HomeMy WebLinkAbout0080 WILTON DRIVE - Health 80 Wilton Drive
Centerville P
A = 208 051
12543
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r::`SSrraGS.p7N
SEWAGE INSPECTIONS
LUCAt1 N 80 U i et on D2.iUe DATE 8127103
VILVJ4:,E Cen.�e`U��"e, 17a.6-6• ASSESSOR'S MAP do LOT
-INSPECTOB o/se/�/z P. (`?acompe/c a,Z
SEPTIC TANK CAPACITY 1000 Gaieon,3
LEACHING FACILITY: (type) I-Ll- 1000 (S1Ze) 1500 ga. eonz.
NO. OF BEDROOMS 3
BUILDER OR OWNER Ke.een Choate
OWNER MAILING ADDRESS
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TOWN OF BARNSTABLE
LOCATION ��J (,I,,&,/! ��il/e. SEWAGE # -
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.�/J/�/%l Lf3L/, �i 1�(�•^ .��i -
•
SEPTIC TANK CAPACITY /li0ly�
LEACHING FACILITY:(type)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNERl�A� �. .�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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DATE :8127103-- -JO Sep19
PROPERTY ADDRESS: 80 6Ji&ton [72ive /NOF ���,J�
6
-- Cente2v-i.eee, t7ah.s_------ ��<ryo AjTge(F
---
02632
- --------------------
On the above date, I inspected the septlC systerrr-at the above address.
Tnis system conslSls of the foll,owing:
1. 7- 1000 ga-pion hept.ic tank. p
Z. 7-Di,3t2.i&ut ion &ox, MAP
> 3. 7- 7000 gaiion paeca.6t Peaching p.it. PARCEL, O�
8aseo on my inspection, I certify the lollowing condlllonAOT
4. 7h.i,3 .i,6 a t i.t Pe Live 3ept.ic -6yhte. (78 Code °�-
5. The zept is .6y.6tem L3 in p/zope/z wo2k.ing olden
at the pae.6ent time.
4. GVaate watea .i,6 66" &eiow the .inve2t pipe oZ
the Qeaching pit.
SIGNATUR
Name - -J- - P- -Macomper_Jr
Ompany �gn@r 6_ Son, Inc .
ess �Q'� _��- ------ ------
- - -C.e.nsP.Y LLLam.,_ �Ja _ _Q.2-6 3 2- 0066
P ^ one - -508 . 115 • ) ) )
TmIS CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY
` I
IOSEPH P. MACOMBER & SON, INC.
Tinks•Cesspools-Leachfleldl
Pvmped & Instilled
Town Se,Oer Connections
P 0 Box 66 Centerville• MA 02632.0066
115.3338 115.6412
f
COMMONWEALTH OF MABSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 �-
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:8 0 Gl c 2t o n D z l v e
Cente2v�,.P.2e, �laee.
Owner's Name: Helen Choate
Owner's Address: 8/?7/03
Date of Inspection: 3arize
Name of Inspector: (please print) aozel2h %. Macom&e2 a2,
Company Name: ;. I). 17acom e2 on ne.
Mailing Address: o x 66
en 4,zL.c e, I azz. 02632
Telephone Number:508- 775-3338
CERTIFICATION STATEMENT
1 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
' Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: F-,�7�3
The system inspector sh bmit a copy of this inspection report o the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 GIi.P.t on D/zive
en e/w e, a3 .
Owner: Ke Pen Choate
Date of lnspection:
inspection Summary: Cbeck A,B,C,D or E/ LA WAYS-complete all of Section D
A. S s em 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:
_7he 3eP.tic zurtem ih .in Pzopea woaking oade2 a.t .the
nnv.Svn,l' � my
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes,no or not determined (Y,N,ND) in the for the following statements. !f"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 sepric 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
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
• 2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 0-i fit on D zive
Owner; fie.Pen ehorate
Date of Inspection: 81271003
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.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
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.
/lam The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
/2 The system has a septic tank and SAS and the SAS is less than 100 feet but 0 feet
private waters •• or more from a
� u"I� well—. 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 ocher
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
li
3
Page 4 of 11
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 80 O i.P.t on D z ive
Cen.te2yi..Q.9e, t7azz.
Owner: /I Len Choate
Date of Inspection: 8/2 7/0 3 `
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No /
_ A ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
logged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool - I—)�
C
_ Liquid depth insesspoel is less than 6"below invert or available volume is less than %day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped Q.
_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
2 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
!/iAny portion of a cesspool or privy is within a Zone 1 of a public well.
,.°Cny 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.)
(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
e
the system is within 200 feet of a tributary to a surface drinking water supply
y_ — e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5.0f I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 80 G iil-on Da ive
en , .
Owner: fleien Choate
Date of Inspection:
Check if the following have been done. You must indicate' s"or"no" as to each of the followin :
Yes No�
_ ddumping information was provided by the owner, occupant, or Board of Health
r//P Were any of the system components pumped out in the previous two weeks ?
_ the system received normal flows in the previous two week period ?
� Have large volumes•lumes or water been introduced to the system recently or as part of this inspection
V Were as built plans of the system obtained and examined?(If they were not avail
able note as N/A
-Z_ Was the facility or dwelling ►ns cctcd for signs of sewage back up?
Was the site inspected for signs
��llof break out ?
_tC _ Were all system components,4Kluding the SAS, located on site ?
Were the septic tank manholes uncovered,opened, and the interior of the tank ins
pected ror (he co
o4thb—arnes or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scumndi, t'or
-L1- _ Was the facility owner(and occupants if different from owner)provided with information on the ro er
maintenance of subsurface sewage disposal systems ? p p
tr
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no/
v Existing information. For example, a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)(310 CMR 15.302(3)(b))
5
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 80 k1.i2.t on Dlt-ive
Lent e2v e e, a��.
Owner: He.2en zoa e
Date of Inspection: 8127103
RESIDENTIAL FLOW CONDITIONS r,.�,...
Number of bedrooms(desigp): t� Number of bedrooms(actual):J�
DESIGN now bued on 310 CMIi 15.203 (for example: 110 gpd x M of bedrooms):
Numbcr of current residents: !!
Does residence have a garbage grinder(yes or no):AV
Is laundry on a separate sewage systemcs or no):2D (if yes separate inspection required)
Laundry system inspected (yes or no): ra'q
Seasonal use: (yes or no): "
Water meter readings, if available (last 2 years usage(gpd)):2001—30, 000 ga eionz=82. 20 qPD
Sump pump(yes or no): .M 2002-23, 000 ga22on,3=63. 02 91)D
Last date of occupancy:
COMM ERCIAL/INDUSTRIAL
Type of establishment:
Dcsign flow(based on 310 CMR 15.203): Afd
Buis of design flow(seats/persons/sgft,ete.):
Grcasc trap present(yes or no): ete
Industrial waste holding tank present(yes or no): 40
Non-sanitary waste discharged to the Title 5 system (yes or no):1— )
Water meter readings, if available: low
Last date of occupancy/use: ,p/Q
OTHER(describe):
GENERAL INFORMATION
Pt5mping Records
Source of information: None ava i eag.Pe
Was system pumped a3 pan of the inspection(yes or no);�
If yes, volume pumped: gallons •• How was quantity pumped determined?
t Rcason 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/Altemative technology. Attach a copy of the current operation and maintenance contract (to be
ined from system owner)
obta
Tight tank M Attach a copy of the DEP approval
ti0 Other(describe): A/�
Approximate aec of all components, d to ' stalled (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no)'---r�
6
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 ld-Uton Dlt-.ve
en e2v.e e, 77�.
Owner: Ke QeR o a e
Date of Inspection: 8127103
BUILDIN'd SEWER(locate on site plan)
Depth below grade: _ 40 /
Materials of construction:.Uocast iron y 40 PVC other(explain): .ems
Distance from private water supply well or suction line: id't
Comments(on condition of joints, venting, evidence of leakage, etc.):
�ninf t nnn f o,o i aka,ge. The .6y.3tem i,3 vented
7haougl the kouee vent.3.
SEPTIC TANK: _/(locate on site plan)
s
Depth below grade: /?
Material of construction: ncrete.Ud metal.2 fiberglass��olyethylene
�othcr(cxplain)
If tank is metal list age:"' Is age confirmed by a Certificate of Compliance (yes or no):,O (attach a copy of
certificate) / J
Dimensions:.9'61�h
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 bonom of scum to bottom o outlet tee or baffle:
How we're dimensions determined:
Com' ments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of-leakage, etc.):
,Pumped the ze tic tank v -
t � e e2u 2 3 6jea2.3. Inie# 9 ou
i -i.n RPace. The tank i,3 6L? i # 1?rzLPW in-unrl onr/ Ahn),)A nn o»ir 0nr0
of ieaka e. Liquid u id A-vei at the out. "
y � et .cnUe2t .ce 5 �
GREASE TRA): (locate on site plan)
Depth below grade:.f�
Material of construction/e concret*M metal /4 fiberglass- polyethylenvt# other
(explain):
Dimensions: SX
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:_ W
Date of last pumping: A14_
Comments.(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
J[,20r]Ao fnrnn ;6 QQ4 Q4QAaQj
Page 8.of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add ress80 N-iit on Dlt ive
en te2v'L e, a.s-s,
OWner:He.Pen oa e
Date of Inspection: 8/2 7/0 3
TIGHT or HOLDING TAN" (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 10
Material of construction:AconcreteJ.Y—m eta l,de�jfiberglass/ d polyethylene�other(explain):
Dimensions: a
Capacity: '410, gallons
Design Flow: d1dgallons/day
Alarm present(yes or no):
Alarm level: 4-111 Alarm in working order(yes or no):,dg
Date of last pumping:—2A
Comments(condition of alarm and float switches, etc.):
7-i ght oh hoid ing tank.6 ate not R2eaent
DISTRIBUTION BOX: Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
D—L6 2..Put..on &ox ha,3 Ong eatgaai. No gv'idpnoe o� zo &d'3 ca'vzy
CQyP2. No vv,idvnro n4 lfvnkrIgp .into oa oiL n4 .thv Pox
PUMP CHAMBER4&jf_(locate on site plan)
Pumps in working order(yes or no): tj�
Alarms in working order(yes or no):,,f&
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
PLLM4 rhaukel? .i.t not olze ieni
8
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `
SYSTEM INFORMATION(continued)
Property Address:8U Ni.gton Dlt-ive
en e2v.c e,
Owner: Keien ho¢ e
Date of Inspection: 8127103
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
_1- 1000 as eion p/zeca.6t eeach.in a ?-i —
If SAS not located explain why:
Located: See nave 10
T`amyp�e
-d leaching pits, number:L—Ap 090
_O leaching chambers, number: 0
leaching galleries,number:
leaching trenches,number, length: O
leaching fields,number,dimensions:
,W overflow cesspool,number: C) ,
10 innovative/alternative system Type/name of technology:%ir,� /`/!lam C7F a40
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
Loamy &oney nand to /.ine coat.6e zanz. No .a-iynz o,, hyd1zaueic /aiPu2e
oa aond.ina. So iiz ate d2u Veye.tat ion iz no2maP Va,3te watelz i.6 66"
geiow the invelzt 12il2e.
x
CESSPOOLS(cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:�ZQ
Depth of solids layer:
Depth of scum layer: AffV
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no)-,y
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
Ceb,312ooi.6 ate not paezent.
PRIV ' (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
LziyU ih not p2ehent.
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ress:80 Q-iit on Derive
en eavt e, mesh,
Owner: l[e ien o a e
r� �I
Date of Inspection: 3
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.
Q I
a
10
Page 1 I of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C •,'
SYSTEM INFORMATION (continued)
Property Address: 80 U-i.Pt on DIL-ive
en e2v4_ e, aa:;.
Owner: he.Pen
Date of Inspection: 8127103
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
x
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 NR
Y gn P gn plan reviewed:
q=Observed site(abutting property/observation hole within 150 feet of SAS)
N-0—,,,Checked with local Board of Health-explain: N+4
q S Checked with local excavators, installers-(attach documentation)
q S AccessedUSGSdatabase-explain:httl? own. Pazn,6ta&Pe. ma. ue.
You must describe how you established the high ground water elevation:
sect: Gahzetu & Mi.P.Pe2 Node.P 72116194 0tound wate2 eievat.ion,3 move .sea Pevee.
se USCiS • <)Psflnuo}inn ,
tune 1992
SecZ: US4E: TOrhn%rnP /31) ODofin 9? 000 1 P.Pri#P An1ziin2 ao aP.3 o4 aaound
),,nfon .aPoi)crfin.nA_ 7nn1inni; 9997
-- -
Leaching
Pit q' :eet
07 T�
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is
feet.
]1
y.•r.war+ -nrr.-•rt�a'nrww•n�T+wr.w�.a�wi•...,•annr�wR+2*�wt�t�e •fir-�--'. .. ,-
1 TOWN OF 130ARD OF HEALTH
SUIISURFACR SFHAGF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION 11
•.•�n-t•.,•.. r-r.i -.-rn�ntnwnt•t��+rwnntc�-at�vrw�ww�r-,��w�w�ww.�r�r'wr� tww •i.• -rr-•r.�. _. •1
-TYPE CA PRINT CLEAALY-
P/IOPERT Y I NSPECTCD
STREET ADDRESS 80 G iii-on DIt ve Ce2te2v-itie, Ma.a.6.
ASSESSORS MAP , BLOCK AND PARCEL # '`
OWNERRIs NAME Keien Choaiq
PART D - CERTIFICATION
NAME OF INSPECTORJoseph P.Macomber Jr.
COMPANY NAHE J P Macomber & SoR Ind'.`
COMPANY ADDRESSBox 66 Centerville Mass. 02632
Strgvt Town or City statr t I P
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
R
CERTIFICATION STATEMENT
0r I certify that I have personally inspected the sewage disposal system nt
this address and that the information reported is true , accurate , and
omplete as of the time of .inspection . The inspection was performed and any
ecommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Cheeckk 'one :
System PASSED r
The inspection t+hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe environment as defined in 310 CMR 16 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have con cted has found that the system fails to
protect the ptiblic health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature AksDate
otecopy
n of this c tlfication must be provided to the OWNER, the BUYER
where applicable ) and the 130ARD OF HEAL'I'll.
* If the inspection FAILED, the owner orahoperator shall u d
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 16 . 305 .
partd . doc
/6 Fx$...... ...30:00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTtj A P P R O V E D
TOWN OF BARNSTABLrnJable Conservation Com:.
,pliration for Mipasal Works Tv � Date6
Application is hereby made.for.a.Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal
System at:
80"Milton Drive Centerville
�v
Location-Address or Lot No.
V.L:LQ5 .4: ....—........._............................................................... ................................................................................................
Owner Address
a Jr . = :.
Installer Address
UType of Building Size Lot----------------------------Sq. feet
DwellingX No. of Bedrooms................ ..........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons---.......--................ Showers ( ) — Cafeteria.( )
� Other fixtures -----------------------------------------------------.-------------•-------------•----------------------------------
W Design Flow............................................gallons per person per day. Total daily flow........................._..................gallons.
WSeptic Tank—Liquid'capacity........--..gallons Length---.------_--- Width................ Diameter.............,.. Depth.....--..--..--.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..--..--.---........ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) - Dosing tank ( )
aPercolation Test Results Performed by-------•----------------•---........------------•----•......-----------.. Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gr4 Test Pit No. 2................minutes per inch - Depth of Test Pit.................... Depth to ground water.........--..........--.
W -----•------------------------•-----•--------------- av1--
OSoilSand & Gre .... ----------------
Description of -------------------------------------•-•-------------..............--------------------------------------------------------- ----------------------------.----------
x
U ..............................................-----•....-------•--.............--•---•••----•••----.......----------..........----------•-••---•--------......------......_.................------------
W
UNature of Repairs or Alterations—Answer when applicable.......................:.......................................................................
gallon.._tonk--•--1---100�...g-allon leach pit .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a'Certificate of Compliant has be n iss ed by the boar of lth.
Signed ---- -
-- ------ �� 6�91--------------
Date
Application Approved By -'------. 7....-.�lP.-.� .....
Date
Application Disapproved for the following reasons- ------ ------------------------------------------------------------------------------------- --------------------------------------
-------------------------------------- --------------------------- ---------- ----- ------------------------------------------------------------------------------- -------------------------------- ----------------------------------------
Date
PermitNo. ?/-`------3-/6---------------- Issued ...------------------.....----------......---- --------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
firation for Dig nr Disposal Works Ton tr r _
_ �� � k � �� n ermtt
Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal
System at:
80 Wilton Drive C�=n t e ry 11e .....-•--�----------•------•------------••-•----------------•--....•-•...._...-----•-----...----
................_------n.----__-_._-___.. ..._-- t ......
Location-Address or Lot No.
......................--..............:.. --•-•....--------•---••-•----•-•----•---•------ ••• •----------._...--- ..._..... -•---------............................_....__
Owner Address
a ....a... Mac omb er:-Jr__�--- -------------------•-------------•--•------ •'--=•-•--------------__--- _ -_-_-.------------ -------------------
i--- Address
PQ
Q Type of Building Size Lot............................Sq. feet
Dwelling No. of Bedrooms................3 ___-___-Expansion Attic ( ) Garbage Grinder "( )
PL4a Other—T e of Building -_-_-____-- No, of persons............................ Showers — Cafeteria
QOther fixtures ----------------------------------------------------------•-••-•------•------••--------.............................................................
w Design Flow... ................................. gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity._-.........gallons Length................ Width................. Diameter................ Depth................
x Disposal Trench- -No..................... Width..................... Total Length.........__........ Total leaching area....................sq. ft.
Seepage Pit No_____ ___________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) ---,Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No.•l................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------------------------------------•-------------------------------------------•-------------•-------...-----•---------•------------------..._•---....--
O Sand & Gravel
Description of Sot1 .----------••-----------•---.....--•---•------•••••-•---•••-•.............................................•-•---------•---
x
w
U Nature.of Repairs or Alterations—Answer when applicable............................•..........____.-................_.................................
------------------1---100.0--as l lo .... ank.----- .... 000._as l lon...1 e a c h... it....------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—'The undersigned further agrees not to place the
system in operation until a Certificate of Complianc has be-n iss'ed by the boar t of h alth.
g � � f'
16 1
Signed .--- . 7 -.. .
--------------
•. ! Date
Application Approved B �J/ V t��s ��
Date
Application Disapproved for the following reasons: -------------------------------------------------------------------------------------------......................................
.�
1 - ...-....- ..... ..........Date.................
Permit No. ----
/� .......... Issued -........................ .........................' .---------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed'( ) or Repaired (XXX)
J.P. acomber J'r.
by.................... 4.---..........--..............................--.......................................lost............. .......-..........................................................--...............--.
at ------8Q----W.ton Drive Centerville
............ -------------------------------------------------------------- -------------------------------------------------------------------------------------- -- - -----------
has been ngfalled in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. --.....�. =.. /..%.......... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... y ,1.............................. Ins ector � /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
// ' TOWN OF BARNSTABLE
No..__-�- /�/i� 80.00
.._�r_.k: FEE..............•-----....
Disposal Works Tuns#rnr#ion "prrmit
Permission is hereby gran - ---J.P.Macomber=-Jr-'.............................................................................................
to Construct ( ) or RepairX( K an Individual Sewage Disposal System
at No.*P..Wilton---Drive Centerville
.......... ..................................
PP P Street �14 as shown on the application for Disposal Works Construction Permit No... Dated..........................................
------------
....................•- , ------------_-----------•--•--------••---
/ Board of Health
DATE............ / �-------------------------------------
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS