HomeMy WebLinkAbout0022 WESTMINSTER ROAD - Health L
estminster Road
ille P
68 064
UPC 12543
NO, 531CR
HASi1NGS, MN
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, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: Q-aQ- �s Fill in please:
k APPLICANT'S YOUR NAME/S: HA OS <'Q1 d oS
r , ; Gar' s BUSIN SS - � YOUR HOME ADDRESS:_ o-02 W(�,5T /I)S��Q �DV IQ lI1 ACC` "M19
" ' r 577
TELEPHONE # Home Telephone Number 0 ftO
NAME OF CORPORATION:
NAME OF NEW BUSINESS C-11 S C t.j I K) SC R Q I C6 S TYPE OF BUSINESS 1c- Aim I oj6
IS THIS A HOME OCCUPATION? YES NO
ADDRESS OF BUSINESS as Gll��gID,ISTE 1.E MAP/PARCEL NUMBER I lUt/ W (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 Stre21e
ure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING CR's o1=Fl MUST COMPLY WITH HOME OCCUPATION
This indivi k fur`me o ny r i e uirements that pertain to this type of business.RULES AND REGULATIONS. FAILURE TO
e S rFature** COMPLY MAY RESULT IN PINES.
C M ENT
�l V
2. BOARDAF H ALTH / /��G f rel
This individual has been informed of permit requirements that pertain to this type of business. L
HAZARDOU TERIALS=EdIONS
Authorized Signa u
/'
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:
TOWN OF BARNSTABLE Date:10
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: k-,LLA`C.J C2C-,W WG .�EkICCS
BUSINESS LOCATION: @ tj,� I DJIST;K CC T R o,llkkflNVENTORY
MAILING ADDRESS: HAQIM l��S( t�'fey �Qd'1 ll,.Cf�Dd TOTAL AMOUNT-
TELEPHONE NUMBER:'
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER: Sc' 3 v2�'1�-J-�'1��� MSDS ON SITE?
TYPE OF BUSINESS: CtgAI MC-,
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
9
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts(Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business,certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) 1 ou must first obtain the necessary 5ig1iatu1-(!5 on this form at 200 Main St., Hyannis.
Take the completed form to the To,.vn Clerk's Office, 1 st. FI., 367 Main St., Hyannis, MA 02601 jown Hall) and get the Business Certificate that is
required by law. _
� DATE: Fill in please:
APPLICANT YOUR NAME/S: I�gRCDS CAS-(�05
BUSINESS YOUR HOME ADDRESS. � i4 1� r.<1 A4/AI
ut PA Oa63a.
TELEPHONE # Home Telephone Number OrR� '`1 - �"l
NAME OF CORPORATION
NAME OF'NEW BUSINESS TYPE OF BUSINESS A lN7�l A/��'
ISiTHIS A WOME.00CUPATION� � YES NO
ADI]RE$S OF BUSINESSoC '!.L)E `T�iHl � "c U�/t_ --MAP/PARCEL NUMBER �'g �� (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 IQLQQ St. - [corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your usine s in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has en-trtf mgd of the permit requirements that pertain to this type of business. MUST�.OMPLY WITH ALL
t" �-a��( � -;a7ARDOIJS MA,TF_RIALS REGI 1 A71n,'NP,
Authorized Signature*
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:
x
No. J�PC06 f J ! Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Th5po$AY �§p$tem Cow5trurtton 30Crmtt
Application for a Permit to Construct( ) Repair( ) Upgradt�_ Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. 'Z,L Owner's Name,Address,and Tel.No. At4o rrC.v3 C-4"io cg
G \VII Z Z W-r3fvK II ILI)-
Assessor's Map/Parcel 0 6?14-/'r-/t,l ((e- --L Q v L
Installer's Name,Address,and Tel.No. �GKJ�� v�lr 7 Designer's Name,Address and Tel.No. 61 s*4 y
Type of Building: _
Dwelling No.of Bedrooms Lot Size l 1 ��+ sq. ft. Garbage Grinder ( )
Other Type of Building :5.'�J c. i No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 gpd Design flow provided 3) b gpd
Plan Date 1 0— Q — Zoo�- Number of sheets_ I Revision Date
Title 2-1- w eyc o,%,�,&y
Size of Septic Tank 1 'O o o Type of S.A.S. 3� cal,
Description of Soil L (W-0
Nature of Repairs or Alterations(Answer when applicable) f QAA.r--L C-G�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application-Disapproved by: Date
for the following reasons
Permit No. ,r � — 1 Date Issued ® 112140
_wY_.'.y�-slate. r.;^ .- _ •f-. i y, - 4 '' , -. _� __� _.. ...+.rr...-.r--..---�._-a _. .. _ .. y_ ..-.7.. _ , _ , __-
JL-
No.C>' t�..---^ , -�^ d Fee _
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC'FiEALTH DIVISION - TOWN Of BARNSTABLE, MASSACHUSETTS Yes
t ZIppYication for 0igpogal Abpztem Con5truction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade )- Abandon( ❑Complete System ❑Individual Components
Location Address or Lot No. Z Z W e)i Min)T,,_0 C Owner's Name,Address,and Tel.No. wl A✓c v3 (-4—�9 o g
r4,ser (z 1
Assessor's Map/Parcel I�- bFS �` � t%P�,-�r✓�I l t G V-1 O a2t3
If I !
Installer's Name,Address,and Tel.No. ����v, �� ���'"7 Designer's Name,Address and Tel.No.
p. o. ;.7x `763 /0. go< GZ-)
vv+A 64,r ;ten-/ ✓2
Type of Building: z, _
DwellingNo.of Bedrooms �/ Lot Size 1 1 ''� + sq.ft. Garbage Grinder ( )
Other Type of Building 5 -t Y °i 1 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 U gpd Design flow provided 3 3 b gpd
Plan Date 1 0' t 3 �`� Number of sheets 1 Revision Date
Title �- ��� ✓� ti>�N
Size of Septic Tank ) 'D o o Type of S.A.S. �, T/.g {v✓ j`%Lrr c �.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: '
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. 1
Signed?7�§� Date
Application Approved by Date
Application Disapproved by: Date
` for the following reasons i' 7
Permit No. r 400 ` f " Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage DisposalSystem Constructed ( ) Repaired ( ) Upgraded 0--�_)
Abandoned( )by �-�- e�n k'W ey i><) L-L_ C-
at '2'2 5 r ✓yi r<)T-e-(Z rt has been constructed in accordance
with the provisions of Title 5 and the for Disposal System stem Construction Permit No.P�-0& Jy'� dated ItG
p P
Installer �IG(��vJ �A Designer /4 Av
#bedrooms 3 Approved design flow \ gpd
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector -^ -----�
--------------------------------------------
No.CX1�� T "Y� Fee Q�
THE COMMONWEALTH OF MASSACHUSETTS
.PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
'Wi5pont i§pgtem Construction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (4 ) .A1ba don ( )
System located at 2�- w e r M 't `Z 2 (�. ✓Q 'n +Q f" V 1 � �
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the da`e of this per
Date �G 1- LP Approved by ��
1
Town of Barnstable
Regulatory Services
l
Thomas F. Geiler, Director
• BARNSTABLE,
9� � Public Health Division
�EDtA°�A Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 10/30/06
Designer: Shay Environmental Services, Inc. Installer: Capewide Enterprises
Address: P.O. Box 627 East Falmouth Address: P.O. Box 763
MA 02536 Marstons Mills,MA 02632
On 10/13/06 Capewide Enterprises was issued a permit to install a
(date) (installer)
septic system at #22 Westminster Rd, Centeville MA based on a design drawn by
(address)
Shay Environmental Services, Inc. dated 10/13/06
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
XX I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
Of U
(In taller's Si nature) o= CARE EN
SHAY
No. 1181
0
�FGIS-T
Me-signer's Signature) (Affix r� p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
Date: (OI J l ��
TOWN OF BARNSTABLE / ��
TOXIC AND HAZARDOUS MATERIALS ON-SITE
NAME OF BUSINESS: P ELt'A"S RAIA 1 a✓G
BUSINESS LOCATION: . Zol a_)!ESTA4jtjg7'Ek R.D INVENTORY
MAILING ADDRESS: TOTAL AMOUNT-
TELEPHONE NUMBER:
CONTACT PERSON: 1'IAPCQS CAMPC6
EMERGENCY CONTACT TELEPHONE NUMBER: '- '-j f`/-q'S.�"7 MSDS ON SITE?
TYPE OF BUSINESS: FA►oy7-W6
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED ' " Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes j A / V O.L t, +��, % t
Laundry soil &stain removers p� !
(including bleach) I A L S
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
TOWN OF BARNSTABLE
LOCATION 6Jc�s� /v,ih.S�e/' SEWAGE# 0(-- Y`t`j
z VILLAGE Ceh hem v, JI_ASSESSOR'S MAP&PARCEL (o$ (nr-f
INSTALLERS NAME&PHONE NO. Lys y rti L
SEPTIC TANK CAPACITY 15 cy (4 ,o
LEACHING FACILITY:(type) S Gp L G (size) t a $�
NO. OF BEDROOMS
OWNER aw-cu s b v S
+PERMIT DATE: U COMPLIANCE DATE:
Separation Distance Between the: x
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility No / Z 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
s—
r S..
B3 �9
g� 'yo.0
z6r
C ow-'6 os ' Pf"Al �—r-vy� tvo"5-e
i 14 1 f=rc.r� �vr
Town of Barnstable P# wc,
s� Department.of Regulatory Services
„WMARLM a Public Health Division Date
ies9 ♦� 200 Main Street,Hyannis MA 02601
rED MA'1�
Date Scheduled (J� z
Time Fee Pd.
Soil Suitability Assessment for Sewage Disposal
Performed By: Witnessed By: 0 �
LOCATION& GENERAL INFORMATION-M ��, t_ ►p®s
Location Address Owner's Name . —
Address
Assessor's Map/Parcel: I a Engineer's Name S4+r
NEW CONSTRUCTION REPAIR _ Telephone#
Land Use i`�QSI c�1u lRr1C`.� Slopes M 5 670 Surface Stones
Distances from: Open Water Body 60 Possible Wet Area__d_ �ft Drinking Water Well —4AL_ft
Drainage Way ft Property Line I ft Other /" ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands�n proximity to holes)
Iv +
U_r 'S' r� ffA ro,L�5
Parent material(geologic) h Depth to Bedrock
T`.
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater 1 yy ;�SskzONGA C ?
DETERMINATION FOR SEASONAL HIGH WATER TABLE 7 i
Method Used: _�yp�cvt wn—Oar t�1s> r- I
Depth Observed standing in obs.hole: r`11p in. Depth to soil mottles:
Depth to weeping from side of obs.hole: in, Groundwater Adjustment = ft.
Index Well# Reading Date: Index Well level _ Adj.Ihetor..,,,_a, Adj.Orouh, later Level
PERCOLATION TEST Dide Thne
Observation
Hole# �I 'rime at 4" tlll�-------__y----�
Depth of Pere Time at G"
Start Pre-soak Time @ a�,lt ��S��s. 15me(9"-6")
End Pre-soak
Rate MinJlnch 'P
Site Suitability Assessment: Site Passed Site-Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\.SEPTIC\PERCFORM.DOC
DEEROBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
istGravel)
p L in 2,3I �' V�-C&ke
e k
Low.
DEEP OBSERVATION HOLE LOG
Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
C ns' %
6 -1D0 F \
- �� a �► oY�3 N � �ab
C �f L-5 a
Lllfz �
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency,
� II
Flood Insurance Rate Map:
Above 500 year flood boundary No— Yes
Within 500 year boundary . No Yes
Within 100 year flood boundary No✓ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on 1 (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required trainilih extiorti a experience described in 310 CMR 15.017.
Signature Date
Q:\.SEPTICVERCFORM.DOC
A. COMMONWEALTH OF MASS
ACHUSETTS
' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
~Y r'.--lay NED
V�
, , ► i �.� DEC 15 2004
r
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: :�01(1�1PSMrn;n ��_
Owner's Name:
Owner's Address:
Date of Inspection: t - I —OUF
Name of Inspector:(please print0QUQ ac A.8mwri
Company Name: l7nunl� a ary'Wn Septic Inspections
Mailing Address:_ R 145
Telephone Number: A 02632
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 maintenanc4 of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 5.340 of Title 5(310 CMR 15.000). The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: eZ� Dat
e: AL 7_ 0 /
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
,4-
('o -
�ffl/5 tiwt � g S�(•^1 a�0�0YG/$ f0 /.�p .�V wv'�Otis
rvvt Flvno Oae to pleas+-jC 6NF c tzeA - M 5 A•s wc�5 Noy v
�D-bc)C was opek-Jt3 C,rlc), be worvo-j
****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
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: s4mw
Owner's Name: C tNat�wc. 1�1 `e to
Owner's Address:.
Date of Inspection: 10 . •7 - a v�
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst asses:
I have not found any information which indicates that any of the failure criteria described in 310 CUR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. stem Conditionally Passes:
one or system components as described in the"Conditional Pass"section need to be replaced or
repaired.The syste n completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined N,ND)in the following statements,If"not determined"please explain.
The septic tank is metal and over 2 old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or on or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic as approved by the Board of Health.
*A metal septic tank will pass inspection if it is sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is availab
ND explain:
Observation of sewage backup or break out or high static water 1 l in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. Sy will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).Th stem will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
is
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: -1.1L uJe t-
k-C
Owner's Name:
Owner's Address: .
Date of Inspection: tO . 1 - p u
C. urther Evaluation is Required by the Board of Health:
Co exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protec is health,safety or the environment.
1. System will pass unless rd of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a er which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a e water
Cesspool or privy is within 50 feet of a borde getated wetland or a salt marsh
System will fail unless the Board of Health.(and Public Water Supplier,if any)determines that the
sy Is functioning in a manner that protects the public health,safety and environment:
_ the in has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water ly or tributary to a surface water supply.
_ The system has a se ' tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank an S and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and AS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to dete stance
**This system passes if the well water analysis,performed at a certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this fo
3. Ot
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: t� N
Owner's Name:_Cher tt� E tc�t P
Owner's Address:
Date of Inspection: 10- l O H
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
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
✓Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓Liquid depth in cesspool is less than 6"below invert or available volume is less than%x day flow
— _ &Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
— _L,kny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
--sr-Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for 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.]
J/j0(Yes/No)The system fa Ls.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 Hoard of
Health to determine what will be necessary to correct the failure.
Large S
gpd. n ystems:
sldered s large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
You must in ither`y 11 or"no"to each of the following:
(The following Grit 1 to large systems in addition to the criteria above)
yes no
the system is within 400 feet o ce drinking water supply
— _ the system is within 200 feet of a tribu a surface drinking water supply
_ the system is located in a nitrogen sensitive area 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 cant threat,or answered
"yam'in Section D above the large system has failed.The owner or operator of any large em considered a
significant threat under Section E,or failed under Section D shall upgrade the system in accordance with 310 CMR
Page 5ofII
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 0t' ♦M� S
Owner- VO
Date of Insp�jnD Y
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes Now
Z Pumping information was provided by the owner,occupant,or Board of Health
� Were any of the system components pumped oat 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?
l/ 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
soor-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:
Yess
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
i
Page 6 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
per e
Owner's Name:
Owner's Address:
Date of Inspection: 1D 7 y
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): "S Number of bedrooms(actual):
DESIGN flow based on 310 C1v1R 15.203(for example: 110 gpd x#of bedrooms):Number of current residents: (D
Does residence have a garbage grinder(yes or no):Zcp
Is laundry on a separate sewage system(yes or no):/�[if yes separate inspection required)
Laundry system inspected s or no): ,t
Seasonal use:(yes or no):AZ acx)a C0,000
Water meter readings,if available(last 2 years usage(gpd)); a0o 3 y, po c�
Sump pump(yes or no):
Last date of occupancy:-� ,
C MMERCIAL/INDUSTRIAL:
TYpe lishment:
Design flow on 310 CMR 15.203): and
Basis of design flow persons/sgft,etc.):
Grease trap present(yes or.
Industrial waste holding tank pre (yes or no):__
Non-sanitary waste discharged to the system(yes or no):—
Water meter readings,if available:
Last date of occupancy/use;----
Pumping(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped:_____gallons--How was quantity pumped determined?
Reason for pumping:
TYPE Off'SYSTEM
eptic 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 components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): N
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:.
�L12
Owner's Name:
Owner's Address:
Date of Inspection: to - 7•-Q t(
B DING SEWER(locate on site plan)
Depth be e:
Materials of co ction:_cast iron _40 PVC_other(explain):
Distance from private er supply well or suction line:
Comments(on condition o ts,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: 12 V ,
Material of construction: ✓concrete_metal fiberglass_polyethylene
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: I
Sludge depth:
Distance from top of stud a to bottom of outlet tee or baffle: fox
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of a tlet tee or baffle:
How were dimensions determined:��Outlet
Comments(on pumping recommendations,inlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
G E TRAP; (locate on site plan)
Depth below e:
Material of cons concrete metal fiberglass,_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet r baffle:
Distance from bottom of scum to bottom of ou a or baffle:
Date of last pumping:
Comments(on-pumping recommendations,inlet and outlet t . baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
S-C1
Owner's Name•
Owner's Address:
Date of Inspection:
TI T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below e.
Material of cons 'on: concrete metal--fiberglass •polyethylene other(explain):
Dimensions:
Capacity: ons
Design Flow: da
Alarm present(yes or no)
Alarm level: AZ
n working order or no):
Date of last pumping:
Comments(condition of and.float switches,etc.):
DISTRIBUTION BOX: ✓ (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 x,etc.):
CHAMBER:__(locate on site plan)
Pumps in working o or no):
Alarms in working order(yes o
Comments(note condition of pump c dition of pumps and appurtenances,etc.):
-Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTE INFORMATION(continued)
Property Address: gar
C MCA
Owner's Name:
Owner's Address:
Date of Inspection: to.- -7 - O
SOIL.ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located explain hy:
14
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovativelalternative system Typdname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): ,
y i�j'l�t acs r ;b4 �'ol s�,e /r X P�
SPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number an
Depth-top of liquic t invert: a
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-):
PRiV . ovate on site plan)
Materials'of constiction
Dimensions: -...._ ._.__..
Depth of solids ,'' - iser
Comments(note condition of s fl,signs ohydt�_ , ponding,,condition of vegetation,Etc) s s
f. i,Ids
Page 10 of I I
OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: A 43 inX"lt VA
Owner's Name:,C � eS 1\ ! )5e
Owner's Address:
Date of Inspection: tb
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
C.
C
3&
it
f
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2
Owner's Name:
Owner's Address:,
Date of Inspection: 1() _"7 - 0 N
SITE EXAM
Slope:. 61 is`•'t' L(-z yofc)
Surface water:.K-,)pt,5 e
Check cellar: r�.)o
Shallow wells "QN P
Estimated depth to ground water IiDeet
Please indicate(check)all methods used to determine the high ground wager 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)
Accessed USGS database-explain:
You must describe howyou established the high ground w/ater elevation: /
c
5
No.
0 - ti._ Fee 5
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS
2ppfication for Migogal 6pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( grade( )Abandon( ) ❑Complete System ❑Individual Components
6l ts'�c n Owner's Name,Address and Tel.No.
Location Address or Lot No.i1.
Assessor's Map/Parcel
Installer's N e,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. Kc - ri 4e+
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this and of Ith.
Signed Date n 7,3 rQ o
Application Approved b Date
Application Disapproved for the following reasons
Permit No. Date Issued
TOWN OF BARNSTABLE
LOCATION `Z.'L 11Lsi d^t�r��� SEWAGE # 10C U
VILLAGE C f C 1 f l' i i ��t" ASSESSOR'S MAP & LOTIL5'061
INSTALLER'S NAME&PHONE NO. rn t � �>v � -1 9 0 Z 77
SEPTIC TANK CAPACITY
r f
LEACHING FACILITY: (type) �-� �'� 1 5��� (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
. .. .. ... ....
i
PGA;�
��
� ( a
No. ""' *�.-...�*�,..F Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pprication for Miopogal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( Xupgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.�.2-- t''�S w c nh,,�S�l =^ / Owner's Name,Address and Tel.No.
Assessor's Map/Parcel L G u�uo 4 E 0 r.(;+
Installer's N e,Address,and Tel.No. Designer's Name,Address and Tel.No.
Lecea��
I:
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. t ( "t t ..S e A(e,
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �Ct 1cO 4 -ec.L C.(A f
Date last inspected:
Agreement:
Tte undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this azd o lth.
Signed Date -:5 ^ �Z,3 _Q 0
Application Approved b ._ Date S`"Z3` Zart�
Application Disapproved for the following reasons
-310
Permit No. Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTMT
a the On-s' e S�o_wag s osal System Constructed( )Repaired �raded( )
Abandoned( )by � w
at 22. Cv�e w+24-1 I Z 6�144 - has been constructed in accordance��
with the provisions of Title 5 and the for Disposal System Construction Permit No. `� dated 3=Z.?-Z
Installer Designer /A A A
i
The issuance of this p,ert1 sh 1 not be construed as a guarantee that the fe will func io a� isgi nd.
Date Inspector y /f v
---------------------------------------
Fee 3
THE COMMONWEALTH OF MASSACHUSETTS
I6 r-00 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migpogal *pgtem ngtruction Permit
Permission is hereby granted to Construct,( )Repair( Up grade( )Abandon
System located at Z Z we17i*7 (,P7 j 0 L ��
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 p t.
Date: 2 �'�'� Approved by ..—:0 ,
. /"�J
1a TOWN OF BARNSTABLE �C.
i
LOCATION '2-`L 1�ajoV�d� �"_�F' SEWAGE # 2-®CX1 "3[0
4 VILLAGE C A 1'f P V I U e ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type).--(-4 l Kr, (size) 121
NO. OF BEDROOMS
BUILDER OR OWNER i ..
PERMIT DATE: 0 0 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
Vq(�
� 3
t
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, JJ�Le � <*—. I— , hereby certify that the application for disposal works
construction permit signed by me dated , concerning the
property located at r < fie r -)�-t - meets all of the
following criteria:
• This 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.
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the 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) 7 C/
B) G.W.Elevation +the MAX.High G.W.Adjustment. _ /5
DIFFERENCE BETWEEN A and B 25'
SIGNED : DATE: `E _ 1-3 —O Z)
[Please Sketch proposed plan of system on b ].
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
L( t-trl l
DATE: 95 r
--- - -�-
I
PROPERTY ADDRESS: 22 WEstminster_Road___
Centerville,Mass .
02632
------------------------ q
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
A. 1 -1:D-00 allon tic tanl . I
� septic
B. 1 -1.0.00•.:gllon leaching pit.
I
Based on my Inspection, I certify the following conditions:
A. 'Tks is a title five septic system ( 78 Code )
B. Certain repairs are needed see estimate sheet.
i
SIGNATURE: 12 _
I
Name: J P_Macomber Jr_______ I
_ I
i
Company:_J.P.Macomber—& Son Inc. I
.. Address:_
Box 66
-------------------- R,fL
Centerville,Mass02632 �
Phone: 508-775-3338
--------------------- 1.�
49.
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRA
C . MACOMBER & SON, INC.
nks-Cesspools-Leachfields
Pumped & Installed
own Sewer Connections
6 Centerville, MA 02632-0066
775.3338 775-6412
I
f
J
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART D
CERTIFICATION
Inspector : Peter Sullivan PE
Location : 22Westminster Road Centerville
Date : May 31,1995
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 complete as of the time of
inspection. The inspection was performed and any recommendations regarding
upgrade, maintenance and repair are consistent with my training and experience in
the proper function and maintenance of on-site sewage disposal systems.
I have not found any information which indicates that the system fails to adequately
protect public health or the environment as defined in 310 CMR 15.303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of this form.
Please note the summary of recommendations as presented in this form.
Lastly please note 310CMR:15.302 Criteria for Inspection(1) "The inspection is not
designed to provide information to demonstrate that the system will adequately serve
the use to be placed upon it by the new owner. "
truly you
ter Sullivan PE
Distribution:
Original to system ownerkti
Buyer ��,,aj OF '
Board of Heath o
� P'f TER
SU!;IVAN
No. 29133
O1PAL E�°�
I
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
\J Address of property 'ZZv%A %r�s n �1
. P Y .. eST"
Owner ' s name
Date of Inspection
PART A
CHECKLIST
check if the following
ng have bee
n don
e:
Pumping information was requested of the owner, occupant, and Board of
Health..
t/ None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of,. this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility .or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
A11 system components; excluding the SAS, 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 SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on *the proper maintenance of SSDS.
cvS
i, PC 'SQ.OK_G(V -S.
cl CXDIC 2�L+�°tL� FUEL- L.E:cUC-ATH
, E PLC c C '150T�-1 t rO Lc ( 4 OUT Lam-
rtZ }-O2. T' �.vj LL
C��EatTL� Q.GC>_X_P, Li i=
8-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
SYSTEM INFORMATION
V
FLOW CONDITIONS
If residential
i
number` of bedrooms
number of. current .residents
garbage grinder, yes or no-
laundry connected to system, yes or no
o seasonal. use, yes .or no
If nonresidential, calculated flow:
• I
Water..°meter readings, . if .available: 5 EE /ate
2� so To AaLF, �
Last date of. occupancy /3 1:6eo wl: :.!-ECC�S�
GENERAL INFORMATION I
• i
Pumping records and source of information:
e'02 S fLNSi ce srzvu i.
System pumped as part of inspection, yes or no
if yes., volume pumped
Re on 'for. pumping:
tc-Lo 6%A�A
Type of s�a �s�tem
Sept '. tank/ istribution bo /soil abs
.Single cesspool orption system
Overflow; cesspool. i
Privy' j.
Shared system (yes or. no)
records, if any) (if yes, attach previous in pection
Other (explain)
Approximate age of all components. Date installed
information: , if known. Source op
rV 1C�o L' 7C> ?a
Sewage odors detected when arriving at the site
yes or no N
{
t
i
• f'
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below. grade:
material of construction: K concrete metal FRP other(explain)
dimensions:" 8- 10 (4 GALLot%j
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 bottom of outlet tee or baffle.
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 recommendations for repairs, etc. )
-- S •R 9 wl�► �
DISTRIBUTION.:;8.0'X:. N6 Q J
(locate on sate:.°.plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP 'CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments :
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
i
i
. d
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B 1
SYSTEM I FORMATION continued , J)1
SOIL ABSORPTION SYSTEM (SAS) : !
(locate on site plan, if '
P possible; excavation not required, but may be
approximated by non-intrusive methods)
If• not determined to be present, explain:
i
Type
leaching pits and number leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching. fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil; signs of hydraulic failure level
condition of vegetation sego 1 of pondih ,
recommendations for maintenance or repairs etc. )
e_AQ L I C F&1 L
i
CESSPOOLS- (locate on site plan) :
number and configuration �p N
depth-top of liquid to inlet invert
depth of solids layer .
depth of scum layer y
dime
nsions
ions of .cesspool
materials of construction
indication' of groundwater
inflow (6#.sspool must be pumped as
part of, inspection) L
i
Comments.
(note condition of soil, signs of hydraulic failure, level 'of pondin
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan) ;.
materials of construction
dimensions
depth of solids. a
Comments: 11
(note condition of soil, signs of hydraulic failure, • level of .pondin /
condition of vegetation, recommendations for maintenance or repairs, etc.
i
• i
t
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
J• PART B
SYSTEM INFORMATION continued
SKETCH. OF.•SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks !
locate all wells within 100'
K10
E .
t
O �.. `Vw` • ..
'Pipe c� \
y
J
DEPTH TO: GROUNDWATER
depth to groundwater pjz G
.
M
hod of determination or a roxim lion: ''
t zro
—DaC� 6 p E e.;
C1 ti
f
05/31/1995 07:53 508-428-3508 C. .-MM. WATER DEBT PAGE 06
'KEY NUMBER <4064 >
NAME <DUNKLESS, JACK
> B-C 1 B-C 2
STREET 241 PERKINS ST-C605 B-C 3 8-C 4
CITY JAMAICA PLAIN ST MA ZIP 02130-4002 PHONE { REF 1 REF 2
REF' 3 REF 4
METER NO•< 3849>
STREET <WESTMINSTER RD D G CONS CtiP9
CITY CEN J L3 NO. �2> 12/31/94 467
PHONE ( ) _ 5T LOC 30 94 36
40 33 u
12/31/93 376 48 ROUTE NUMBER 31 06 30 93 30
SERVICE DATE 05/17/71 12 31/92 298 25 1-
METER DATE 09/23/86 06/30/92 273 36
CAPACITY 7 12/31/91 237 26
STYLE T10 06/30/91 211 29
SIZE 1
RATE SCHEDULE
KEY PIT PLASTIC
NOTE RR REAR
ADDITIONAL CONS 0
ALTERNATE MIN
0
MaapF�+vi
*NOTE ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. AocEss cover must tali f
-10' min. from
Existing Foundation house to septic tank � B' of fbdd graft a
TOP OF FOUNDATION = ELEV. 100.00 (Assumed) s tank coven � be ,�,�ry,BOX cow must be SECTION A A
ertr�stati>tes
6 In. of Rraslrod gins° PROFILE VIEW OF LEACHING SYSTEM utf. _ 22,,�wastmir.s Rd ..
-Grade over Septic TaNc-g200 3 HOLE tt-ta tirade over D-Boa-92 wr SAS-9200 ate^""`•
DIST. BO� 7 . -1 . ..... .his.
• _ _ s'1.1 #A-�.a audad tLn. •�I/r"- 1/s-L.i.t 1e..4we .� � >'-•a:, s ..
r
S e M02 Top OF System-Ow-M-00 .
3• Norirssn WSPECr10N cover must be r y' r
�o t2 NEW Sm0 01 a Dealer vrRrdn 6 in. or tLnid�ed grads ` !
PWEn 1,500 GAL foot b� aid
FROM EXIST.FUUNDATEN `� SEPTIC TANK o 20' a EmctM.o.pm ' • =t
11 H-10 ea+. 0, P- ao N a o 0 o
CONCRETE RILL FOI1/10i1 o N C4 O [7 [7 O O O O . --r �}
-o io y> an a 5 •--5= 3.5 o 0 0
v 2 s 8 8S' ="1.7;t ea2oawrwro.v �rsc«ps�oos»wateo'aw.�«boT.aie. a
SYSTEM PROFILE 6 r,af 3/4!-1 t/2' t2' I " 4' 8' 4'
c«r,pocled atone
Not to Seale = t v ye 5• STRIPouT ALL' o GENERAL NOTES
c c a Effective Witt" EffecMOUND t Length
1. Contractor is responsible for Digsofe notification, Verification of Utilities
6 Inof 3/4'-t t/2 m SOIL ABSORPTION SYSTEM (SAS) and protection of all underground utilities and pipes.
oonpoated atom 0 Bottom of Test Hole 1 Elev.- 80.00 2. The septic"tank onj distri ution box shall be set
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE w onondwater Oba_e< NE ved - NO OBSERVED500 - C H-20 LEACHING UNITS / WIGGINS PRECAST level on 6 of 3/4 -1 1/2 stone.
Not to Scale 3. Backfill should be clean sand or gravel with no
stones over 3" in size.
4. This system is subject to inspection during installation
PERCOLATION TEST P# 11463 by Carmen E. Shay - Environmental Services, Inc.
5. The contractor shall install this system in accordance
Date of Percolation Test- OCTOBER 12. 2006 with Title V of the Massachusetts state code, the approved plan
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations.
Results Witnessed By. DAVID STANTON (BARNSTABLE BOH) 6. If, during installation the contractor encounters any
EXCAVATOR: Shay Env. Svcs. ALL WVM FM FMM 1W soil conditions or site conditions that are different
Percolation Rate: Less Than 5 MPI 0 84" asttaeinioN sox SHML BE -lT on�1E cowl from those shown on the soil log or in our design
SET LEVEL FM AT LEAST 2 FT: installation must halt & immediate notification be
Test Hole Test Hole "-` r 35r OUTLET •_"- --`•' made to Carmen E. Shay - Environmental Services, Inc.
No. 1 No. 2 7. No vehicle or heavy machinery shall drive over the
DEPTH SOILS ELEV., DEPTH I so1Ls ELEV. f - _ 5`r wnET +r " septic system unless noted as H-20 septic components.
Note: Remove soil down to el. 86.00 (Estimated) &
0 97-00 0 93.00 - : r 8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
__ , • 12 replace with clean coarse sand w/perc. rate less than or g• All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
' 4- - SCH. 40 T.,/ „� or equal to 2 min./in. before & after placement 10. All solid piping, tees do fittings shall be 4" diameter
FlLLL FILL P P 9• 9
0--60' 87.00 0'-60' B&OO PLAN SECTION CROSS-SECTION Schedule 40 NSF PVC pipes with water tight joints.
Sandy Sandy 11. Municipal Water is Connected to ALL OF The Residence and Abutting
LOOM to rR 3/2 io oam 3/2 3 HOLE H-10 DISTRIBUTION BOX Properties Within 150 Feet.
Ae NOT TO SCALE TA T, y� T��� O T T��+� Z $ THE PROPERTY LINES ARE APPROXIMATE AND
so-- Yr Am •00 •- 72" 87.00 l l l (r W/�/ [_/ COMPILED FROM THE COLONIAL LAND SURVEYING, ENTITLED
oamy Loamy
Sand Sand CERTIFIED PLOT PLAN OF #22 WESTMINSTER RD, CENTERVILLE, MA
to YR s/B 10 rR a/b `98 DATED JUNE 29, 1995
85
84 Be 86.00 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
72•- Med. 72.- Med. �` - 100.03' IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
$and Sand ---___ 98 THE SEPTIC SYSTEM INSTALLATION.
Cr � _, - �-,,,
EXISTING SAS TO BE PUMPED OUT AND FILLED IN PLACE
84'- t44 80.00 84'- t44 G 81.00
NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACI•IATE
FROM THE EXISTING SAS TO BE DISPOSED
`9? -: __ OF AS PER BOARD OF HEALTH SPECIFICATIONS.
37 - -8s THERE ARE NO- WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
Depth to Pere: SIEVE ANALYSIS TAKEN ® T * -3_ I '='�-�'=�•-•.::: ,,n - --
Perc Rate-- G5 MPI per Seive Analysis t t' •1 - SHED ASSESSORS MAP 168 PARCEL 064
Groundwater Not Observed NEW I f••' _-90
No Observed ESHWT 1500 gal. I = c. •;:;_, - _ LEGEND
ADJUSTED H2O Elev. = None 1' Septic Tank �=-�' =�=i
�TEST`-HALE_#1
3- au 2e caul ACCESS nANHMES 00 O ELEV.= 93.00 '-92 DENOTES PROPOSED
io FAILED SASJ TEST HOLE #2 104X 1 SPOT GRADE
ro• QD
UNDER NEW SAS 29.1 74 ELEV.= 93.00 O DENOTES EXISTING
sr h REMOVED to X 104.46
----- -- t SPOT GRADE
n
I, �1 ^1 1 '96, �, PL PROPERTY LINE
PKET
` THE ACCESS COVERS FOR THE SEPTIC TANK, EXIST, ` DECK _ 96P PROPOSED CONTOUR
DISTRIBUTION BOX AND LEACHING COMPONENT L-
' •T,•_�; SHALL BE RAISED TO WITW 6" OF Septic
gal. l I _ I EXISTING FINISHED GRADE Septic Tank ��- _ l Retaining W I ` -----
} STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITS GAS BAFFLES OR EQUALS Removed DUE TO E /: I ---- -97 G CONTOUR
PLAN VIEW ON ALL OUTLET TEE ENDS ( -- EIISTIIVG ' ��
`98 I 4' PVC ' I DEEP TEST HOLE &
3-2e RUMABLE COYM - Cleanou 3 BEDROOM I i
�r'r`?- goosE ��\ PERCOLATION TEST LOCATION
• - =:.:. --_ 4 _- I I I 1 .- - 6 FOOT STOCKADE FENCE
rT'wW%.T- Y mi. met to whet I 1
1f I
�REr r rr f} eaEr i 1, ; E
ounEr -}I-• I I a REV.: 10/30/06 - AS BULT WITH NEW SAS CONFIGURATION AND TANK
w- TT��I l I b o A
s-r Cs °•s-r•
____Ey ;M� � to,, GRAVEL ------
- BUILT
I DR"AIA AS
..j,._-_ GRAVEL ; OF PROPOSED SEPTIC SYSTEM UPGRADE
------ DRIVEWAY l
CROSS SECTION END-SECTION i �`� i PREPARED FOR
I 'PROJECT BENCH MARK MR. MARCUS CAMPOS
TYPICAL 1500 GALLON SEPTIC TANK TOP OF FOUNDATION I ; - i ; \��\ AT
ELEV. = 100.00 (Assumed I LOT #3 #22 W E ST M I N ST E R ROAD
NOT TO SCALE o 15,158 Square Feet +/- i l `�
(H-10 LOADING)
C ENTERVI LLE, MA
Design Calculations 100.00
PL
Number of Bedrooms 3 Bedroom EXISTING I I y�H q sq PREPARED BY:
Garbage Grinder: No t ' CARAI�'N E. SHA Y
Leaching Capacity Required: 330 W./Day (MIN. PER TITLE V) _ - `/ I � -,----- - -� �, �
Septic Tank : - 2 x 330 Gal./Day = 660 USE NEW 1,500 GAL Septic Tank.
A ENVIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA Using percolation rote of Q min.,inchE',,S' 2'MIN.S' TER ROAD P.O. Boy( 627
Bottom Area: 0.74 gol/sq. ft. x 370 sq. ft. = 273.8 gollons O-•
Sidewoll Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gollons 0 20 40 50 ��G!S T E��o EAST FALMOUTH, MA 02536
Providing: 331.80 gallons (4.0 FOOT RIGHT OF WAY) s N
gNITAR\P TEL/FAX : 508-539-7966
Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS. HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH,
TO BE USED WITH 3.5' OF WASHES) STONE ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 1"=20' DRAWN BY: CES ATE: OCTOBER 13, 2006
ON THE ENDS. NO STONE UNDER. SCALE: 1"=20'
PROJECT#SD976 FILENAME: SD976PP.DWG SHEET 1 OF 1