen (revised 04/35/M Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddress: 143A Old Stage Road Centerville,Mass. Owner: Doris Walker Date of Inspections 9/28/98 TIGHT OR HOLDING TANK:A.W4?—(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction:A!Iconcreic tAmetaLV Fiberglass,APolyethylene.vl other(explain) IVA Dimensions: Capacity: AN gallons Design flow gallons day Alarm level: Alarm in working orde(.,V Yes;NQ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or hnldinq tanks arP not prii-Gent DISTRIBUTION BOX:_t,lJe.• (locate on site plan) Depth of liquid level above outlet inven:A_ Comments: tnote if level and distribution is equal, evidence of solids carryover, evidence of leakage into or,out of box, etc.) Distribution box is not present PUMP CHAM8ER:,d,?&A0, (locatc on site plan) Pumps in working order: (Yes or No),AA Alarms in working order (Yes or No)-VA Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump _chamber is not present I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 143A Old Stage Road Centerville,Mass. Owner: Doris Walker Date of Inspection: 9/2 8/9 8 SOIL ABSORPTION SYSTEM (SAS):, (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: ' leaching pits, number:1, leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dime sion overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to medi um sanri-N_n ci gnc: lf hydraulic CESSPOOLS: Ake , (locate on site plan) Number and configuration: Depth-(op of liquid to inlet inven: Depth of solids layer: A7 Depth of scum layer: Dimensions of cesspool: Materials of construction: A. Indication of groundwater: Plf inflow (cesspool must be pumped as pan of inspection) Cesspools are not present Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not present PRIVY:!Jve., (locate on site plan) Materials of construction: A44 Dimensions: Depth of solids: l"t Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -Privy is not present ir•v1r•d 04/2S/S7) P490 1 of 10 SUBSURFACE SE%yAGE OISPOSAI SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION fconlinvcd) Propenr Add+e11: 1 43A Old Stage Road 'Centerville,Mass. Owntl: Doris Walker 04{c 0( Inspection: 9/28/98 SKETCH OF SEWkGE DISPOS�II SYSTEM; include ties 10 at least two Permanent references landmarks or benchmarks housel locals all wells within 100' (locate where public water supply 0 �N ' i ao I93A old 6?-0, e - �,VtL 9 {r.ri•.0 WWII)I1) � )�Q• J or 10 SUBSURFACE SEWAGE DISPC;:.'1 SYSTEM INSPECTION FORM P;x T C SYSTEM INFOlt;.; .PION (continued) Propeny Address: 143A Old Stage Road Centerville,Mass. Owner: Doris Walker Date of Inspection: 9/28/98 Depth to Groundwater/�rr Feet Please indicate all the methods used to determine High Groundwatw Elevation: Obtained from Design Plans on record _4bservation of Site fAbuning property observation hole, basemcr*sump etc.) Determine it from local conditions Check with local Board of health Check FEM^Maps heck pumping records heck local excavators, installers Use USGS Data Describe in your own words how you established the.High GrourcJwrcrElevation. (Must be completed) Water Contours Map. Gahrety & Miller Model 12/16/94 v'r...nT rn.1•�r•.T1—\nraew•nt.wA-wn/�rrinRn7.++�.rwRwwrn ne+•s1Y 1nl7n�n wY �'�'I'��rr�•.tr.r'� TOWN OF Barnstable BOARD OF HEALTH ti_•T�^.•.t..-T•"^'S� Uf(FACF 9EHA()F-DISPOSAL �SYSTEM INSPECTION FORM - PART D^- CEI1'fIF1CATIUN� , .-TYPL OR PRI141 CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 143A. Old Stage Road Centerville,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME Doris Walker PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sei -Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City 9tat• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ne ; Sys teui PASSED , The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con cted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date One copy of this cer ifieativn must be provided to the OWNER, the BUYER ( where appl Icable ) and the I30ARD OF 11ZAL711. * If the inspection FAILED, .the owner or"oporator shall upgrade he syste within o'ne ,Year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3•10 CMR 16 , 305 . partd .doc S.i W � Z7 THE COMMONWEALTH OF MA.SSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION RE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection_ *Dtrcct()r. tltc l) i wii ul' Watcr !'uUutiUn C Ontrol i -1 s �1 � � L�� c Town of Barns table ❑Ecarii iEC1t aT Health, SaTEPy, and EnVlranmentcl Ser'/1Ca• 3 s t2rt5'L.3L Public HE2ith Division 267 Ndan•SfrEer: Hyannils iil;n� C2EQ1 FAX Date: I/ Numcer of pages co COuow. To: From: 1000, 1A AA �— ` Y tiff L-1 V V L_�I )rN--)u Phone: . one: 508-OU63'6,41 Fz: ahane: �� 7 Fa.: ohcne: 03- °0 o30a CC: RE L-�_' z-: [ Ur?L I McKean Thomas From: McKean Thomas To: Barry Ed; Dunning Jerry; Harrington Glen; Miorandi Donna; Saad Dale Subject: Bedroom Additions Date: Monday, January 12, 1998 3:02PM IF THERE ARE ENGINEERED PLANS ON FILE According to Brian Dudley, anytime a bedroom addition is proposed, the septic system must be inspected by a DEP certified septic system inspector to determine if the system is working properly, regardless of whether or not we have engineered septic system records on file showing what the existing septic system could handle for capacity, IF THERE ARE NO ENGINEERED PLANS ON FILE If there are no engineered plans on file, the applicant must be told to hire someone to both inspect the septic system and to determine the capacity of the system. A professional engineer or registered sanitarian should be hired to evaluate the capacity of the system. That same person could complete the multiple page inspection report. WHEN IS AN INSPECTION NOT REQUIRED? When an addition is proposed which would not increase the daily flow, such as a dining room, the State" Environmental Code does not require an inspection. However, we must have an as-built plan on file to show the location of the components before approving a building permit application. Page 1 i i No.._._.l�. _�°..... FR$.4.3--.00........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................. Town......oF...Barns.tab.1e....................................................... Applira#ion for Disposal Works Tomitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: ad ......1 �..A...Old...Stage...Ro...... .......... ...... .............----•----------------••-•.._..--------•--------------...............---........---... Location-Address or Lot No. .......T'hQM0.a_.AAx1.dx eXS................................................... .....aent.e.XV1 .lp..----•---..................--------------...---.........------ W Joseph P. Maco `'r & Son Inc. Centerville Address a .................. -----................ Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................. .. .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures --------------------------•--•-- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ ;.. x Disposal Trench—No..................... Width...................: Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-••---------------------------•••-•------------------------------............................_.............................................................. O Description of Soil......Sand__--&...Grave-1--.......................................................... ---------------------------------------------------•--•---------- x V .---------------•-•-•---•------------------•---•-----•-•-----••---._............................------------------•----------------------•---••-••----••-------------•-•••----••-------------•-••---.-_.. W -------------------------------------•--------------•--••------------------------------•----------------------------....----------------------------------...-----............................_......... U Nature of Repairs or Alterations—Answer when applicable...... -1D00---gallon---tlala.k...&.... �.-� ----------------------------------------------•- ......--•-•••••-••-•--•--•-•----•--••----------------•-•--------•--•--•-•-----•------•--•--------------------------------------------...........pi t Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ilTLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b s ed by the bo Ord o,/hth. � 1 n / p Sig.. d---- -- --.fit-'. ...-1......---�------ 4�(. •l�"�s.. Date Application Approved By....... . Date Application Disapproved for the following reasons:-•--------•---•------------------------••---•-•-•--•---•-•-••----------•------....---•••------•-•---------.----- -•------•----•........................................••------------------•-•---•..........-•------•---•--••---•...._...-------------•------------------•--•--•--••• -•---•-•---...-----•--•---------. y Permit No........................................................ Issued...�Q.~.:��l._--•--•-•--Date-•---- Date JW No.- -!/..J.p..... FEs.:` 0........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................................... ----.... ..Barnstable le-..:--------------------------------.-.-.... Applir�a#ion for 11ispos al arks Tonstrurtiun Permit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: 1VA Old Stake Road,_., .-----•........... ,..... „. ......_...f...•-••---••---• .............................................••--••••--------•--•-••-•--•---••-•--•----•------•-- Location-Address or Lot No. ......hQlllc'd _AmdrJSL,V.S................:.. ..... 'e.rite.n)L il le...•---•---•--.....------------•-----..............---......... W Joseph P. BCor%wr cgG-.Sb 11C . Centerville Address .... Installer Address d Type of Building ,; Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .............:.............. No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ........................................... ------------------------------------------ ------------------------------- -------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by........................... -•---------- •---------------- --------•---..... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ xi --------------------------------------------------------•------------------------•-•--------------------------------•....•----------••••---------------------- O Description of Soil......Son-d...&.-Ca.rame.1.....-------•----------------------••---------------------------------------•---.....---•--•-------.......------.....-•------ W U ..............................................••-----------•---------------•-••••--•-....._...-----••--------------•••••----•-----•••---------._...••-•-•--..................---••---•-••-•-•-•-•-••-•-- W U Nature of Repairs or Alterations—Answer when applicable..._nIO-0.0---9M. 11 1-C) _-ta:Yt.�t:_-.Q�--...1..-IOln')...�';allon ....................................... ••••---•----•----•-----•--...-•--••----•---••••-••------••-•--•-------------------------------•---•--•••-•..............................................pit Agreement: The undersigned agrees to install the aforedescribeli Individual Sewage Disposal System in accordance with the provisions of TITIZ 6 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boai d o 'h lth. -A �- r` Sig ed._.. :s ti ------ -•-• a-F- -- � W. ...//��-=`/✓%� Date Application Approved By...... Date Application Disapproved for the following reasons-.......................................I ..-•-----------------------•-------------------.....••-•----••--••-•-----••••••---•--........•----.....••-----•-•••••••--•••---------•----•-----...---•---••---••-••-•--•-----••--••----•-•••--......••. Date Permit No.......... `f................. _ _ Issued. -- .. 41 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` Town Barnstable a (9rdifirate od TampliFanir THIS IS TO CERTIFY, That the Individual Sewage Dispel System.constructed ( ) or Repaired (X ) by---.:...�t� ?x�}�...P x_._M : oak e ... .. a? ._Inc ---_•••-- -----•-•-•..••. �.. I taller at.___131.A Old :.Stake-__Roe_d, Centerville : : Andrews ...-----•--•••--•................... -------•-•-••••. has been installed in accordance with the provisions of r of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. .......�-� .......... dated_ /0.�X':../-�............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 13E CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA,;TORY ," -. DATE n �t r 1 l/� 7 M ��r,�r KIs �ectQr ,,,�� • P �" 'f�Y �..._ .+4Me+tK3�'.F•i.-''F '� wf m 1 '4[, 'W iY[,'4f r _ 4 b�..-„ L 'r1 Y�t r �. ,�i.� ,� !X °[ M,��" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH To�Pn`� Barno t"le ri ...................OF.---........................:. :._.:..........------...........................--... No....................... FEEU...0.0......... Disposal Worhp ( onstrwtion rranit Permission is hereby granted JOse h Po KAcomber & urn91c , --- --- ----- .................-••. •-• -••--•••• •-•---- to Cons r c ( ) or Re air ) an IVivi.teal Se. r e Disposal System at No {}ld SL ge...._oa 6�en ervi e�, �rld�+°ew$....,,... Street as shown on the application for Disposal Works Construction Perm r o .._.g, �,ted_._�i��....�� r�' t^ dtom- .................. Board of Health � _ t DATE.._•/l�-" FORM 1255 HOBBS &WARREN. INC., PUBLISHERS x- IqS of � C TOWN OF BARNSTABLE 1L0C-,%T10rNJ SEWAGE # VILT1..AGE .� ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. . SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Xl --(- (size) NO.OF BEDROOMS I BUILDER OR OWNER Z�� 5l,/ �^ PERMITDATE: COMPLIANCE DATE: I'I I OU 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 1 on site or within 200 feet of leaching facility) Feet Edge of Wetland and L.5aching Facility(If any etlands exist hin 300 fe of ac acility et 1�:.,ushe r i i 'RoA- iq' q#6„ L O C A T ION S A G PERMIT NO. V: /39f V,ILU GE 0-on-f er-L 9 Ile INSTA LLER'S NAME i ADDRESS 7. (p. HlqroH fir- -- BUILDER OR OWNER A�� DATE PERMIT ISSUED /0 - `79 DAT E COMPLIANCE ISSUED ,y} P /I)v�reCo's , 0 , /z�3 193A alb, �J`��o e_ C"�P.If1�dy�1NlQ.