HomeMy WebLinkAbout0041 WESTMINSTER ROAD - Health 41 Westminster Road
Centerville P
A 168 077
low
UPC 10259
No.H163OR �ST.CpN5J�4
NABYINOB, MN
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I Commonwealth of Massachusetts /y/P la
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz r'
Owner Owner's Name
information is n I„�VI'II� MA 10/01/15
required for every Sar ICh l .11
page. y/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:when filling out forms A. General Information
on the computer, �j
use only the tab 1. Inspector: /
key to move your
cursor-do not Brian Reyenger
use the return key. Name of Inspector
Ranger Construction
ly Company Name
46 Crowell Rd.
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508-274-9753 SI 13242
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/02/15
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
**'*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.
6
t5ins-11110 Title 5 official Inspection Form:Subsurface Sewage Dispo�Ste-mPage 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments'
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Ownees Name
information is required for every Sandwich MA 10/01/15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
See"Notes"on pages 10 and 13
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11110 Title 5 OfBdal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
„ 41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owners Name
information is required for every Sandwich MA 10/01/15
page. CityfTown State Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sew
age Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owner's Name
information is
required for every Sandwich MA 10/01/15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)-.
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than'/z day flow
t61ns•11/10 Title 6 Official Insp
ection Form'Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owner's Name
information is required for every Sandwich MA 10/01/15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No _.
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t51ns•I l/M Title 5 official ins
pection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Westminster Rd.Centerville
Property Address
Belekewicz
Owner Owner's Name
information is required for every Sandwich MA 10/01/15
page. CitylTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
M ❑ Were all system components,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 400
t5ins•11/10 Title 5 Official Ins
pection form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owner's Name
information is required for every Sandwich MA 10/01/15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1000 gallon Septic tank, D-box ,6 x 6 Leach pit
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings,-if available last 2 ears usage d NA
( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: currently not
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owners Name
information is required for every Sandwich MA 10/01/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: NA
Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If..yes,volume pumped:.. gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5lns•11110 Title 6 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Westminster Rd. Centerville
Properly Address
Belekewicz
Owner Owner's Name
information is required for every Sandwich MA 10/01/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed (if known)and source of information.-
Septic tank/leaching originally installed in 70's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: 150+/-
feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good Condition 4"PVC
Septic Tank(locate on site plan):
Depth below grade: 1.0
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000
Sludge depth:
3"
t5ins•11110 Title 5 official Ins
pection Form:Subsurface Sewage Disposal System•Page 9 of 117
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owner's Name
information is required for every Sandwich MA 10/01/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 36"+/
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is showing signs of deterioration ,although fair condition for age- liquid level at slightly below
correct height , Sanitary T's intact, pumping recommended
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Westminster Rd.Centerville
Property Address
Belekewicz
Owner Owners Name
information is required for every Sandwich MA 10/01/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5lns•11110 Title 6 Oflidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owner's Name
information is required for every Sandwich MA 10/01/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
good gondition-installed in 2003
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 OfBdal Inspection Forth:Subsurfaoe Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owner's Name
information is required for every Sandwich MA 10/01/15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 -6x6
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,etc.):
System appears to be in working condition- 100%dry at time of inspection
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ms•11110 Title 6 official Inspection Forrtr.Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owner's Name
information is required for every Sandwich MA 10/01/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation,
etc.):
t5ins•11/10 Title 6 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 Westminster Rd.Centerville
Property Address
Belekewicz
Owner Owners Name
information is
required for every Sandwich MA 10/01/15
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building.Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A 24
AZ = Z-
A 4 2-
`
37 '
0
. a
FRo
t9na-�u�o
71Us 5 015de1kqxxAm Fame Subwtacs Sewage Dbpmd Systern•Pe9e 15 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Westminster Rd. Centerville
Property Address
Belekewicz
Owner Owner's Name
information is Sandwich MA 10/01/15
required for every
page. cityrrown State Zip Code -Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 10'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
site evaluation
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Adjacent design plans on file showing no ground water Q 10'below grade
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51ns•11/10 Tide 5 Official Ins
pection Form:Subsurface Sewage Disposal System•Page 18 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
41 Westminster Rd.Centerville
Property Address
Belekewicz
Owner Owner's Name
information is required for every Sandwich MA 10/01/15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t51ns-11/10 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 17 of 17
MAP
PARCEL.
LOT ..
DATE: 5/8/03
PROPERTY ADDRESS:41 west Minster Road
.,. Centerville,Mass. 5ress.
VED
.rr. _..J...... `t ------------------------
_ 02632__________________ 2003
STABLE
PT.
On the above date, I inspected the septic system at the above
This system consists of the following:
1 . 1 -1000 gallon septic tank.
2. 1 -Distribution box.
3. 1 -1000 gallon precast leaching pit.
Based on my inspection, I certify the following conditions:
4 . This is a title five septic system. ( 78 Code)
5. The septic system is in proper working order
at the present time.
6. Installed 1 -Distribution box.
7 . Installed new line from the tank to the box and from the box to the
leaching pit. Permit #03-170
8. Pumped tank at time of inspection. /
SIGNATURE:s� _ _��
Name:-J.P. Macomber Jr_______
Company: Jose.ph_P_ Macomber_& Son , Inc .
Address: Box 66
Centerville , Ma_-02632-0066
Phone:- 508-775-3338
--------------------
THIS CERTIFICATION DOES NOT CONSTITUTE-FA GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
•
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
y
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 41 West Minster Road
Centerville,Mass.
Owner's NameDDr
lald.Harper
Owner's Address: 5 8 03
2 Route 6k
Date of Inspection: Sandwich,Mass 02537
Name of Inspector: (please print) Joseph P. Macomber Jr.
Company Name: Joseph P. Macomber & Son Inc
Mailing Address: Box 66
CpntPrvi 1 1 p Ma 02632
Telephone Number:_508-775-3338
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Failsoe
p
Inspector's Signature: Date: r-F"d,4
The system inspector shall su it a copy o, f 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 now of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 41 Westminster Road
Centerville,Mass.
Owner: Donald Harper
Date of Inspection: 5/8/0 3
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. ystem Pa s:
�[?1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the
nrespnt- time-
B. System Conditionally Passes:
416 One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally,
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
°A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
, Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
- obstruction is removed
distribution box is leveled or replaced
NDexplain: Installed new distribution box and new line from the tank to
box and from the box to the leaching pit.Permit # 03-170
X)e) The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
f
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 41 westminster Road
Centerville,Mass.
Owner: Donald Harper
Date of Inspection: 5/8/0 3
C. Further Evaluation is Required by the Board of Health:
_.V) Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
/1)0 Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
Ad The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well.
A49 The system has a septic tank and SAS and the SAS is less than 100 feet but W feet or more from a
private water supply well". Method used to determine distance.
*"This system passes if the well water analysis,performed at a DEP certified laboratory, for 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.
3. Other: /� n
3
s Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 41 Westminster Road
Centerville—,Mass.
Owner: Donald Harper
Date of Inspection: 5 8 03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
-/cesspool �:4 1046 C,Oi^y 7
Liquid depth in eesspeal is less than 6"below invert or available volume is less than %,day flow
7/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
f times pumped O .
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
t/ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for 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.]
iJa (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
/the system is within 400 feet of a surface drinking water supply
kthe system is within 200 feet of a tributary,to a surface drinking water supply
Z/the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone I1 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 41 Westminster Road
Centerville,Mass.
Owner:Donald Harper
Date of Inspection:y/A/o 3
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
1"O'Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ _ Was the facility or dwelling inspected for signs of sewage back up
�/ Was the site inspected for signs of break out?
✓ Were all system components, xeluding the SAS, located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum ?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no/
f/ 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)J
5
Page,6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:41 westminster Road
Centerviiie,Mass.
OwnerAonald Harper
Date of Inspection: 5 8 0 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: ID
Does residence have a garbage grinder(yes or no): .��
Is laundry on a separate sewage system(yes or no):We)(if yes separate inspection required]
Laundry system inspected(yes or no): L'c7
Seasonal use:(yes or no):�ftj
Water meter readings, if available(last 2 years usage(gpd)): No measurable water useage
Sump pump(yes or no):AV for the past two years.
Last date of occupancy:Lk"
COMM ERCIAIANDUSTRIAL
Type of establishment: /9
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):Ay
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe): wl�
GENERAL INFORMATION
Pumping Records
Source of information: lD—1 f k
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: I&z>gallons--How was quantity pumped determined?
Reason for pumping:_Heavy scum & solids layers were present. '
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
420 Single cesspool
42,� 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)
.U� Tight tank;et/4 Attach a copy of the DEP approval
Other(describe): oiW
Ap roximatq age Qf all com onents,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): -4V
6
Pagel 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:41 westminster Road
Centerville,Mass.
Owner:Dona 1 d Harper
Date of Inspection: S/R/n-
BUILDING SEWER(locate on site plan)
u
Depth below grade: _
Materials of construction:, cast iron Z0 PVC/tOother(explain): IVA
Distance from private water supply well or suction line: a'?,-
Comments(on condition of joints, venting, evidence of leakage,etc.):
Joints appear tight.No evidence of leakage The system is
vented throug the house roof vents.
SEPTIC TANK: (locate on site plan) Ided
Depth below grade: .4
Material of construction: concreteVO metalW4 fiberglass-lJ�olyethylene
/1ld other(explain)
If tank is metal list age:A)6 Is age confirmed by a Certificate of Compliance(yes or no):,VZ(attach a copy of
certificate)
'6''do,o %D'i� "Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:Q-
Scum thickness: 46
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Hovey were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.leakage, etc.):
Pump septic tank ever 2-3 years.Inlet & outlet tees are in place.
The tank is structurally sound and shows no evidence of leakage.
GREASE TRAPfocate on site plan)
Depth below grade: tiff
Material of construction:AMconcreteA, neta /�fiberglassx// olyethylenert//other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: lVh
Distance from bottom of scum to bottom of outlet tee or baffle: I
Date of last pumping:_.AL}
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Grease trapig not—Present.
7
Page 8ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 westminster Road
_Centerville,Mass.
Owner:Dc)na 1 d Harper
Date of Inspection:5/8/0 3
TIGHT or HOLDING TANK4&9(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete &0 metal 4 fiberglass j�polyethylene 4�?other(explain)•
Dimensions:
Capacity: allons
Design Flow: allons/day
Alarm present(yes or no):
Alarm level:_O Alarm in working order(yes or no):�
Date of last pumping: tiR
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present. _
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: �d
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
Tnsi-aller3 new box at time of inspection Permit# 03 170
PUMP CHAMBER locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): A
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Pump rhamb r is not present
8
i
Page 9vf I 1 '
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:41 westminster Road
Centerville,Mass.
Owner: Donald Harpgr
Date of Inspection: 5 f Am 3
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
1 —1 000 gal 1 nn nrt-ras 1 ea .hi ng pit.
If SAS not located explain why:
Located: See page . 10
Typed�
t/leaching pits,number:
leaching chambers, number:0
_Ajoleaching galleries,number: 0
_A)Dleaching trenches,number, length:
leaching fields,number,dimensions: 6
,A20overflow cesspool, number: n
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Loamy sand to medium fine sand.No signs of hydraulic failure
or pondina.Soils are drv.Vegetation is norma .Leac ing pi
is presently dry.
CESSPOOL$f,&,�)&cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: (_
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
C'PSSnnol � are not present.
PRIVYe� i 6(locate on site plan)
Materials of construction: Z/l�
Dimensions: AIM
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy isnet—present.
9
i
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:41 West Minster Road
�`
Owner:Donald Harper
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public.,Yater supply enters the building.
O � i
'Ile - CV \
10
y
i
01
L si
i
4
Fee$50 . 00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi2;pO2;d1 *paem Cott' trurtioti permit
Permission is hereby granted to Construct( )RepairXDX1Wpgrade( )Abandon( )
System located at 41 Westminster Road Centerville Mass
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Consmf tion st be completed within three years of the date Z.this permDate: Z 3 b 3Approved b
0
-----------------------1 ---------- --------
f % I;, 3THE COMMONWEALTH OF MASSACHUSETTS
l BARNS BL� MASSAQH F=TT
CWpimq oyt sjotuo.<Iddns jotisn�,olign djogm oi000� t J 0 9 slloM Ili 21eoo-1 •s>IjvuryDuzq
Ijo I »uoloJaJ tuouauLo r�i f teffet$1'p(eaa ft4jr p o8¢Mos o41 Jo yowls a op!nad
�{ 'ISIG 30YM3S d0 HJ.L3}IS
IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )RepairecKXX) Upgraded ( )
Abandoned ( )by J. P.Macomber & Son inc.
at 41 WestminstRoad Centerville,Mass e ordance
with the provisions of Tide.5 and the for Disposal System Construction. ated 2=T4 3
Installer J.P.Macomber & Son inc, D dog
The issuance of s e t shall not be construed as a guarantee that the syste t' igned.
Date d Inspector
(ponultuoo) AtOI.Lvmo im N13.LSAS
0 .L2i`d(I
————- A�-AI9IeLO.adSl�Il k1t�,I.S3S�bSOdSIQ 30d_M3S 33yd asaf1S
S1N3WSS3SSd A2IdINa'I0A 2I03 L0K- FEb_t�IOI
I I Jo 01 4?d
i
Page 7 I of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) 1
Property Address:41 Westminster Road
Centerville,Mass.
Owner: Donald Harper
Date of Inspection: 5/8/0 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
No Obtained from system design plans on record-if checked,date of design plan reviewed: NA
yEc,_Observed site(abutting property/observation hole within 150 feet of SAS)
Nr) Checked with local Board of Health-explain: nlA
yg.&--Checked with local excavators, installers-(attach documentation)
Ye Accessed USGS database-explain:,httn- tnwn _hnj-nstable.ma.us.
You must describe how you established the high ground water elevation:
Used: Gahrety _& Miller Model. 12/16/94 Ground water elevations abo34e sea level.
Used: USGS: Observation well data _ Jane 1992
Used: USGS' Tpchni r-al hnl 1 Pi-i n c)2_n on—1 P1 a tra 9 Anni]a1 rcangtmg of grn„nri
W;If-pr Q�;P* ; s January 1992
Leaching
Pit /r;eet
I
�t�o
Groundwater: Fe Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpier Method
Therefore, the vertical separation distance between the bottom 1
Of the leaching pit and the adjusted groundwater table is ! yed
feet.
I1
i
.,....nt•+.-ntTs.•-.Tr.+n._mr•nssw.,f.•�..,a�.rmarn�.+....rnr.•..n+.t.ssrat+,...�r,m,tm .T�.-r.rr-it—,--._. ,-
TOWN OF Barnstable BOARD OF HEALTH
SUI)SURFACR SEWAGE DISR)SAL SYSTEM INSPFCTION FORM - PART D •- CERT1 FICATION i
T fit-T••.••.'.-T.t I7t-.�T"1.�1I.,1'.1.1f'1 TTlR1f ftr'.ttt'r"f t"14RR111/IRIA_` R Tn n
-TYPE OR PAINT CI.CAALY-
PROPERTY INSPECTED
STREET ADDRESS 41 Westminster Road Centerville,Mass.
x ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAMEDonald Harper
PART D - CERTIFICATION T
NAME OF INSPECTOR _Joseph P. Macomber Jr..
COMPANY NAME Joseph P. Macomber & Sofi ' Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street Town or City Stat0 11P
COMPANY TELEPHONE (508 ) 775 - 3338 . FAX ( 508 ) 790 _ 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage dia osa'1 s
this address and that the information reported is true , accurate , system at
omplete as of the time of+in pection , The inspection was performed and any
recommendations regarding, 4 1 igj Maintenance , and repair are consistent
with my training and expe�r; ace in the proper function and maintenance of on-
site sewage disposal systems ,
i ,fit;{It,
Check one :
I/1'//System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
heR101 or the environment as defined in 310 CMR 15 - 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA sectiol, of
this form.
System FAILED* \
The inspection which I have con acted has found that the system fails to
Protect the pi,blic health and the environment in accordance with Title
6 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
A'e k.
Inspector Signature t Date D J�
X( ndcopy of this certification must be provided to the OWNER, the BUYER
re applicable ) and the 130ARD OF IIEAL'I'it,
If the inspection FAILED, the owner or""operator shall u
pgrayete
within one year of the date of the inspection, unless alloweddorthe requiredm
otherwise as provided in 3.10 ChIR 16 . 305 .
partd . doc
i 2
No. 7� J—I% Fee 5
Entered in computer:THE COMMONWEALTH OF MASSACHUSETTS
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplication for Miopool *pztem Con0truction permit
Application for a Pernut to Construct( )Repair(XX)Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. 41 Westminster Road Owner's Name,Address and Tel.No. 5 0 8—8 3 3—21 6 9
Centerville,Mass. 02632 r)onald Harper
Assessor's Map/Parcel 1(019-o 11 S a ndw i s h,Ma s s. 0 2 5 3 7 y
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:
Dwelling XX 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.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Replacing bad line from the septic
tank to the leaching pit.Installing one distribution box between
e tank and pit.
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 Board of Health.
Signed Date 4/21 /0 3
Application Approved by p Date 63
Application Disapproved for the following reasons
Permit No. "2��> f`7® Date Issued 3 0
50.00
No. 2 Qo�3--h7o � Fee$
;e
! V4:.1,"Irk THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:'
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for Miopoml Opmem Construction Permit
Application for a Permit to Construct( )Repair(X N)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 41. Westminster Road Owner's Name,Address and Tel.No. 5 0 8—8 3 3—21 6 9
' Centerville,r4ass.02632 Donald Harper 492V§hfA>liijdgtjVSjA0&d
Assessor's Map/Parcel K pq_V r7 ri ftft@W i Ch Mass.0 2 5 3'7 6 ,
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:
Dwelling XX 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.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Replacing bad line from the septic t8
tank to the leaching pit.Installing one distr but on box between
the tank and pit.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described o -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 Board of Health.
Signed f- Date 4/21 /0 3
Application Approved by Date
23 G 3
Application Disapproved for the following reasons
Permit No. 200'S' ('70 Date Issued q 2,3/0
-- tt- --------------------------
------- _
d THE COMMONWEALTH OF MASSACHUSETTS
"`� 6Ce,#%A BARNSTABLE, MASSACHUSETTS Y
Certificate of Compliance,,, `R
IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repairedx(XX)Upgraded( )
Abandoned( )by J.P.Macomber & Son inc.
at 41 Westminster Road Centervi4.#1Q;Mass', has been constructeddin ac ordance
' with the provisions of Title 5 and the for Disposal System Construction Permit No. ZOO 3^170 dated cr 2310
3
Installer J.P.Macomber & Son inc. Designer J.P.Macomber & I Son c,
The issuance of t "s a it22shall not be construed as a guarantee that the syste t*: tgned.
Date 0 3 Inspector
� tF
� k
----------------------------------
No. 200 3_(10 Fee$5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
A
Miopooal *p5tem Construction permit
Permission is hereby granted to Construct( )Repair)(D)j)Cpgrade( )Abandon( )
System located at 41 Westminster Road Centerville,Mass.
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Constru tion st be completed within three years of the date of this pe
Date: � Z 31 V Approved by _,o�we,
• ( l
TOWN OF BARNSTABLE
LOCATION y/ We
S rM 1A1,S fete fd SEWAGE #- oD 3- / '-D
VILLAGE C e1V fe R:V 1 tZ,2 ASSESSOR'S MAP & LOT�(j8 �
INSTALLER'S NAME&PHONE NO. j� ,/L��Q C &,g e e -t" 57® Al
SEPTIC TANK CAPACITY ��- _4,2— 071 l it
LEACHING FACILITY: (type) (size)
"I
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: L41�3 D3 COMPLIANCE DATE: Z3 03
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 s
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TOWN OF BARNSTABLE
LOCATION W e S rM /.Al.S 1 e K -,fee SEWAGE #.7 20�— / 'f 0
VMLAGE C eltll ekV/Z O ASSESSOR'S MAP & LOT ?" 0
INSTALLER'S NAME&PHONE NO. T A? Al A C 0-,/yl Al
SEPTIC TANK CAPACITY Z2— a X 'm ,y
LEACHING FACII.ITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: OMPLIANCE DATE: I z-3 03-
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,le` ng facility) Feet
Furnishetby ,
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