HomeMy WebLinkAbout0002 RACHEL CARSON LANE - Health 2 RACHEL
LANE,'. CENTERVILLE
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis,MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: 1 l f 1 , 1� FilHp pl ase:
APPLICANT'S YOUR NAME/S:
BUSINES YOUR HOME ADDRESS: 2 C�
r lt-�
%--'Z�j -�I t�S .i r. Gl �1�- a�G
tm TELEPHONE # Home Telephone Number U
° 7 .
NAME OF CORPORATION:
NAME OF NEW BUSINESS 'T-(Vztv 6`0 e2-kce- TYPE OF BUSINESS
IS.:THIS A HOME OCCUPATION? YES NO Cc,"t�e�(1� L, f aZ6.32
ADDRESS OF BUSINESS � 21 ea J>fr.c 1-,�� MAP/PARCEL NUMBER O V (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required tq legally operate your business in this town.
1.. BUILDING COW Ab
'S OFFIC
This individu I fDAme o an "ri u' ements pertain to this type of business.MUST COMPLY WITH HOME OCCUPATION
RULES AND REGULATIONS. FAILURE TO
Auth ri ignature* COMPLY MAY RESULT IN FINES"
MMENT
2. BOARD OF ALTH
This individual h n in r ed f the ermit r irements that pertain to this type of business.
MUST COMPLY-WITH-ALL
H"ALL
Authorize ignature** MUS MATEF�IALS ItEG�1LATIOS .
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
d_< < ;
FIMEr�. Town of Barnstable
do
•AMSTAet e.
Department of Health, Safety, and Environmental Services
39.
i639• Public Health Division
♦0
A'ED1A°�p P.O. Box 534, Hyannis MA 02601
Office: 508-8624644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
November 23, 1998
Louis Vuilleumiier
P.O.Box 12
Cummaquid, MA 02637
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at Rachel Carlson Lane, Centerville was inspected on
November 5, 1998,by, Joseph Macomber, Jr. Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of
1.995 TITLE 5 (310 CMR 15.00)due to the following:
• Backup of sewage into facility due to an overloaded or clogged SAS.
• Sewage back-up or breakout or high static water level observed in the distribution box.
You are ordered to bring the septic system into compliance within two (2) years of the date of
discovery. November 5.2000.
First you must hire a licensed Town of Barnstable septic system installer to submit a sketch
diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367
Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00,
The State Environmental Code, Title 5.
In the meantime, you shall ensure that no raw sewage backs-up into the dwelling or discharges
onto the surface of the ground or into surface waters. You must maintain the system by hiring a
licensed septage hauler to pump the septic system whenever it is necessary.
Any person aggrieved by any order issued by the local approval authority may appeal to any
court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE B OF HEALTH
as cKean, R.S., C.H.O.
Agent of the Board of Health
q\health\dbfiles\tit1e5 i.doc
vuillcum/wp/q/Is
Town of Barnstable
• Department of Health, Safety, and Environmental Services
BARNSeaat.>L,
' ,0� Public Health Division
f�"A0�A 367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
PL-,W /Z DATE: N��
02Co 37
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at CU
was inspected on A),Z,j by `71_1 1, ,V%c,21n6�,-T, a Massachusetts
licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 C 5.00) due to the following: nn r
w � 1 O a'-t^'` i n[ U2
b X
S
You are ordered to bring the septic system into compliance within of the
date of discovery. Th ore,
m for la/ d 0
First, you must hire a licensed Town of Barnstable septic system inst er to submit a
sketch diagram of proposed replacement septic system component(s) to the Town of
Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will
bring the septic system into compliance with 310 CMR 15.00, The
Code, Title 5. Gh a
In the meantime, you shall ensure that no raw sewag 2harge�
s'onto the surface of the
ground or into any surface waters. You must maintain the system by hiring a licensed
septage hauler to pump the septic system whenever it is necessary.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER.OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
�mimwnmowuai.a«
TOWN OF BARNSTABLE
MOCA ''JN AAA-4el CAKSON I— /l SEWAGE# c
VILLAGE 6,101V rerLY/6, ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACTTY
LEACHING FACILTTY: (type) /-%/o � e�iG�9��t, �T (size) b
NO.OF BEDROOMS
o >
°r BUILDER OR OWNER �,15 �i:C1L�aw—/Vn
PERMTTDATE: 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 o le n cility) Feet
Furnished by
1 �
16 2° +`
7. •` l �• t" 1 T
DATE:
PROPERTY A D D R.E S S: ,RaUhel Carson Lane
Centerville,Mass.
02632 .
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1 000' gallon septic tank..
2 . 1 -1000 gallon precast leaching pit.
eased bn my In5r ctlon, I certify the following conditions:
3 . This is"a title five septic •system:.••(•: _6. Code ) '
4 . The septic system is in failure.
. 5 . The• leaching. pit is in ;'failure and must be replaced
with a new leaching are under the 95 septrc code.
6 . Septic tank is fine and be used as part of the new installation.
7 . Pumped- septic system as part of the - inspection.
SIGNATURE: 1-
Name J P Macomber -- i
Company:_J. P_Macomber_ &_ �on'`Inc
Address
__Cente�rvilLeLMa•�•�s_02b32 ' ' ,
Phone:
---548.�Z-7-S-�338_____-- --
THIS CERTIFICATION DOES HOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON) INC.
TankPCes-spools-Lsach(Ields
. Pump*d & Instillyd
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632.0066
77.5-33M 776-6412
vs
COMMONWEALTH OF MASSACHUSETTS
ID EXECU
TIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTIO '
ONE WINTER STREET, BOSTON, MA 02108 617.292.5500
WILLIAM F.WELD /1/O� 44TRL11 \>
Governor Scum
ARGEO PAUL CELLUCCI � 6 1D B.STRI I
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR �.Commiss'tor
PART A "
CERTIFICATION
�
Property Address:2 Rachel Carson Lane Centervil Mdress of Owner: P.Box 1 s
Date of Inspection: 11 /5/9 8 Mass. (I different) Cummaquid,
Name of Inspector: Joseph P-Marnmber Jr. 02637
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name; J.P"Macomber & Son Inc.
Mailing Address: BOX Centerville,Mass, 02632
Telephone Number: 5 0 8—7 7 5—3 3 3 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, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
leeds Further Evaluation By the Local Approving Authority
�/ Fails
Inspector's Signature: Date:
The System Inspecto shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owne
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
l� I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303,
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
40 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upo
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; o
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tan(
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:Uwww.mapnet.atate.ma.us/dep
Printed on Recycled Paper
• �-fit t y ;;�L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propcny Address: 2 Rachel Carson Lane Centerville,Mass.
owncr: Louis Vuilleumier
Date of Inspection: 1 1 /5/9 8
el SYSTEM CONDITIONALLY PASSES (continued)
MICA/- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
` piets) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with app(ova
p l of the
Board of Health). Describe observations:
broken plpe(s) are replaced
obstruction is removed
distribution box Is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection If(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Vlj Conditions exist which require further evaluation by the Board of Health In order to determine if the system is failing to procea tt
public health, safety and the environment.
t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within So feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THi
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
1L� The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply c
tributary to a surface water supply.
The system has a uptle tank and soil absorption system and the SAS Is within a Zone I of a public water supply well.
The system has aseptic tank and soil absorption system qnd the SAS is within SO feet of a private water supply well.
J The system has a septic tank and soil absorption system and the SAS is less than 100 feet but SO feet or more from a
private water supply well, unless a well water analysis for eoliform bacteria and volatile organic compounds indicates th.
the well is (tee from pollution from that facility and the pre�se,�nce of ammonia nitrogen and nitrate nivogen is egwl to c
less than S ppm. Method used to determine distance . (approximation not valid).
)) OTHER
(r•vi••d 0�/3s/!1) ��0. 3 0l SO
. , • l.f,C 1. � . ?y.L4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 Rachel Carson Lane Centerville,Mass.
Owner: Louis Vuilleumier
Date of Inspection: 11 /5/9 8
D) SYSTEM FAILS:
You must indicate ei;!,er "Yes" or"No" as to each of the following:
¢ I have determined that the system violates one or more of the following failure criteria as defined 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 l No
_�/ _ Backup of sewa into facility ors ystem component due to an overloaded or clogged SAS r cesspoo
,.,k/ 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 ces9� p�esl Mess than 6" below in or available volume is less than 1/2 day flow.
O/ 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.
V Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
J� Any portion of a cesspool or privy is within a Zone I 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 wrth no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
Q LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
AID . The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No,
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2 Rachel Carson Lane Centerville,Mass.
Owner: Louis Vuilleumier.,
Date of Inspection: 1 1 /5/9 8
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No ,
Pumping information was provided by the owner, occupant, or Board of Health.
ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note �f 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,ekluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2 Rachel Carson Lane Centerville,Mass.
Owner: Louis Vuilleumier
Date of Inspection: 1 1 /5/9 8
FLOW CONDITIONS
RESIDENTIAL:
Design flow: P.p. droom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):�
Laundry connected to system (yes or no):,YF-rs
Seasonal use (yes or no):06 p
Water meter readings, if available (last two (2) year usage (gpd): /4 ��! 9 ,O4 pf;5,1 (� c
Sump Pump (yes or no)AD / — W.1 '
Last date of occupancy:k
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: A1,# Aallons/day
Grease trap present: (yes or no)
IMP
Industrial Waste Holding Tank present: (yes or no),e,&
Non-sanitary waste discharged to the Title S system: (yes or no)A.1A
Water meter readings, if available: A)/9
AV
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and soy�rse of infor tjpn:
System pumped as part of inspection: (yes or no)
If yes, volume pumped: ZO a Ions _
Reason for pumping:, All-t Ald-7- / ° c1 �� ���k �- GUST
tvr -T T
TYPE OF YSTEM
Septic tank/c#iu 4AAioa-be'+dsoil absorption system
Single cesspool
AO Overflow cesspool
A)O Privy
Shared system (yes or no) (if yes, anach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other /Ujt
APPROXIMATE AGE of all components, date installed (if known) and source of information: �y
Sewage odors detected when arriving at the site: (yes or no)
(zw1sed 04/25/)7) Yage 5 of 10
• f.
r
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2 Rachel Carson Lane Centerville,Mass.
Owner: Louis Vuilleumier
Date of Inspection: 1 1 /5/9 8
BUILDING SEWER:
(locate on site plan)
Depth below grade:-4—$
Material of construction: 2 st iron 40 PVC_other (explain)
Distance from rfivate watery well or suction line�—
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
Joints appear tight; No Pyidpnrp of leakagp;
System is yented__ thrnllgh the hn11GP vpni-
SEPTIC TANK:.IOd
(locate on site plan)
Depth below grade:,
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance l�&(Yes/No)
Dimensions: e lv
Sludge depth:
Distance from top of sludge 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 botiorgrpf outlet tee or baffle:_
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Pump tank every 2-3 years.-Inlet & outlet tees
are in place;The septic tank is structurally �ound and shows
on pvirinrp of 1pakAgP
GREASE TRAP:Z
(locate on site plan)
Depth below grade:14//�'
Material of con struction:,4/Aoncrete46netal/jlFi berg Iass All Polyethylene/je,�bther(explain)
Dimensions: leed
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:,_,&Z/j
Distance from bottom of scum to bottom of outlet tee or baffle: 414
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage,-etc.)
Grease trap is not present.
I
(revised 04/25/)7) Pago 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:2 Rachel Carson Lane Centerville,Mass.
Owner: Louis Vuilleumier
Date of Inspection: 1 1 /5/98
TIGHT OR HOLDING TANK:AAW—*Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construct ion:/VA concrete&i metal 4WFiberglass�Polyethylene&other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: TtVAlarm in working order Al Yes;,VA No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Tight or Holding Tanks are not nrpspnt _
DISTRIBUTION BOX:A -
(locate on site plan)
Depth of liquid level above outlet invert: A/ .
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Distribution box is not present
PUMP 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 appunenances, etc.)
Pump chamber is not present _
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:2 Rachel Carson Lane Centerville,Mass.
Owner: Louis Vuilleumier
Date of Inspection: 1 1 /5/9 8 ,,)1 0
SOIL ABSORPTION SYSTEM (SAS):LI4d p"a" P/Y,Crjtt �y
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type. /
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions: 2
overflow cesspool, number:
Alternative system:
Name of Technology: 8
Comments:
�ancrondiloatnso 1, signs of
hydraulic
ofpgnding, condition of vegetation, etc.)
y Leachin it is in h drauli,c failure;
Waste water is over the invert pilpe.All vegetation is normal . -
Leac ing pit must be rplaced with a new leaching unc3Pr t-; t-1 0- f; va
95 Code,
CESSPOOLS: ALA/4
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: AA
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Cesspools are not present.
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Cesspools are not present.
PRIVY: 11hNal
(locate on site plan)
Materials of construction: NA Dimensions: NA
Depth of solids: NA
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Privy is not present.
(revimed 04/25/97) Page 8 of 10
SVBSURFACE SEwACE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (coniinutd)
/:open) Add:css: 2 Rachel Carson Lane Centerville,Mass
O.:nm Louis Vuilleumier
0431 01 Inspcc6on:1 1 /5/98
SK[TCK OP SEWACE DISPOSAL SYSTEM:
include tics to at Itast two permanent rt(erences landmarks or benchmarks
locale all wells within too, (Locate where public watt[ supplY comes Into house)
p
f ,
�l
r
of 10
(t•vl••� 0:/�1/17)
1
SUBSURFACE SEWAGE DISP(: L SYSTEM INSPECTION FORM
C
SYSTEM INFOI;'.. .f ION (continued)
Property Address: 2 Rachel Carson Lane Centerville,Mass.
Owner: Louis Vuilleumier
Date of Inspection:1 1 /5/98
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater FIEvation:
Obtained from Design Plans on record
i bservation of Site (Abutting property, bservation hole, basemer)i"sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
;'C"heck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groun<ilwa*ef Elevation. Must be completed)
Used Gahrety & Miller Model
12/16/98
Pag, 1�of 10
(revisal 04/25/97) '
r.n..r..-nrr..�•.-.- ..►�.nr•n�+rr+.ni..�+�.wnw+w..�wrn+�rn.+m.�vr.�-�.n+•+ .�.-..r•r-..'.n..-'..�>.r-•1
'I'UNN OF Barnstable BOARD OF HEALTH
SUnSU11FACR SFNAUF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CEWN FICATION
`� F�•�I1 T•'.'t'.—�.I.R�•�TR/I1A T.111nR AEI'A'nl��'S"'A•InVA.\RI..-1T��'r�nR7 IYn. MVT'1+�r —r.•
-TYPE OA PRINT CLCAALY-
PROPERTY INSPECTED
STREET ADDRESS 2 Rachel Carson Lane Centerville,Mass '
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Louis Vuilleumier
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Ince.. '
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Tom or City State LIP
COMPANY TELEPHONE ( 508 ) 775- 3338 FAX ( 508 I 790 - 1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system nt
this address and that the information reported �s,,true , accurate ) and
complete as of the time of ,inspection . The itislsection was performed and any
recommendations regarding upgrade , maintenance , .a�nd repair .,are consistent
with my training and experience in- the proper function and maintenance of on-
site sewage disposal systems .
Check one ;
System PASSED 7
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con cted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the DOARD OF HEAL'I'll.
If the inspection FAILED , .th'e owner or"`oparator shall u* pgrado ' tho system
within one ,year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CH11 16 . 306 .
Partd . doc
203 499 040
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PS Form 11, December 1994 102595-97-e-0179 Domestic Return Receipt
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Public Health DIVISM11
sown of Barnstable
P 0. Box 534
hyannis;Massachusetts 02601
L®C ATI SE o,C,E PERMIT U0.
4a�d
It�IST R• UJ E ADDRESS
BU1L:DER 5 Q LM A DRESS
DQZ'E PERMIT ISSUED
•ATE COMPLI W�ACE ISSUED : — — —
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TOWN OF BARNSTABLE qq_&
LOCATI0N,4 �A C-� O C A Q Sd� �d
SEWAGE #
VILLAGE e!��ki-Aza vdk/ "ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. r_ :A9C0107 6f f—
SEPTIC TANK CAPACITY iZ �n c �c
LEACHING FACILITY: (type)4 _0¢�Y � l5 (size).
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLI NCE 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
P
/`�-%
Fee 5 0. 0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes
RvOication for Mie;Vaaf *pgtem Con!6truction permit
Application for a Permit to Construct( )Repair�X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 2 R a•c h e t Carson Lane Owner's Name,Address and Tel.No. c 18 5 STONEY P o i m t
Centerville ,Mass . 02632 Road Cummaquid ,Mass . 02637
Assessor's Map/Parcel l Q b 3 6 2—6 2 6 9 Z. t1aAL e,.r.+m mr
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No.5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc . J.P.Macomber & Son Inc .
Box 66 Centerville ,Mass . 02632 Box 66 Centerville ,Mass . 02632
Type of Building:
DwellingX X X No.of Bedrooms 3 Lot Size sq.ft. Garbage GrinderlQ 0 )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 355 gallons per day. Calculated daily flow 3 x 110=3 3 0 gallons.
• , P_lan Date Number of sheets Revision Date
•Title'
• ,S ze of Septic Tank 1000 existing Type of S.A.S.2— 560 gallon rbamhars ,
DescriptionofSoilMedium sand to fine coarse sand .
Nature of Repairs or Alterations(Answer when applicable) Adding two 500 gallon chambers
to the existing septic system. Chambers packed in 4 ' of stone
25 ' xl2 10 x2
Date last inspected: 2/15/9 9
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 of to place the system in operation until a Certifi-
cate of Compliance has been iss �tis eoar�f al
Signe / Date 2/15/9 9
Application Approved y Date
Application Disappro for the following reasons
Permit No. Date Issued
No. Fee 5 0. 0 0
' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
c
P,UB1( HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes
01pprication for ;0ioozar *pgtem Construction Permit _
Application for a Permit to Construct( )RepairX X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 2 Rachel Carson Lane Owner's Name,Address and Tel.No.C 185 STONEY P o i m t
Centerville,Mass . 02632 Road Cummaquid ,Mass. 02637
'&— Assessor's Map/Parcel ,^b _ 3 6 2—6 2 6 9 Z. gaiU e i m 1 w
Installer's Name,Address,and Tel.No.5 O 8—7 7 5—3 3 3 H Designer's Name,Address and Tel.No.5 0 8—7 7 5—3 3 3 H
J.P.Macom'ber & Son Inc. J.R.Macomber & Son Inc .
Box 66 _Centerville ,Mass. 02632 Box 66 Centerville ,Mass. 02632
Type of Building:
DwellingXXX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinderl(O )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 335 gallons per day. Calculated daily flow 3 x 110=3 3 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1000- existing Type of S.A.S.2—=560 ga I 1 nn chamhara
DescriptionofSoilMedium sand to fine coarse sand.
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r�>
^Y• P
Nature of Repairs or Alterations(Answer when applicable) Adding two 500 P a l l o n chambers
t,o the existing septic system. Chambers packed in 4' of stone.
Z51x12 ' IO"xZ'
Date last inspected: 2/15/9 9
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 of to place the system in operation until a Certifi-
cate of Compliance has been iss=byt oar�f 1
Signe. Date 2/15/9 9
Application Approved(eiy�r
Date
Application Disapprofor the following reasons ✓!
a
00
Permit No. ;r Date Issued
.F%"
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY that the On-site w s to Sewage Disposal System Constructed( )Repaired(X X Upgraded( )
Abandoned( )bvJ•P•Ma e o m b e r & Son Inc.
at 2 R a c h�e 1 Carson Lane Centerville ,Mass. s een constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer J.P.Macomber & Son Inc . DesignerJ. P.Macomber & Son Inc .
1 The issuance of this per s 11 not a ued as a guarantee that the s tEm will function as1W�
es'i pe /
u
Date Inspector ov ,(
— ' --------------------------------
No. I Fee $ 5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwis po$al *p.5tem (CotWtruction permit
Permission is hereby granted to Construct( )Repair(X X)Upgrade( )Abandon( )
Systemlocatedat 2—Rachel Carson Lane Centerville ,Mass.
and as described in the above Application for Disposal System Construction Permit. The applicant reco nizes ' /her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Constructio must Ve completed within three years of the date of t
Date: Approved by
�j la9ro7
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
1, Joseph P.M A comber Jr ., hereby certify that the application for disposal works
construction permit signed by me dated 2/16/99 , conceming the
property located at 2 Rachel Lane Centervi 1 1 P ,Ma s—a meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
• If(tie proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
/6
B)Observed Groundwater Table Elevation(according to Health Division well map)
SIGNED : DATE:
LICE S SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
q:health roldcr:ccn
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tt TOWN OF BARNSTABLE
LOCATION,'- I A C. LL C A k 6,0xJ .j'
SEWAGE # n
VILLAGE ---F.ciAt"., -f, n ' ASSESSOR'S MAP dt LOT n L/
INSTALLER'S NAME&PHONE NO. ��.. �"_ .�I19 co;yi S f dL 7 7 3 3 3
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)4—Ids (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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
p
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p
/ f.
f 1
` �, pip
'70
fie- F��.. .......
No.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH—
_ 1�V. .??
.............OF...:. ----.._....... ------
Appliration -fur Uhipviitt1 Works Towitrurtion Vaniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
��5®/✓'---------- -------------- --------------------------- -------------------------------------------
Location/-AAJddres !/ or/Lot No.
...........
...�P..... �/.L. ...................... ....................... !�................................................................P
W Owne Addre s
aT� .. ` ----------------------
Installer Address ,
U Type of Building Size Lot. �__,t_``� .Sq. feet
Dwelling—No. of Bedrooms-----------________________________Expansion Attic ( ) /11G Garbage Grinder ( )
aq Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
P`' Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow...........................:----------------gallons.
WSeptic Tank—Liquid capacitV;1 gallons Length---------------- Width................ Diameter__---_---.-___ Depth...-_____--._-.-
x Disposal Trench—No--------------------- Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No--------/....... Diameter�;..X ._--- Depth below �nlet.. ...... ...... Total leaching area.___--_.__._-___-_sq. ft.
z Other ]distribution box ( ) Dosing tank ( ) t7�- �C��— 1 7`7C
Percolation Test Results Performed by------- ----------------------••-•-•-••-•--•-•••-----•-•• --••-••. Date........................................
,� Test Pit No. I----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water-----------.---._._-----
V-1 Test Pit No. 2................minutes per inch Depth of Test Pit---------------------- Depth to ground water--.--._..--.--.-___----.
9 ----------------
' ----------- �.Z_ ....
O r. �
----•---•-----
Desc-ription of .....it -
U
------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------•-•------•---------------------- ---------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article tI of the State Sanitary Code—The undersign5o further agrees not to pla e the system in
operation until a Certificate of Compliance has been issued by the board 0 health.
Ligne ----------- ------------------------------- Date
Application Approved BY -- ---------- --------
---�s �� ...-7. .
Date
Application Disapproved for the following reasons-----------------------•_--------_-------------------------------------------------._--------------_-------------
............................... •---.--•-•••..--_.._...--------•----•-----•--•---•-••-••••-------------•-
Date
PermitNo......................................................... Issued.....................................-..................
Date
-------------------- -----------------------------------------------
No........ :I F>�s... ........'.THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH-
-
_ .. . ...._..._.....OF.....
. __.............
Appliratiun -fur 13iopuottl orku Cnunotrurtiun Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
Owner t� Address
Installer Address
Type of Building Size Lot... ..1_____________Sq. feet
Dwelling—No. of Bedrooms----------- -. ------•_____-__---_--_-.Expansion Attic ( ) /I/v Garbage Grinder ( )
a4 Other—Type of Building ---------------------------- No. of persons____________________________ Showers ( ) — Cafeteria ( )
A'' Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
W Septic Tank—Liquid capacity/, ''gallons Length_-_-__-______-- Width................ Diameter-----.---------- Deptlt.._....__......
x Disposal Trench—No..................... Width-------------------- Total Length------------------.. Total leaching area--------------------sq. ft.
Seepage Pit No---------,_-i Diameter_--,__k''5;:t.___ Depth below inlet____ ___ ... Total leaching area......-_-_--_____sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) O�- �G/`�1- - 7` �-
a Percolation Test Results Performed by--- ------=------•-------------•-----------•----------•------------ Date---•-----------•-----------------•--
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-----------------.......
fzq Test Pit No. 2................minutes per inch Depth of `lest Pit-------------------- Depth to ground water........................
x r '- .1 L
Description of SP11--- `G - -- -- r
.............------•---
✓A -..,r ------------- -------------- --------- ----------------
U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------._.__._--______._-___---___-_---- ..................
---•-----------•--------------••-•---------------•---------------------•-----------------•--•----•-------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article YI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health. '
Z /
-- .
Application Approved BY " E: .... 2�1 .
•-•--
Date
Application Disapproved for the following reasons_____________________________________________________________________________
--------------- --•-•.-----•--
------•-•-----•••------•----_.._..•----•-------•--•-•-•---•.
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
.......OF......... . . ...............................................................
GGGGGG (�rrtif iratr of 0111mphaurr
TH S CE 'T �,Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ..4.... ---
------ ------------------------------------- --------------
Installer )
!/
f ---------------
iev
has een installed in accordance with the provisions of Art' e 'I o fl e State Sanitary Code as described in the
application for Disposal Works Construction Permit No.... �G ._____.___. dated..... _-__ .-_7_.1�...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ,
DATE --36-- F�----------- - Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OEALTH
oZ ., ..OF...............
No... .......v..
FEE---Z ...........
` Dinvo,6a V?4
-C oramtrurtio.n rrmit
Permission is hereby granted--------- -----� ------- ------------------ ...........................................
...
to Construct ( r Repair ( n Individual Disposal Syste
V V- Al.. - ------------
St eet - �y
as shown on the application for Disposal Works Construction Pt N .______J__�_ Ijated__:._ `_1-�.___.._..
..........
Board of Health
DATE.
•----------------•------...............•..............•-----------•-----.....
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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