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HomeMy WebLinkAbout0040 PARK AVENUE - Health 40 PARK AVE., CENTERVILLE i r UPC 12534 ' 0.2-153LOR MAiTINOi.YN No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliLation for Disposal 6pstrm construction vertu Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System )q Individual Components Location Address or Lot No. L�o POK AVE Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel G� lTC-�t[ cC Ttf®c�5 -- Aun0 MczN,PWZy 14E 4F_ TA Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Caocwr�� c-C� V M rip&9 /A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 4W gpd Design flow provided 4)i' gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or.Alterations(Answer when applicable)__ :ra_5-*7 Q-L , N E:cy H-2.0 V—(:60V LV ITW R1,56P-,, a Q<T A _, ss_ d [Tnky TEE: Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Heal Signed Date Application Approved by r Date I'd 7 2 ZQ)-9- Application Disapprovedy Date for the following reaso Permit No. 00 I T �' Date Issued & /Z Cq - Ni 34 k_ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS TippYication for Misposal Opstem Construction 3permit Application for a Permit to Construct( ) Repair X) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 40 POK AvE Owner's Name,Address,and Tel.No. GExl rrl ill u.0 T1fou 5 + AmAl M1m3:AJ& zt�lF_y Assessors Map/Parcel a ()a og : a- 7 C=,C"0r_0LATE AUr<' 46:e_5 f_ ,-?A Installer's Name,Address,and Tel.No. j —C(�-j'j.$�Z 1 Designer's Name,Address,and Tel.No. GaoswlaE C_0T6 eP I'3 mks�P�" tJ1i4 Type of Building: y� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) X► A gpd Design flow provided 4)JR gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations.(Answer when applicable) NE w H-Q 0 D-ISOY Ly tTlf TZI Date last inspected: c 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 Certificate of Compliance has been issued by this Board of Health. S ed Date Application Approved by f Date top p VZO,- Application Disapproved by, / Date reason _-'7 for the following Permit No. ifl �ii-1 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by CtP��( )rC at UnP/QkK- y E C j61rdkV i4X_G' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No&11 - 341 dated 1,0/1 Z/Z-Ot 7 Installer 0A PEGJ t T)C EIV TE'aAR.sees Designer IJ L #bedrooms AA Approved design flow gpd The issuance of this permit shall norty be construed as a guarantee that the system will fitindtion as d signed. Date ���:X` F/ Inspector Y RI --------------------------------------------------------' ---------------------------------------------------------------+---------------- No. 20 t-4 — 3 q,�_ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at 440 K. and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 ��/l 2/ ?D I' Approved by Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F t"•� 40 Park Ave Property Address W, Ann McInerney Owner Owner's Name - information is required for every Centerville MA 02632 10-31-17 �y page. Cityrrown State Zip Code Date of Inspeci Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When rms A. General Information / on thethe COmOpUter, ````� QFtMgd;��i,4i /a?lo 8S� use only the tab 1, Inspector: key to move your p cursor-do not James D.Sears = Jf�M E S use the return Name of Inspector ;y key. Capewide Enterprises Company Name �'lfjgT�rkG�� 153 Commercial Street Company Address rrunrur► Mashpee MA 02649 CityfTown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority la� 11-1-17 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I5ins.doc•rev.6116 Tllle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 L011a V.s l, a5ed xeJ dH OOZE L 60Z l,0 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information is Centerville MA 02632 10-31-17 required for every page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal, Tank D Box and two pits. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): I t5lrre.doc-rev.6116 Title 5 Official Inspect,on Form:Subsurface Sewage Disposal System-Page 2 of 17 Z 95ed xed dH OOZZ L 60Z i3O AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 40 Park Ave Property Address Ann McInerney Owner owner's Name information is required for every Centerville MA 02632 10-31-17 page. City/Town Slate Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): ❑ 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 16.303(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 Mns.doc-rev.6/16 Tifle 6 official Inspect on Form:Subsurface Sewage Disposal System•Page 3 of 17 £ a5ed xeJ dH 00:ZZ L 602 l,0 AoN Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information is required for every Centerville MA 02632 10-31-17 page. CiVrown 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 INEW is less than 6" below invert or available volume is less than day flow PF7�s t5ins.doc•rev.6116 Tllle 5 Official Inspect on Form:Subsurface Sewage Disposal System•Page 4 of 17 t7 abed xed dH 00:ZZ L 602 60 AON f Commonwealth of Massachusetts Title 5 official Inspection Form WVM Lf� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information is required for every Centerville MA 02632 10-31-17 page. city/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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 6 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. 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 fl 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. t5lns.cloc rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Peae 5 of 17 c, a5ed xeJ dH 00:ZZ L 1.0Z I.0 AoN Commonwealth of Massachusetts tz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information is required for every Centerville MA 02632 10-31-17 page. Cityrrown State tip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 I t51ns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sege Disposal System•Pape 6 of 17 9 a5ed xe:1 dH OOZZ L 60Z i3O AON I Commonwealth of Massachusetts Title 5 official Inspection Form s Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name Information is required for every Centerville MA 02632 10-31-17 page. CityfTown State Zip Code Date of Inspection D. System Information Description: 1500 Gal.Tank D Box and two pits. Number of current residents: na Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection D Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage 2015-91,000Gals g ( y g (gpd))' 2016-122,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/personslsq.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: i 6ns.doc•rev.U15 Title 5 Official Inspection Form:Subsurfaca Sewage Disposal System•Page 7 of 17 L a5ed xeJ dH 60:22 L 60Z 60 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information is required for every Centerville MA 02632 10-31-17 page. cityfrown State Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ED 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): L f 15 ns.doc•rev.6M6 TWO 5 Offrial Inapecti3n farm:Subwrfeoe Sewage Disposal System-Page 8 of 17 9 abed xeJ dH 60:ZZ L60Z 60 AON i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 40 Park Ave Property Address Ann McInerney Owner Owner's Name requir required a Centerville MA 02632 1031-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (corn.) Approximate age of all components, date installed (if known)and source of information: 1992 10-2017 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 34"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SC -40. Septic Tank(locate on site plan): Depth below grade: 2 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 Gal. Precast H-10 Sludge depth: 2 15ins.doe•rev.6116 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 6 a6ed xezi dH 60:ZZ L 60Z 60 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information is required for every Centerville MA 02632 10-31-17 page. CityrTown 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 29" Scum thickness o" Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank at working level.Tank and covers at 2' below grade. Two inlet Tees, outlet tee. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doe-rev.W6 Tille 5 Official hspeaion Forth:Subsurface Sewage Disposal System-Page 10 of 17 06 abed xe� dH l,0:22 L 60Z 60 AON Commonwealth of Massachusetts Title 5 Official Inspection Form z Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information is required for every Centerville MA 02632 10-31-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): •Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No I t5ins.doc-rev.6/16 Title 6 Official Inspection Form:6ubsurface Sewage Disposal System Page 11 of 17 6l abed xed dH WE L 1,OZ i3O AcN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form .Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information for every on is Centerville MA 02632 10-31-17 required page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is New 10-2017. D Box at 5' below grade wltwo lines out and cover at 611 . Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms In working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): ` If pumps or alarms are not in working order,system is a conditional pass, Soil Absorplion System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc rov.6116 Title 5 Official Inspection forth:Subsurface Sewage Disposal a9 po System•Peke 12 of 17 Z i, a6ed xed dH Z02Z L 60Z I.0 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information required for every Centerville MA 02632 10-31-17 page. cityrrown Slate Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativetalternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is two precast pits. Pit#1 at 4' below grade w/cover at 2". Pit#2 at 56"below grade wlcover at 2'. Both pit's have clean wall's like new. 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 15vro.doc rev.6/16 Tille 5 Official Inspection form:Subsurface Sewage Disposal System Page 13 of 17 El, a6ed xed dH 20:ZZ L 60Z 60 AON ZN Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owners Name information is required for every Centerville MA 02632 10-31-17 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.): Mns.doc-rev.&16 Title 5 Official Inspecdor Form:Subsurface Sewage Disposal System-Page 94 of 17 b 6 abed xed dH £OZZ L 60Z l,0 AcN Commonwealth of Massachusetts Title 5 Official Inspection Form s. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information is required for every Centerville MA 02632 10-31-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 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 u I r ovS% ---� 0 K -3 U t r pal - �/4�•r t5ins.doc•rev.6116 Title 5 ONzial Wmpection Form:Subsurface Sewage Disposal System•Page 15 of 17 g� a6ed xed dH £OZZ L60Z 60 AoN i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owner's Name information is required for every Centerville MA 02632 10-31-17 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Mir Estimated depth t high ground water: 14' 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 propertylobservation hole within 150 feet of SAS) ❑ Checked with local Hoard 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: Auger T.H. 14' no G.W.. Bottom of pit at 10' below,grade. Bottom of pit at 4'above T.H. Depth. i Before filing this Inspection Report,please see Report Completeness Checklist on next page. i 15ins.doc•rev.6/16 Title 5 Official lnspecticn Form:Subswfaca Se-age Disposal System•Page 16 of 17 g 6 abed xeJ dH £O?Z L 1,0E i3O AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Park Ave Property Address Ann McInerney Owner Owners Name information is required for every Centerville MA 02632 10-31-17 page. Cityrrown 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 elther drawn on page 15 or attached In separate file I tSlns.doe.rev.6/16 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L abed xed dH £OZZ L 60Z 60 AoN f CAPE. & ISLANDS ENGINEERING SUMMERFIELD PARK 800 FALMOUTH ROAD,SUITE 301 C MASHPEE,MA 02649 (508)477-7272 FAX(508)477-9072 October 1, 1999 Mr. Tom Boisvert 15 Cherry Street Hyannis, MA 02601 RE: 40 Park Avenue, Centerville, MA Dear Mr. Boisvert: I have reviewed the septic inspection report by Joseph R. Macomber& Sons, Inc for the property located at 40 Park Avenue, Centerville,MA The original design capacity was over 900 gallons per day. The Macomber report does not indicate anything that would lead me to-believe the existing system cannot accommodate a 4 bedroom house. Sincerely CWi '•'b Al 'p.C�� ��y !4L , RJB/cma y '�f��1., r���; L. 7 , 9/28/99 DATE:___________ ° PROPERTY ADDRESS:_4,0._Park Ave ___ _— Centerville_,Mass_______ 02632 ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1-1500 gallon septic tank. 2 . 1—Distribution box. 3. 2-600 gallon leaching pits r III pack-4 on my �i6sp9bfiBB; I certify the following conditions: 4. This is a title five septic system. ( 78 Code ) 5. The septic system is in proper working order at the present time . SIGNATURE: f _ _ Name:_,L L, Macgmber JTr--______ � 8 Company: Jose.2h_P. Maco.mber_& Son , Inc . Box 66 ''� sF,o 4" Address: _ _ __ Centerville , Ma_-02632-0066 � D Phone: 508_775_3338_______ Z t THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connectlons P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 I COMMONWEALTH OF MA.SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 7R LTD Y C Secr ARGEO PAUL CELLUCCI DAVID B. STR Governor Cottuaiu SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION PropertyAddrsss: 40 Park Ave Nam.ofowr."Ann McInery Centerville ,Mass . 02632 Address ofOwn*(: Darts oflnspecli= 9/28/99 Joseph P.Macomber Jr . Name of Inspector:(Please Print ose) P I am a DEP approved system Inspector purwant to Section 16.340 of Tide 6(310 CMR 16.000) company Name: J. P.Macomber R Son Inc . M&INAddrass: Box 66 Cenf-erid l l e ,M2SS __02632 Tdephorse Number: 5 n�7rs-33�o -- -- CERTIFICATION STATEMENT I certify that i have personally Inspected the &@wage disposal system at this address and that the Information reported below is true, accurst• and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on. It swag@ disposal systems. The system: r Passes Conditionally Pass@s _ Needs Further valuation By the Local Approving Authority _ Fai AIJI iWhAAA A Inspector's Sigruture: 14uwx Darts: y � The System Inspector ell submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days 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 ow shall submit the report to the appropriate regional office of the Department ohEnvironmental Protection. The original should be sent to VW system owner•and copies sent to the buyer,If applicabis, and the approving authority. NOTES AND COMMENTS e i revised 9/2/98 Page I of 11 Pr.led on Recycled Prptr I T . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropeMAddraw�a: 40 Park Ave Centerville ,Mass . owner: Ann McInerny Dar+of Insp.ction: 9/2 8/9 9 WSPECTION SUMMARY: Check A. B, C, or D: A. SYSTiM PASSES: I have not found any information which Indicates that any of the failure conditions described in 310 CMR 1f6.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: y� One or more system components as described in the `Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,,no, or not determined(Y, N, or NO). Describe basis of determination In all Instances. If 'not determined% explain why not. The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was Installed within twenty (20) years prior to the date of the Inspection: or the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial infiltradon or exfiltradon. or tank failure Is Imminent. The system will pats Inspection If the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass Inspection If (with approval of the Board of Health). broken pipets) are replaced obstruction Is removed distribution box Is levelled or replaced - The system required pumptrig-non than•fourtimes e•yeardus to broken or obstructed pipe(s). The Tyrtsem wWtyesr-- Inspection if(with approval of the Board of Health): - broken pips(s) are•replaced obstruction Is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOW FORM PART A CERTIFICATION(continued) Property Address: 40 Park Ave Centerville ,Mass . Owner: Ann McInery Date of Inspection: 9/2 8/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by,the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH:INILL.PRQTECT THE PUBLIC HEALTRAND SAFETY AND-THE ENVIBONMENT: Cesspool or privy is within 50 feet-of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(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 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 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the press ce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid).- 3) OTHER 1#0 ,I Lid AN revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 Park Ave Centerville ,Mass . Owner: Ann McInerny Data of inspection: 9/2 8/9 9 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes Now _ /.// Backup ofsewege iMofecilityror•sTsteen component due tto an overloaded orcbgged-SAS-or•cesapc+d. -�----=- !/ 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 distr bution ox.abo uplf,ert 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. f1 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. kol Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _L00000r Any portion of a cesspool or privy is-within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organio•compounds, ammonia nitrogen-and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facilitywith 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 J _ the system is within 400 feet of a surface drinking water supply _ !"' the system-is-witf+in 200 feet of•a•tsiwtar�t•toasurfaoa. 4nkin9•wa4er-supply _ • -- •• -- _ ._ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 i f ( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ProYAddress: 40 Park Ave Centerville ,Mass . Ownw: Ann McInerny Date of Inspection: 9/2 8/9 9 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-zompoaants.ha►abaan pupMwd4os at•Jeast•,two•aweske and%&&-wystsm hasbaanascsiaoiagwssal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components;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: Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation f distance is unacceptable) / 115.302(3)(b)) L - — The facility owner.(and.^^m._... -;.ant-,Jf different frDm..owner)a+uare.prv�rided.with i^f� =p:npar SubSurface Disposal Systems. i j - revised 9/2/98 Page 5orn I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddress; 40 Park Ave Centerville ,Mass . owner: Ann McInerny Date of Inapecson: 9/2 8/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: 1/0 g.p.d./bedroo Number of bedrooms(desi n) Number of bedrooms(actual):j Total DESIGN flow , Number of current residentsdikk Garbage grinder(yes or no): Laundry(separate system) 1 as or, r o :_ If yes, sepatate.lnspection.required Laundry system Inspected•�ye or no) , Seasonal use(yes or no):'�1 Water meter readings,if available(last two year's usage(gpd): 00-210, Sump Pump(yes or no):d 19 i�0 Last date of occupancy:f�_ COMMERCIAL/INDUSTRIAL: QQ Type of establishment: Design flow: AM apd ( Based on 16.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)�rD Non-sanitary waste discharged to the Title 6 system: (yes or no)AO Water meter readings,if available: Last date of occupancy: OTHER:(Describe) All Last date of occupancy: // GENERAL INFO1FiMATION PUMPING RE��C �ORDSdso}r_rc�e of�njormation: 1f& System pumped as part of inspection: (yes or no)" If yes, volume pumped: gallons Reason for pumping: .�17 TYPE YSTEM TYPE tank/distribution box/soil absorption system Single cesspool Overflow cesspool AM- 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 A1Copy of DEP Approval Other to APPROXIMATE AGE of all lccomponents,date ins�Ne 4 f kiNwn)•and so_urse of•infarmation: -• � '70 99 Sewage odors detected when arriving at the site: (yes or no) i revised 9/2/98 Page 6orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) Property Address: 40 Park Ave Centerville ,Mass . Owe: Ann McInerny Date of Inspection: 9/2 8/9 9 BUILDING SEWER: (Locate on site plan) 7� Depth below grade: / Material of construction: cast Iron V 40 PVC_other(explain) Distance froet5private water supply well or suction line Diameter I Comments: (condition of joints, venting,evidence of leakage,-etc.) Joints appear tight No PvidpnrP of 1PakaoP SEPTIC TANK: QQ f' ej (locate on site plan) Depth below grade: Material of construction: concreteA*mefaW*Fiberglass 4_PolyethyleneVA other(explain) A If tank is Inetal,list age V4 13.age.co',nAfirmed by Certificate of Compliance 4W (Yes/No) 7"Dimensions: /�r 6 c F"&1 1� Sludge depth: Distance from top 91 sludge to bottom of outlet tee or baffle-; rag Scum thickness:, Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottw of o et a or baffle: How dimensions were determined: Comments: (recommendation for pumpin condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structuraHntegrity, evidence of leakage,etc.) rump tank every 2-3 years . Inlet & outlet tees are" in place .The tank is structurally sound and shows no evidence of GREASE TRAP: (locate on site plan) Depth below grader Material of con3tructionconcreteWmetal4!AFiberglas3VA Polyethyleneother(explain) Dimensions: Scum thickness: AIAC Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffleA Date of last pumping: V/g 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 present . I revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAd&ww: 40 Park Ave Centerville ,Mass . Ownw: Ann McInerny Date of hopecdon: 9/2 8/9 9 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction-AMC oncreted//metal 0Fiberglass4¢PolyethyleneA4¢other(explain) IV.4 Dimensions: Al Capac11 Design A' gaons Design flow: --gallons/day Alarm presentAZ Alarm level: Alarm in working order:Yes, No 40 Date of previous pumping: 104 Comments: (condition of inlet tee, condition of alarm and float switches,etc.) fight or Holding tanks are not present _ DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: 'eh Comments: (note,if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - — Distribution box has two laterals .No evidence of solids carry over, No evidence of 1pakaga intn or niit of the hox PUMP CHAMBER:9,&/e_ (locate on site plan) Pumps in working order:(Yes or No) l� Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump chamber is not present . revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corTdnuod) yAd&eu: 40 Park Ave Centerville ,Mass . Owrwr: Ann McInerny Date of kwoction: 9/2 8/9 9 SOIL ABSORPTION SYSTEM(SAS).2 (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: //////���1111►► leaching chambers, number leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensl ns: overflow cesspool,number: Alternative system: Name of Technology: 1.G�9G Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to fine sand Nn ci one of ga�lur- CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to Inlet Invert: Depth of solids layer: Depth of scum layer: Dimensiohs of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) e 9 snnnlc ara nnJ- p� ®S61it Comments: (note condition of soil, signs of hydraulic failure,.level of.po"ng,condition of-vegetation, etc.) essDools are not pracant PRIVY:A (locate on site plan) l Materjals of conks tructi n: em Dimensions: /y/¢ Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) rivy is not present w revised 9/2/98 Page 9of11 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORS.! PART C SYSTEM INFORMATION (00n*x+04) ProportyAddrssa: 40 Park. ;Ave Centerville ,Mass . Owr,«: Ann McInerny, Dau or 4up..odl : 9/28/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: , Include des to at least two permanent reference landmarks or benchmarks locate all walls within 100' (Locate where public water supply comas Into house) i. i Q � zo °� a° ° 7 revised 9/2/98 Pitt 10oru I M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address;: 40 Park Ave Centerville ,Mass . Owner: Ann McInerny Date of Inspecd0n: 9/2 8/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells 0 - Estimated Depth to Groundwateh Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property,observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/16/94 i i revised 9/2/98 Page 11of11 I a•TIRIA YRITs1�-'t—rnrmrI.renlle'1rrt+�n.+Tfal r.•e'TAsniteT*nnn mT+t7+1�rRren Rom+ TR'TeT�.1Tm'�t.f..r••� TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SF.HAGF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION 1 `••4f•1�T•:�::♦—T.IIT.•'.T.TTH.ITT'Riff-I TRTIQeT/a'R'R1T.r�S•ir'IIRR' >1R11��TTTO-Yf/�OTIf�fT�7 TrtH .+•+I-!'T•1'>•-11� -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 40 Park Ave Centerville ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Ann McInerny PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber:;,-Jr . • COMPANY NAME J.P.Macomber & 3'6n Inc , COMPANY ADDRESS ' Box 66 Centerville ,Mass . 0263.2 Street Town or City State LIP COMPANY TELEPHONE ( 508J 775 - 3338 FAX ( 508 ) 790 - 1578 fR CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposalj 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 witli my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: —//— Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con acted 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 . e In Signature Date �� ne copy of this c rtification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF HEALTII. * If the inspection FAILED, the owner or"1'0perator shall u d within one year of the date. of the inspection, unless allowed ortrequiredm otherwise as provided in 3,10 CMR 16 . 305 . partd.doc W D 7 P) J� 0� THE COMMONWEA LT OF MA.SSA.CHUSE TTS 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 S SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 2 1 A of the General Laws. Issued by The Department of Environmental Protection. I...r x 1•rp% 1) 1 sunvl �V3tct 1'uUutwtt �vun.l _1 _ TOWN OF BARNSTABLE LOCATION ('A .1�, SEWAGE # VILLAGE C�,�i�j•y,�/� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Je,/ rSo-e2 LZ c- SEPTIC TANK CAPACITY LEACHING FACILITY:,(type) %(31%5 r�2 = YFr) (size) NO. OF BEDROOMS _PRIYATE WELL OR PUBLIC WATER BUILDER OROWNERA „ DATE PERMIT ISSUED: -7- 22 -/ a-- DATE COMPLIANCE ISSUED: �' y VARIANCE GRANTED: Yes No I K -7-7 �3 J +� DATE: 9/28/99____ PROPERTY ADDRESS:_4.0•_Park Ave ___ -- Centerville, ass_______ 02632 ------------------------ 7 0y 0 Z z On the above date, I Inspected the septic system at the above add°rd s. This system consists of the following: -.9 1 . 1-1500 gallon septic :_tank. 2. 1—Distribution box . 3. 2-600 gallon leaching 8 g Pits packe aced or n of m 1i 1 rr y hspgbf B8 ; I certify the following conditions_ "V6 4. This is a title five septic system. ( 78 Code 5. The septic system is in proper working order � at the present time . fill— SIGNATURE: f _ N a m e:_�, �rta�s►� r r�------ Company: Jose2h_P. Macomber_& Son , Inc . ---- --------- — Address: Box 66 Centerville , Ma . 02632-0066 -------------------- Phone:...508_775_3338_ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUUYc Sec, ARGEO PAUL CELLUCCI DAvID B. STF Co:tuni,sr Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION P,,P,mAd&--: 40 Park Ave Narrmof0wrwAnn McInery Centerville ,Mass . 02632 Address of Owner: DsLoflrupettion: 9/28/99 Joseph P.Macomber Jr . Name of 4upector:(Pleas+P&W P I errs+DEP•vpoved ayrtam Inspector peusuartt to Section 15.340 of This 5 (310 CMR 16.000) comp.anyNanw: J.P.Macomber R Son Tn _ . ;A&M gAdaass: Rox 66 rPnrPryj 11 e ,Maac 02632 Telephorsa Number: C g 8 CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below is true, accurat+ and complete as of the time of UupactJon. The Inspection was performed based on my training and exparlence In the proper function and maintenance of on- It awage disposal systems. The system: r;r Passes Conditionally Passes _ Needs Further Valu&tlon By the Local Approving Authority _ F►i F Aif lrtspector'A Sipruture: 11 J Dais: `' v The System Inspector all submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)whhin thirty 130) days completing this Inspacton. If the system Is a shared system or has a design flow of 10,000 gpd or greater, the Inspector and the system o.. ' "ll submit the report to the appropriate regional office of the Department oh£nvironmental Protection. The original should be sent to tree system owner•and copies sent to the buyer,If applicable, and the approving authority. NOTES ANO COMMENTS revised 9/2/98 Page I of11 �) vr,nt.d an A.tycka r,psr � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM •1 PART A CERTIFICATION (con wed) PropeMAddre.sa: 40 Park Ave Centerville ,Mass . Owrw: Ann McInerny Data of 4►sp.ctiort: 9/2 8/9 9 WSPECTION SUMMARY: Check A, B, C, of D: "1 A. SYSTEM PASSES: I have not found any Information which Indicates that any of the failure conditions described In 310 CMR 1G.303 exist. Any failure .criteria not evaluated are Indicated below. COMMENTS: 8. SYSTEM CONDITIONALLY PASSES: One or more system components as described In the 'Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes.no, or not determined(Y, N, or ND). Describe basis of determinatlon in all Instances. It 'not determinsd', explain why not. Ak The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was Installed within twenty (20) years prior to the date of the Inspection; or the septic tank, whether or not metal,Is cracked, structurally unsound, shows substantial Infiltration or exfilustion, or tank failure Is Imminsnt. The system will pass Inspection If the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed In the disulbutlon box Is due to broken or obstructed pipa(sl or due to a broken, sertied or uneven distribution box. The system will pass Inspection If (with approval of the Board of Health). broken plps(s) are replaced obstruction Is removed distribution box Is levelled or replaced • The system required pumphtg•more than'four-dmas-a•yeardue m broken or obstructed pips(s). The syrtrrrt w0Vv r-- Inspection If(with approval of the Board of Health): broken pips(s) are'replaced obstruction is removed r revised 9/2/98 Page 2ofII a t, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 Park Ave C e n t e r•v Y l l e ,Mass . Owner. Ann McInery DaU of Inspection:.9/2 8/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING W A MANNER WH1CRYM1PRQ1ECT THE PUBLIC UMTKAND SAFETY AND.THE EiiI1080NMENT Cesspool or privy is within 50 feet of surface water �f1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: �Q 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 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 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the pra,s,�e ce of-ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distanced(approximation not valid).- 3) ,OTHER 42a Led ON revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) P"*ertyAcklireu: 40 Park Ave Centerville ,Mass . Owrw: Ann McInerny Data of : 9/28/99 D. SYSTEM FAILS: You must Indicate either"Yes' or"No" to each of the following: I have determined that one or more of the following failure conditions axial as described in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yea No/ 1/ Backup of-sewage irrtofeciNtyror-r/atent componerMdue�to an overloaded orcbggedSASor"sspool. 1--�• • 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'bution ox abo a outl vert due to an overloaded or clogged SAS or cesspool. l�rs I,-// Liquid depth in cessptol is less than 6" below invert or available volume is less than 1/2 day flow. _ Z/ Required pumping more than 4 times in the lest year NOT 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. tributary to a surface water supply. / race water supply or t P — v Any portion of a cesspool or privy Is within 100 feet of a surface PP Y Y f,"' Any portion of a cesspool or privy Is-+within a Zone I of a public well. fl Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for r•coilform bacteria,volatile organic.compounds, ammonia nitrogen and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: 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 J !/ the system is within 400 feet of a surface drinking water supply _ f"' the system•is-+within 200 taetolatfib+►iarirtow+urfaoodrir►kiwgw+terwpply• - _ ._ the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. I revised 9/2/98 Page 4of11 1 • 1. SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION FORM 96 PART B CHECKLIST PropertyAadrou: 40 Park Ave Centezville ,Mass . Ann McInerny owner; Data of Inspection: 9/2 8/9 9 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 compoa&nts.kawbaan puRN"d+farat•Jaast two•aweaha and�tba'system hasbasaascaiaiag wasa al flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this Inspection. — As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. -K — All system components,ozciuding 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 baffle: or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The aize and location of the Soil Absorption System on•the site has been determined based on:- L — / Existing Information. For example, Plan at B.O.H. — Determined In the field(if any of the failure criteria related to Part C is at issue, approximation f distance is unacceptable) (15.302(3)(b)) — The facility owtuu.(and.oc�tte if ditfarant frzaLovmer).were,prnvldad wlth Infprmati pn the nrnpar ALaUn•ry .f Subsurface Disposal Systems. 1 i I revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �! PART C SYSTEM INFORMATION Prop*rty Address: 40 Park Ave Centerville ,Mass . Owner: Ann McInerny Date of k apectkm: 9/2 8/9 9 FLOW CONDITIONS RESIDENTIAL- Design flow:_!in g.p.d./bedrep . Number of bedrooms(deal n)� Number of bedrooms(actual):_ Total DESIGN flow , Number of current residents:DW Garbage grinder(yes or no): Laundry(separate system) ( es or©o :_ If yes,separatelnspection.required --• Laundry system Inspected ye or no) I Seasonal use(yes or no): Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no):4 j9 — Z� + UIAdg— Last date of occupancy:�� COMMERCIAUINDUSTRIAL• Type of establishment• Design flow: A9 sad ( Based on 16.203) Basis of design flow Gress*trap present: (yes or no)AN Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 6 system:(yes r no)A114 Water meter readings,if available: Last date of occupancy:�� OTHER:(Describe) Last date of occupancy: A // GENERAL INFORMATION PUMPING REC_O7S and�so}+rce offrmation: System pumped as part of inspection: (yes or noLa If yes,volume pumped: gallons Reason for pumping: .�/, TYPE OF YSTEM Septic tank/distribution box/soil absorption System Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other �� _ APPROXIMATE GE of al�nSpone t , atN't, e f kn�wn)•an ofJnformation: -• i/ � Sawa"odors detected when•arriving at the site: (yes or no)" revised 9/2/98 Page 6orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Park Ave Centerville ,Mass . Owrw: Ann McInerny Data of Inspection: 9/2 8/9 9 BUILDING SEWER: (Locate on site plan) ,r Depth below grade: / Material of construction: cast Iron Y 40 PVC_other(explain) Distance fro5private water supply well or suction line Diameter _ Comments:(condition of Joints,venting,evidence of foakoge-,-etc.) - — Joints appear tight No PyidpnrP of laakngP - S C TANK.-4&V q 9 (locate on site plan) Depth below grade: Material of construction: concrete4#metal tFibergla3344 Polyethylene4 44 other(explain) A If tank is Inetal,list age Wlf. Js.age.confumed-by Certificate of Compliance 44f_(Yes/No) J ��� � w Dimensions: /0 6 rl r y Fel��)� '6747 �j Sludge depth:, �7 l 0 Distance from top Pt sludge to bottom of outlet tee or bffl ae rag Scum thickness:�l Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bo of o et a or baffle: How dimensions were determined: Comments: (recommendation for pump( condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, suuctur&Hntegrity, evidence of leakage, etc.) `rump tank every 2-3 years. `Inlet & outlet tees are. in place .The tank is structurally sound and shows no evidence of PA)Cri4P GREASE TRAP: (locate on site plan) Depth below grade: Material of consuuctionr(1Qconcret%(O—metaly/Fiberglass(!A Polyethylenot&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: /V/? 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.) rease trap is not present . revised 9/2/98 Page 7orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Addre:3: 40 Park Ave Centerville ,Mass . Owner: Ann McInerny Date of Inspection: 9/2 8/9 9 TIGHT OR HOLDING TANK:_4&,G(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grader Material of construction:A4concreted/, metaWLQFiberglasstJ�i Polyethylenaother(explain) Dimensions: AAA Capacity: AA gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes, No VO Date of previous pumping: W,4 — Comments: (condition of inlet tee,condition of alarm and float switches,etc.) 1Q t or Holding tanks are not trpspnt DISTRIBUTION BOX:z (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note-if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — — Distribution box has two laterals .No evidence of solids carry over, No evidence of leakage intn nr not of the hnx PUMP CHAMBER:Y.2yJe (locate on site plan) Pumps In working order:(Yes or No) Alarms In working order(Yes or No Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump chamber is not present revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) P,op.nyAd&eu: 40 Park Ave Centerville ,Mass . OWrw: Ann McInerny Dau of Irupect : 9/2 8/9 9 SOIL ABSORPTION SYSTEM(SAS):2 (locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number: leaching chambers,number: leeching galleries, number: leeching trenches,number, length: leaching fields, number, dlmsnsl ns: overflow cesspool,number: 0 Alternative system: l Name of Technology:Zz4aLR�G Comments: (note condition of loll, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to fine Sandi Nn �z; ong of h... ga;;1 gailope CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to Inlet Invert: Depth of solids layer: Depth of scum layer: Dimensiohs of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic falluro,level of ponding,condition of-vegetation. etc.) eSSDOOIS are not praepnt PRIVY:yw_ (locate on site plan) Materjals of construe n: �/� Dimensions: Depth of solids:-" Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) riyy is not present revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECT)ON FORM PART C SYSTEM WFORmA nON(coadrrwd) Nop.MAddras.►: 40 Park., ;Ave Centerville ,Mass . owrwe: Ann McInerny, o.z► o( : 9/2 8/9 9 SK.ETcH OF SEWAGE DISPOSAL SYSTEM: Include tl►s to at least two permanent referents landmarks or benchmarks loc►t► all wells wlWn 100'(Loests where public water supply comes Into house) r. - ..rat L..� ` , �t ),. .1 � , �•._ .�- +. �. ' S o a � �I Olt o° °+ ,% d) 4°° 4.. ; b c.��• ilk .. � _ . �. . revised 9/2/98 rgf10of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C f SYSTEM INFORMATION(continued) Property Address: 40 Park Ave Centerville ,Mass. Owner: Ann McInerny Date of Inspection: 9/2 8/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwatej* Feet Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11of11 •wnnTr T-n.TT/�TT� mrar.nns.wnrTn.TIRI�.1.nT.'TTT.flTJIYTf.'.In'.RR�`Y 17nn�wTl .T�.-�TT.T•+n.�:..ter.r• TOWN OF Barnstable WARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION J "•TI'1�T•:t: —T,II1t�.T.TTI1t rt11`RIRIT\1fJR'I/Tr:1T1:T"{7T'i1TP��1I1r�1'!'IIAA'I�M'.R� �.An V�rT•frlr�♦ -TYPE OR PRINT CLEARLI'- P110PERTY INSPECTED STREET ADDRESS 40 Park Ave Centerville ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Ann McInerny PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber.. Jr . , COMPANY NAHE J.P.Macomber & 8'6r Inc , ,. COMPANY ADDRESS Box 66 Centerville ,Mass . 0263.2 Street Town or Clty State LIP COMPANY TELEPHONE ( 508-1 775 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : .System 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 acted has found that the system fails to protect the i-lublic 1%e!hlth and the environment in accordance with Title 6 , 310 CMR 15 . 303 , iand as specifically noted on PART C - FAILURE CRITERIA of this inspection form . 'v c Inspector Signature Date �!_� ecopy of this c rtification must be provided to the OWNER, the BUYER DFn .here applicable ) and the BOARD Or HEAL1'll. If the inspection FAILED, thb owner or""o"perator shall upgrade ' the system within o'ne year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CHR 16 . 306 . partd.doc i No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for Migpool *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. v h ve. Owner's Name,Address and Tel.No. Assessor's Map/Parcel � Installer's Name,Address,and Tel.No. L� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /-Sod Type of S.A.S. o o t �S Description of Soil Nature of Repairs or Alterations(Answer when appLicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oard ealth. Signed Date Application Approved by Date 11 — 9 Application Disapproved for the followi g reasons a Permit No. `7 Y Date Issued ,A M r r No. � Fee i r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for �Dizpooaf *pztem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C r v e Owner's Name,Address and Tel.No. Assessor's Map/Parcel 2&T Q o2- Installer's Name,Address,and Tel.No. f L•. Designer's Name,Address and Tel.No. AA ( �� � car Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /Sod Type of S.A.S. 40 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 14G r,K Q ro Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oard Health. Signed Date Application Approved by Date. 1jT`7�S' Application Disapproved for the fo low g reasons Permit No. Date Issued '- --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS itertificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at �4,0� 0 F 0 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date %'( / Inspector --------------------------------------- No. — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS '=i0 pogal *p5tem Congtruction Permit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) System located at �{ � �4 g x b �0 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 TOWN OF BARNSTABLE LOCATION o (� , ,� SEWAGE # / , VILLAGE C,►,,�trv,//� ASSESSOR'S 'MAP & LOT INSTALLER'S NAME & PHONE NO.V-/� 1/'lcLdJ► ie,, 7-S&u,)J.4 c- SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /9/5 l Z= yFTj (size) zoo G NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER &A DATE PERMIT ISSUED: -7W 2 DATE COMPLIANCE ISSUED: y-IV -/ 8" . VARIANCE GRANTED: Yes Not _ r I Tr ! D I� 2� ASSESSORS MAP NO: 70 . PARrFI NO-� �"'�.- # 30 00 J�.Gl'- � F�$......... .... ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH APPROVED TOWN OF BARNSTABLE Cat AV.V iratiou for Bhips al Works Ton Application is hereby made for a Permit to Construct ( ) or Repair (`X) an Individual Sewage Disposal System at: 40 Park Ave Centerville ................_........_...................................................................... •••••-•----•--•------••-•--•-••-•-••••---••••-•-•••••••---........------•............•-•---.....-- Location-Address or Lot No. McInnerne'y W ;......................:.. --•-•............................................................. ............................................. ...... ....-----..............._ l f Owner Address J P Macomber Jr. U Installer Address Type of Building Size Lot............................Sq. feet • DwellingXX No. of Bedrooms..............a...........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers ( ) a YP g --------•----•-•------------ P ( ) — Cafeteria Otherfixtures --------------------------------------------------------------------------------------------------------------------------------------•...........---- 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. 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------.................. P4 ..--------•-••-------------••-----------------....---------.......-----......---•----••---•••--•----........................................................ 0 Description of Soil...................................•------------....-•-•------.......--------..:---------------------------......-----...-------------------•--•-------......-----.----- x Sand & Gravel v ------------------------------------- ------.. ---------------------------------------------- •---------------------------------------- •-----------------------------•------------------_----- W ----••---•----------------------•--•---------- --------------------------------------------------------------------------------------- '� U Nature of Repairs or Alterations—Answer when applicable.------1-1500;_1gallon tank. -d-box ..two--leaching omits' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code— he ndersigned further agrees not to place the system in operation until a Certificate of Complia� has bee ue y h oard he h. Signed ..... ........ ........ -` ��..... 7�2���2 Dare Application Approved By ....... ..-- .. .. -.� ..`7_,. ............................................................ Date Application Disapproved for the following reasons- .........................................................--------_----------------................................................... ------- --------- ----------------- -----------------...............................................................--- ---------------------- - ------------............................... ........................................ Dare PermitNo. .-. 3-6-1.............................. Issued .................................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ApVtiration for Biu uaal Works Tvno �rt4rrmff Application is hereby made for a Permit to Construct ( ) or Repair . X) an Individual Sewage Disposal System at: 40 Park Ave Centerville ................_................................................................................ -----------.....-------•••--•-----....-----•-------------•--------------------------........------ Mclnn .rnev Location-Address or Lot No. . Owner Address , --nmb e.x Jr. ......................................... ......•--------•---•------.....--------------..........---•-------.........---............---._--- Installer Address � feet Type of Building Size Lot...........................S q. Dwelling`; ;No. of Bedrooms...............,...........................Expansion Attic ( ) Garbage Grinder ( ) `k Other—Type of Building No. of persons............................ Showers Pk YP g -------••-•--------------•-- P ( ) — Cafeteria ( ) a4 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. 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....__._............_._. a' ---------------------•------•-----•--------------...._...--------------------............-----------------•-•---........................................... 0 Description of Soil..............................................................................................---------------------------------------------------------._......_...--•- W ................ V W U Nature of Repairs or Alterations—Answer when applicable______1-1 NQE,allon tank. 1-d-box ---------------------------------------------------------•-• P_%r o---l•o �h�nr ------•---•--------------------•-•-•-•--------------•----------------------------------•----------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code— he undersigned further agrees not to place the system in operation until a Certificate of Complia> as bee sued/by hesboard he h. Signed ...... ..-� .......... .. . . ... /'-- 2�_ �2 g 71 /... Date Application Approved BY ......------U i e �� -2..- -... :_. �-.....3....� . --------...._............._---.----------------------. Date Application Disapproved for the following reasons: .................................---- -------------------------------- ------------------------------------------------------ ...................................... Date Permit No. -----715-K"--KnI----_------------------------ Issued ........................................................ y Date THE COMMONWEALTH OF MASSACHUSETTS �. ���...✓✓✓ BOARD OF HEALTH TOWN OF BARNSTABLE �LEICttf ratr of Q:1Vnty1ianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XX ) by J.P.Macomber Jr. - --- --------------------------------------------- - - ------------------------ -- -- ------------------------------------ ------------------------ ------------------------- Installer at .....+ ....Park-...Ave----Centerville ............ has been installed in accordance with the provisions of TITLE 5�fr The State Environmental Code as described in the application for Disposal Works Construction Permit No. -------/.-a. .�3..6�..1------------ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILcLL FUNCTION SATISFACTORY. DATE CJ..-^.��-... � - ---------------------------------------------- Inspector ... �.. --------........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH +No.. a TOWN OF BARNSTABLE .�, ...�/-•- FEE.....$ . 3. . t ................... Disposal Works Tunutr ivit rrutit Permission is hereby granted......J.-P-AN _.cnmhe.n.rJr.....---•---•.....................•-•----------------------•--•-----••......--.............. to Construct ) or Repair (X) an Individual Sewage Disposal System at No....�p..Park Ave Centerville ...... . . . .. . ..---•-.---------------------------•--•-----•--•-••-------....--••------------•-----•-.....----•....... Street as shown on the application for Disposal Works Construction Permit No.2� 6 _ Dated.......................................... ---------------------------- `' .......................................................... Board of Health DATE........... - . — a- -- -............................................. FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS