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HomeMy WebLinkAbout0074 POND VIEW DRIVE - Health '74 Pond View Drive Centerville P A = 229 039 ir o ® NO. 1521/3 ORA ;Pi 10% Petercluskie,John 74 Pond View Dr CONTRACT Customer Name— Centerville,MA 02632 Customer Signature SKETCH Contract Date_ 508-951-2964 Sales Representative Signature -- • ATTACHMENT Customer Phone— Contract Price 21 1 2 9 , 5 r a 9 111 11 12 /s 14 1s 18 17 18 19 20 21 23 24 0 28 27 28 29 b 31 32 33 3, 35 38 37 38 39 40 41 42 43 41 45 OB 47 48 49 60 624 S/ ss 58 87 BB sB 80 2------ .._....--_-- -- -- — ---'-- '— -- --_ 71�._... -r-'- - — An - s - - -. _-- - - --— - - -- okA ..... - ------ 12 is F- 17 Is j,------ I f �t - -- I I — - 23 - - --- i 24 25 I - - -� - I 26 27 2B i I i I P I+ I� 1 — T 31 eae,w arw.nt�.w...auoo�. —_ ! _} - -- - —-- -- --- 33 — --— — — '—— -- -- — — — — — —— — — —�—_l .— — — — -- -- — — -- —— — — l34 I 1 -) 1 --( -- -- - - I - - - -- -'- _ 35 I 1 NOTES: 'Each box equals one foot unless otherwise noted.This sketch is a good faith representation of the work to be done,it is understood that all dimensions derived from this sketch are approximate,and that all locations of outlets,light fixtures,plugs,jacks and/or switches are subject to change 11 necessary. T ,per .\ COMMONWEALTH OF MASSACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION r RECEIVED D V• OCT 1 � Z004 TOWN OF BARNSTABLE TITLE 5 "FACT"oEPT. OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ,1 (ZfId lJ j f iJ V r C PARCEL, Owner's Name: )wvl PP,�QM c� t' LOT I Owner's Address: 7,p l �t�ic�n SI"+ (31_A G►� �fi�c�eTl_r� �I S'o� Date of Inspection: gi p}. 11.10 L1 Name of Inspector: (please print) S hc�tl� S��rTcxlc. Company Name:gyp.- U;ohr Ene.cptri�,�S �•� Mailing Address: P O,6 x '1G3 Ceni-GCLn Telephone Number; S Off, CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 S ction 15—340 of Title 5(310 CAM 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ate: 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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ryi " 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. sv -- r-- rn Title 5 Insnection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM'--�NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE I}ISPOSAL}SYSTEM INSPECTION FORM' f PART A CERTIFICATION(continued) Property Address: I N path)0 ti tJ O y, t;cntarU�tl� [Yla Owner: e Date of Inspection: 9 TJ 7 1Qq 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: 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration.or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank zokpproved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with. approval of Board of Health): broken pipe(s)anexeplacad. obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: y Page 3 of 1.1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS �( SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: a j Owner: coh Date of Inspection: 1 1:7 1 t,l C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 I 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's*.Method used to determine cl stince . "This system passes if the well water analysis,performed at a DEP certified laboratory,.for coliform bacteria and volatile organic compounds indicates that the'well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is'equil 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: q - ' 1 Page 4 of i l OFFICIAL INSPECTION FORM'-�-°NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DhPOSAUSYSTEM'INSPECTION FORM PART.A . CERTIFICATION(continued) Property Address:_7 u Qh ow Owner:Date of of Inspection: !Ej 1-7 jenq_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No JLO Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Xp Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool rX_,C> Static liquid level in the distribution box above outlet invert-due to an overloaded or clogged SAS or cesspool D—o Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow no Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n o Any portion of the SAS,cesspool or privy is below high ground water elevation. _aO Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. -per Any portion of a cesspool or privy is within a Zone 1 of a.public well. p_p Any portion of a cesspool or privy is within 50 feet of a private water supply well. — 00 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 analyi4jThis system passes if the well water.-analysis, performed at a DEP certified laboratory;for coMrm bacteria and volatile organic•compoands indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is-equal to-or less than S�ppm,provided that no other.failure criteria are triggered.A copy of the analysis must-be attached to this form.]- (Yes/No)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 mast serves facility with a design Ilow of 10,000 gpd to 15,000 gpd• f -& 1�` You must indicate either"yes"or"no"to each'af the following: (The following criteria apply to large systems-in.addition to the criteria above) yes no _ _Othe 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 — 0 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a . significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CNvIR 15.304.The system owner should contact the appropriate regional office of the Department. ' Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: '71 j Po Arj )t i p L.J _J2 fl, Owner:_T,!> n P +P -•�51��e Date of Inspection: Q 17)oq 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 X Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and-the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no , _ Existing information.For-example,a-plan at tine 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(3)(b)] a , Page 6 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGRDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: -114 Qp(w) L2 A.,.) -nte.!cU01e-, 'f'11CA Date of Inspection:_ f 117.1� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):D nif yes separate inspection required] Laundry system inspected A-::s or no): �$ Seasonal use:(yes or nc;: 03 Water meter readings,if a,aiiable(last 2 years usage(gpd)): Sump pump(yes or no):no Last date of occupancy:-rj Fj COMMERCIAL/INDUSTRIAL Type of establishment: . Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or 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) Tight.tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all compo ents,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS fi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 1 u &ncJ o f cul 0 Owner: J'f 11, IP-e g e.�1\f e Date of Inspection: 011 oN BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron �40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: ,�.`� Material of construction: concrete metal_fiberglass_—Jolyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 15'0(U oc�•, 1_le�'ps Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:Z 9" Scum thickness: %�% %% Distance from top of scum to top of outlet tee or baffle:4 : _ _ Distance from bottom of scum to bottom of outlet tee or baffle: -.%o�� How were dimensions determined: ` Comments(on pumping recommendations,inlet ando—utlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _has PL1G ��1��� c5y}1e� 'f`S 'T���l �1t��le1 `lr�-� GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_metal fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of l l OFFICIAL,INSPECTION FOAM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 114 ndUfe-L­' Qr 0wner:So c .ems � Date of Inspection: p 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/day Alarm-present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: (10 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.): -- 0 1S `N m (` p PUMP CHAMBER: (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.): 1 . ' Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS (C SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7q 0G2(8('.1 -�C C tr- Owner: a Klt Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ _ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): L2� . �*- 1_1 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I Page 10 of 11 q - OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART C k SYSTEM INFORMATION(continued) Property Address: Q �-b/ t I n r Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. I ocate all wells within 100 feet.Locate where public water supply enters the buil ing. l . I eC of -e, \ 6aCaQ 42, ©d - o • e Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM (� PART C SYSTEM INFORMATION(continued) Property Address: FO W U l"e.►J Q r, Owner:�til zt-Gr J �til��'G d Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water I L4-I-feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) jj�6 Accessed USGS database-explain: You must describe how you established the high ground water elevation:�c�tS t Fc...L�►- 11 E��5T4 ►ZaoF I La►JE FID6f z1 on zub — j 13- M � 47 5-�}� z'o° tub rLvop, N r 20 - �0" s n i �y 4.0' �3.9y 3q�Z p5 LP " I�IO• fo_7 t G�15j� Fo5r Goal EREb ``/�I Ho \6 5EE D (AIL 2zL-p" KiT��I�0 WA, L \ E 6 ,o �I� FLDOI � PL�� �o CSC I F-q TI o o 15 c � � DATE:8/6/02 PROPERTY ADDRESS:-74 Pondvie Drive ----------w------------ Center-- Mass _-- --- ------ 02632 ------------------------ On the above date, I inspected the septic system at the above adJrQ This system consists of the following: 1 . 1-1500 gallon septic tank. AUG 8 2002 2 . 1-Distribution box . TOWN OFBARNSTABLE 3. 2-500 gallon leaching chambers . ( 25 'X13 'X2 ' ) HEALTH DEPT. Based on my inspection, I certify the following conditions: uz 4 . This is a title five septic system. ( 95 Code ) 5 . The septic system is in proper working order at the present time . 6. The system was installed in 1999 1. Waste water is 17" below the invert pipe of the chambers . SIGNATUR : t Name: J. P. Macomber Jr. Conipany:Joseeh P._Macomber &_ Son, Inc. Address: Box 66 -------------------- Cenerv_ille�_Mas_02632-0066 Phone: 508-775-3338 --------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY ETan�ks-!Cesspools-Leachfields P ACOMBER & SON, INC. Pumped & Installed Town Sewer Connections 66 Centerville, MA 02632-0066 775-3338 775-6412 • r - COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r i i Vey TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 74 Pondview Drive Centerville,Mass , Owner's Name: Joseph Bombara Owner's Address: 68 Carla Road Date of Inspection: 8 6 2 Name of Inspector: (please print) Joseph P.Macomber Jr . Company Name: J.P.Macomber & Son Inc . Mailing Address: Box 66 enterville ,Mass . 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 Section15.340 of Title 5(310 CMR 15.000). The system: �—//Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: (7—(/o ®� The system inspector shall bmit 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 f Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 74 Pond view D r i v e Centervi e ,Mass. Owner: Joseph Bombara Date of Inspection: 8 6 0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. stem.Passes: I have�OCMR �153 �exis . �nyy hich indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 3ailure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time B. System Conditionally Passes: 06 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank:(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: —,V0 Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propem Address; 74 Pondview Drive CEntervi e ,Mass . Owner:Joseph Bornbara Date of Inspection: 8/6/02 C. Further Evaluation is Required by the Board of Health: / b Conditions exist which require funher evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: 4Z Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: M The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or rributary to a surface water supply. /0 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple. Ik The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 40 The system has a septic tank and SAS and the SAS is less than I 0 feet bul 50 feet or more from a private \+ater supple well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nirrogen 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 anached to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 74. Pondview Drive Centerville .Mass. Owner: Joseph Bombara Date of Inspection: 8/6/0 2 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ X. ckup 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 i� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool g iim 44 c X,!r-'x OdX , �iquid depth in ceol is less than 6"below invert or available volume is less than ''/z day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped (j . 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 ater supply. f Any portion of a cesspool or privy is within a Zone 1 of a public well. VzW y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) .JD (Yes/No)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• 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) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary.to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 74 Pondview Drive Centerville ,Mass . Owner: Joseph Bombara Date of Inspection: 8/6/02 Check if the following have been done. You trust indicate"yes"or"no" as to each of the following: Yes ?v'o/i P/ Pumping information was provided by the owner, occupant, or Board of Health — Vere any of the system components pumped out in the previous two weeks ? 4 'W Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? t/ _ Was the site inspected for signs of break out ? -11—/— Were all system components, Iuding the SAS, located on site ? V/ 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: Yes, no �_ 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(3)(b)) 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 74 Pondview Drive Centerville .Mass . Owner: Joseph Bombara Date of Inspection: 8/6/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): a� DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms):5X110—A-36 � Number of current residents: Does residence have a garbage grinder(yes or no): 40 Is laundry on a separate sewage system ( es or no):VO (if yes separate inspection required) Laundry system inspected(yes or no): � Seasonal use: (yes or no):AO Water meter readings, if available(last 2 years usage(gpd)): 2000-36, 000 gal Ions=98. 63 GP Sump pump(yes or no):,db 2001-79 , 000 gal Ions=216. 44 GPD Last date of occupancy:_ COMMERCIAL/INDUSTRIAL Type of establishment: A1.4 Design flow(based on 310 CMR 15.203): JQ gpd Basis of design flow(seats/persons/sgft,etc.) Grease trap present(yes or no): Industrial waste holding tank present(yes or no):" Non-sanitary waste discharged to the Title 5 system (yes or no):" Water meter readings, if available: Last date of occupancy/use: W/W OTHER(describe): 16 GENERAL INFORMATION Pumping Records Source of information: � /� -Iml '4�04 Was system pumped as pan of the inspection(yes or no): If yes, volume pumped: 0 gallons -- How was quantity pumped determined? Reason for pumping: .Gi# TY YOF SYSTEM Septic tank,distribution box, soil absorption system ,JA Single cesspool 0Overflow cesspool Privy d 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) /�D Tight tank -' `Attach a copy of the DEP approval Other(describe): e�0 Animate aue of all compo e s date installed (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property AddressJoseph Bombara 74 on view Drive Owner:Centervi1le ,Mass Date of Inspection: 8 6 6 2 BUILDING SEWER(locate on site plan) letDepth below grade: �� /' Materials of construction: cast iron t/40 PVC44 other(explain): Zo Distance from private water supply well or suction line: �D°fie Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight .No evidence of leakage .The system is vented throug h the house vents .SEPTIC TANK: on site plan)/f`16PP4&W Depth below grade: M- Material of construction:�oncreteA16 meta lyAfi berg]ass polyethylene 4Vther(explain) 160 If tank is metal list age:V.0 Is age confirmed by a Certificate of Compliance(yes or no)!V6 (attach a copy of certificate) 4 // Dimensions: /4 /G;,v/- 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 of outlet tee r baffle: How were dimensions determined: ..�SW41 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump the septic tank every 2-3 years/ . Inlet & outlet tees are in nlace .The tank is structurally sound and shows no evidence of leakage . GREASE TRAP (locate on site plan) Depth below grade: 4M Material of construction:ledconcrete meta** fiberglassw*_polyethylene�vRother (explain): ,,f//9 Dimensions: 1110 Scum thickness: 00 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: V1% Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present . 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:74 Pondview Drive Centerville.Mass . Owner: Joseph Bombara Date of Inspection: 8/6/0 2 TIGHT or HOLDING TANK WC-(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Aj,4 Material of construction: AL4 concrete AM metal fiberglass & polyethylene 4.,W other(explain): W4 Dimensions: A14 Capacity: NA gallons Desien Floµ: AM gallons/day Alarm present (yes or no): A Alarm level: AU Alarm in working order(yes or no): Date of last pumping: —J14 Comments(condition of alarm and float switches, etc.): Tight or holding tanks are not present DISTRIBUTION BOX: 2(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): Distribution box has one lateral .No evidence of solids carry over.No evidence of leakage into or out of the box . PUMP CHAMBEWff,,ul, (locate on site plan) Pumps in working order(yes or no): AA Alarms in working order(yes or no): AM Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Pumi) chamber is not present 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 Pondview Drive Centerville ,Mass . Owner:Joseph Bombara Date of Inspection: 8/6/0 2 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) _2_500 gallon leaching chambers . ( 25 ' X13 ' X2 ' ) If SAS not located explain why: Located see page 10 Type ," leaching pits, number: 0 leaching chambers, number:--3�V ;�F ,(.L leaching galleries,number: D leaching trenches,number, length: Zk leaching fields,number,dimensions: overflow cesspool, number: n �-�- � p innovative/alternative system Type/name of technology:/ e A Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.). Loamy sand to mpditim fine sand No signs of hydrau'lir failure or—upon-damns Soils are dry . Vegetation is normal, 1 aste wager is 17" below the invert pipe . CESSPOOLSI�fj�_(cesspool must be pumped as part of inspect ion)(]ocate on site plan) Number and configuration: C Depth—top of liquid to inlet invert: Aj,� Depth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Cesspools are not present . 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.): Privy is not present . 9 Page 9 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 Pondview Drive Centerville ,Mass . Owner:Joseph Bombara Date of Inspection: 8/6/0 2 SOIL ABSORPTION SYSTEM (SAS):Zlocate on site plan,excavation not required) 2-500 gallon leaching chambers . (25 'X13 'X2 ' ) If SAS not located explain why: Located see page 10 Type V leaching pits,number: 0 leaching chambers,number;9-3-Z'3 leaching galleries,number: D leaching trenches,number, length: t7 leaching fields,number,dimensions: Ala overflow cesspool, number: g�) "innovative/alternative system Type/name of technology:/r� '6 ,,r C9',0-C&®6 Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamy sand to medium fine sand No sign_ G of hydraulic failure or ponding Sails are dry Vegetation ; 2 DO ---gl Waste water is 17" below the invert pipe . CESSPOOL%� (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: AM Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): (cesspools art- not present . PRIVYI/2&Y., (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.): Privy is not present . 9 Pagc 10 of 1 1 . OFFICLA.L INSPECTION FORM — NOT FOR YOLUNTA.RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continucd) Prcptrt� Aodrew 74 Pondview Drive C_s�Ucti ct e .Mass. Orocr: Joseph DI It of In)pmioo: 2 SKSTCH OF SEWACE DISPOSAL SYSTEM PTOridt I Ixtich of the '(wilt dilpoltl imcm including tica to it Icaat rwo permancnt rcfcrcncc IunCmdrx) or Ocnrnmukf. t o<�ir tll w�llt within 100 fccl. t.occtc what public wider supply cnlcrt the bvilding. No., Pen >\ Syso and; Coml Prov Date: r - 10 Page 11 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 Pondview Drive Centerville ,Mass . Owner:Joseph Bombara Date of Inspection: 8/6/0 2 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please'indicate (check)all methods used to determine the high ground water elevation: 1 Obtained tern design plans on record-if checked, date of design plan reviewed: O erved site abuttin rope bservation hole within 150 feet of SAS) .ljljd fehecked with local Board of Health-explain: hecked with local excavators, installers-(attach documentation) Accessed USGS database-explain:447AZI//Anw, 440Ln m', 1014 'WX You must describe how you established the high ground water elevation: Used ; Gahrety & Miller Model . 12/16/94 Ground Water Elevations above Sea level . Used ; USGS : Observation well data. Tune 1992 Used ; US ec roun Annual ramgps of ground water e evations . January 1992 1p � Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 •rn-nl^r.+•r-r—.•rt-•1-r:srr.•nrrrr..r..r....r..r.:-.�-r-m'r:-r+•-s--�m�v*az-a:rcr.rsr. - ... .. -.. TOWN OF Barnstable WARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL ,SYSTEM INSPECTION FORM - PART D •- CERTIFICATION .•••�•••-T••.'•.:i-T.t t�^.��T1.T.�TI'i7:iTt T':T�ST11 T.}"}'Tt'T t•t r't ifTT4 RtTRr 1�4t'I.0 TfRT:TIi:!Sq�C-7 nT R•HRf RTSSTS -TYPE OR PRINT CI.EARL1'- PROPERTY INSPECTED STREET ADDRESS 74 Pondview Drive Centerville ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # �. OWNER' s NAME Joseph BomBara PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc-." COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 J 775 - 3338 FAX ( 508 790 _ 1578 R 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 ilcted 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 J- Date ecopy of this certification must be provided to the OWNER, the BUYER On where applicable ) and the BOARD OF HEAL111. * If the inspection FAILED, the owner or"" Perator shall upgrade * ayetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .doc f TOWN OF BARNSTABLE LOCATION ��NG�. y/ L[J ��• SEWAGE# �9 .Z ,VILLAGE' CleAffeo< VI— f ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. /: Al AC 0/4 deg> SS0,4/ ,,eSEPTIC TANK CAPACITY �O O LEACHING.FACILn Y: (type) C#AA119ef S(size) .-D O G,f G ,NO.OF BEDROOMS J 'BUILDER OR OWNER Per 6 C PERMTTDAI ' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet •, Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility). Feet Furnished by _ � �� 1' � GG♦ �. dry � ° � �� � � / `� / �b ����, � � �� � 4 r � - -�� t R ti w No. �/ 02 3 Fee 5 0• 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migozar *p5tem Construction 3dermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) C }Complete System ❑Individual Components Location Address or Lot No. 74 P o n d v i e w Drive Owner's Name,Address and Tel.No. 7 7 5—4 15 9 Centerville ,Mass . 02632 Ernest Deforge Assessor'sMap/Parcel Jq1 74 Pondview Drive Centerville ,Mass Installer's Name,Address,and Tel.No. 5 0 8-7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 7 7 5—3 3 3 8 J. P.Macomber & Son Inc . J. P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 Box 66 Centerville ,Mass . 02632 Type of Building: Dwelling x x No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily flow 3 x 1 10 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1500 gallons Type of S.A.S. 2-500 gallon chambers Description of Soil Loamy sand to medium fine sand . Nature of Repairs or Alterations(Answer when applicable) Om it t in g cesspools . Installing 1-1500 gallon tank, l-Distribution box and 2-500 gallon chambers packed in 4 ' of stone . 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 an not to place the system in operation until a Certifi- cate of Compliance has been issue by thisdB -!d,0He lth. Signed ."� Date 3/2 7/9 9 Application Approved by Date — Application Disapproved for the fo(dowin§qeasons Permit No. l- 3 Date Issued z r 0,10 No. // — 02 3�� Fee $ 5 0.0 y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS h Z.pprication for 30igpogat 6p6tem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) IXXIComplete System ❑Individual Components Location Address or Lot No.7 4 Pondview Drive Owner's Name,Address and Tel.No. 7 7 5—415 9 Centerville ,Mass. 02632 Ernest Deforge Assessor'sMap/Parcel A A 9 O 74 Pondview Drive Centerville,Mass Installer's Name,Address,and Tel.Np. 5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 7 7 5—3 3 3 H .P.Maoomber & Son\4nc . J.P.Macomber & Son Inc . ox 66 Centerville ,Mass. 02632 Box 66 6enterville,Mass. 02632 Type of Building: Dwelling x x No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily flow 3 x 1 10 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1500 gallons Type of S.A.S. 2-500 gallon hhambers Description of soil Loamy sand to medium fine sand. !Y Nature of Repairs or Alterations(Answer when applicable) Om i t t i n g c e s s p o o l s . I n s t a 11 i n g 1-1500 gallon tank, l-Distribution box and 2-500 gallon chambers packed in 4 ' of stone . Date last inspected: Agreement: ` r` The,undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions?Qf Title 5 of the.Ervironmental Code"an ,not to place the system in operation until a Certifi- cate of Compliance has been issu by this B')f f Health. f 1 Signed Date 3/2 7/9 9 Application Approved by Date 14 -:5 0 Application Disapproved for the f owin reasons t f�� Permit No. 99 �` �-I t ?;r Date Issued ———————————— t ——————————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that thet0, .=site Sewage Disposal System Constructed(41 )Repaired UpgradedXXX) Abandoned( )by J.P.Macomber & Son Inc . at 74 Pondview Drive S e n t e r v i l l a ,Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NJ;9 - dated Installer J. P.Macomber & Son Inc . Designer J.P.Macombdr & Son Inc. The issuance of this pe it shall nq be construed as a guarantee that the ys er will function as deserted. Date �, � "I Inspector 1 /'� _ r 0 --- —`----------------------------Fee -- No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE., MASSACHUSETTS =igpogal ERpgtem Congtruction Permit Permission is hereby granted to Construct( )R pair( )Upgrade 6 X)Abandon( ) Systemlocatedat 74 Pondview Drive`,Centerville ,Mass. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by � �4 TOWN OF BARNSTABLE LOCATION 73�' oAld of e o-/ SEWAGE # 99 z 3 VILLAGE C ek4 e V11 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. J,A M AC 0 M eeR> sow SEPTIC TANK CAPACITY LEACHING FACELITY: (type)X-, LCz dw 6#4 M leg-f f(size) .Sr0 0 64 NO.OF BEDROOMS BUILDER OR OWNER P G e PERMITDATE: COMPLIANCE DATE: (15/3dl ° Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I ��3 s� 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, Jo s e ph P.Mac o m b e r J r . hereby certify that the application for disposal works construction permit signed by me dated 3/2 7/9 9 , concerning the property located at 74 Pondview Drive Centerville ,Mass . meetsallofthe following criteria: /The failed system is connected to a residential dwelling only.. There are no commercial or business uses associated with the dwelling: The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. TT e bottom of the proposed leaching facility will not be P Po g ty _ located less than five feet above the ximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor thod when applicable] he S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) elo B) G.W. Elevation A +the MAX. High G.W. Adjustment. DIFFERENCE BETWEEN A and B I�� �> SIGNED : DATE: " 17 [Sketch sed plan of system on back]. q:health folder:cert Omitting existing cesspools . packed in 4 of stone . , Distribution box . 1500 Qallon tank . LO%C AT ION _._. '' S WAGE PERMIT NO.. VILLAGE IN A L 'S NAMY 8 DRESS B Ut"LDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED f 7 . • a THE COMMONWEALTH OF MASSACHUSETTS BOARD Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at- I ---­-------------------- --------�. -a------------------------------------------------------------ Address or Lot No. Owne Address in lier Address Other Distribution box ( Dosing tank ( ) epairs or tgreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article X1 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has>4�issued b22!he boa f ljtW. Date ---'----------------------''---'---'--'--------'----'-----'---'----'----------- o"te Permit Issued...................... ................................ � Date -^-------------------------------- ��� THE COMMONWEALTH OF MASSACHUSETTS BOARD F H�'-frL.,v—, TH Appliratiun -fur ]i.ivuuttl Works Tunutrurtiun Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at cat' n-Address or Lot No. ...... ...... ----••....... ....................•..... ,--•- --- ------•------------- -•-------------------------------- ---------------- ---Owne . l -------------------------------•----•-------Address In ller Address Type of Building Size Lot--________________________Sq. feet Dwelling—No. of Bedrooms__------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ __ W Design Flow............................................gallons per person per day. Total daily flow....................................-----...gallons. WSeptic Tank—Liquid capacity...........gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area...............-----sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet-------------------- Total leaching area---------------__.sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water.._.-_..___-._-..---.. f� Test Pit No. 2................minutes per inch Depth of Test Pit-.--__---.__________ Depth to ground water....................... ------------------- ---------------------------------------------- •------------------------•------•..................................................... ODescription of Soil-------- .................................. ••-•------------•-------._........---•---•--•-------._..._._......_...._._..---••------.....-•--•--------- ----------------- x -----•---•-••----•------------ W ----••------------ ------•-------------------------------------------------------------------------- ---------• --------- - -----• - ------------- U Na re of Repairs or Alter< IQrIs Answer when a plicable... .. ._ 1 J./�..o.e _../'._ ..__�._._____-_-- (/A r�m r" pG, "- --- - •--•--------------------- -------------------------- g Agreement: ent: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has eeN issued b - he boar f Signed ' =-=-- . " --- '----�;It 07_; '- --- .. l Y Date Application Approved By.......... __ _______________ ------------ Date Application Disapproved for the following reasons----------------•---•---•---------------•-------.--__._------------•---------------•----•------•---------•------- ---------•-------------•--------------------------------------------•---••--•----•----------------------- Date PermitNo. ------------------------------------------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` ...`.............OF_........<s��..s� Hit. �rrtifirtr of f�umlianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----_-_----_------------ �'� ( r S-5- V e—----------- ------------------------------------------------------------------------------------------------------- Installer atG----•-..... ---- ------------------�------. -- ---------------------- ------------ -------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._--__._-5�/_7_____________________ dated......... ...3_... e......_!:........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.-- %; ,L 3 . 1 ` DATE------•- --------------------------------•------•------•--•----•---------- Inspector---- -- ... -•-- ........................... THE COMMONWEALTH OF MASSACHUSETTS r . BOARD OF HEALTH ct,r.. OF_...... --------------------------------------- No. , �--==��-------------- FEE.' _.:----;•---- , Di pv.6al Norkii Qlunitrurtiun Vrrmit Permission is hereby granted------------AF -4- i- 5 s fi.:��: ------------------------------•- to Construct ( ) or Repair (K) an Individual Sewage Disposal System at No---------7 q----------- ....... �L------ f,---------- .,�f Street r as shown on the application for Disposal Works Construction Permit No.. __ ---------- Dated------ __ __.._ --•------•-------•--- ......................................... l� Board ofJIealtli DATE ---------------............................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS