HomeMy WebLinkAbout0263 SOUTH MAIN STREET - Health 263 South Main St
207-097-001 Centerville
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DATE1 .4/12/00 ----
PROPERTY ADDRESS: 263. South_Main_StLtQL__
_
02632
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank.
2 . 1 -Distribution box.
3 . 1 -1000 gallon precast la hi
Based on my Inspectioen,cl cenRlfp4-e.following condltlonc
4 . .This is a title five septic system. ( 78 Code ) 7 Pj
5. The septic system is in proper working order
at the present time.
6 . The waste water is 62 inches below the ivert pipe
to the laeching pit.
SI GNAT URE'-/
N a m e:_1 �.2t�ssm>�a.z�ir�_-----
Company: Joaeph_E-- Macomber_& Son , Inc .
Address:_ Box-66 _
Centerville Ma__02632-0066
Phone:___508 775_3338_______
THIS CERTIFICATION OOES NOT CONSTITUTE A QUARANTY OR WARRANTY
JOSEPH P. MCA
COMBER & SON, INC.
Tinks•Cos:pool:•L$achflIId6
PUMPS Installed
Town Sewer Connectlons
P.O, Box 6775.3J38`ry 1lo. 122632.0066
e
2 _A
4..
Kate Whouley
263 South Main Street
Ceiaterville,Mass.
(12b32 '
Septic System Consistes Of;
1 -1000 gallon septic tank.
1 -Distribution box.
1 -1000 gallon precast leaching pit.
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXI
3ecretar
ARGEO PAUL CELLUCCI DAVID B. STRUH:
Governor Commission:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Prope,tyAd&.;263 South Main Street NameofOwnw Kate Whouley
Centerville, ass. 02632 Address of owner:
Date of Inspection: 4/1 2/0 0 Joseph P.Macomber Jr..
Name of Inspector:(Please Prim A
I am s DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
compa„yName: J.P.Macomber & Son Inc.
Maairag Address: Box 66 Centerville,
Telephone Number: - 5-3 3 3 8
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails /
inspector's Signature: �j, Data: ;�jZ_ob
The System Inspecto all submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wWn thirty (30)days of
completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner
shall submit the report to the appropriate regional office of the Department of'EnvironmenatM Protection. The original should'be sent tollte
system owner and copies sent to the buyer, if applicable, and the approving authority. .
NOTES AND COMMENTS
revised 9/2/98 Page IofII
�,Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTWN FORM
PART A
COMFICATION (ooitt4tued)
ftwwtyAddreas: 263 South Main Street Centerville,Mass.
OwTMr. Kate Whouley
Dena of'p—':4/1 2/0 0
9Ni5P£CylON SUSA&C iY: Check .4, B, C, of D:
A. SYSTEM PASSES: t
I have not found any Information which Indlcuss that any of the failure condWons described In 310 CMR 16.303 exist. Any faaurs
criteria not evaluated are Indicated below,
COfrlMOM:
B. SYSTEM CONDITIONALLY PASSES: `
'i�v One or mors system components as described In the'Condtl"W Peas'section need to be replaced w repaired. The system, upon+
completion of the replacement or repair,u approved by the Board of Health,will peas.
Indcate ye', no.or not determined(Y. N. or NO). Describe basis of deternJnation In W Inatuwes. If'not determined%explain why not.
The septic tank Is metal,unless the owner or operator has provided the system Inspector whh a copy of s Certificate of
Compliance (attached)Indicating that the tuft was Installed within twenty(20)yews prior to the date of the lrtapection; c
the septic tank, whether*(not metal,Is crooked,etmowrally unsound, shows substantial Infiltration or exf4usdon. or tan
failure Is Imminent. The system will pass Inspection If the existing septic tank Is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstrucud pipe(
or due to a broken, settled or uneven distribution box. The system will pass Inspection If(with approval of the Board of
Health).
broken pips(s)we replaced
obstruction Is removed
distribution box Is levelled or replaced
• The ayetsm faquhsd pumplrtg-mm than1wir time#-a"ardua to broXenvt obstroetod pip*(a1. the iysttrm wW-p=v--
inspection If(with approval of the Board of Health):
broken pipe(+) are roplacid
obstruction Is removed
revised 9/2/98 Page 2ofIt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 263 South Main Street Centerville,Mass.
Owner: Kate Whouley
Date of Inapectioo: 4/12/0 0
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 the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CM1R 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH.]MLL.PRQTECT THE PUBLIC HEALTH.AND SAFETY AND THE EN1 IBONMENT--
.1� Cesspool or privy is within 50 feet-of surface water
Cesspool or privy is within 60 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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. Method used to determine distance x/ (approximation not valid).-
3) OTHER
Aw A
revised 9/2/98 Page 3orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddress: 263 South Main Street Centerville,Mass.
own«: Kate Whouley
Dau of Inep.e°°'-4/12/0 0
D. SYSTEM FAILS:
You must Indicate either "Yes" or "No" to each of the following:
A_ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The bash for this
determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the tallul
Yes No
Backup o+eewage bra 4eciNty w -pow oomporwwwd000to an overloaded oroNgg�d8,0.&orcesspool. -' '
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS a
cesspool.
Static liquid level in th distri tion bo above outlet Invert due to an overloaded or clogged SAS or cesspool.
Liquid depth In waspootis less than 6" below Invert or available volume is less than 1/2 day flow.
Required pumping more than 4 timea in the last year Mo due to clogged or obstructed pipe(s).
Number of times pumped-/—..
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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 60 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater than 60 feet from a private water supply wall with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
•►coliform bacteria,volatile organic.compounds, ammonle nitrogen•and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 god or greater(Large System)and the system Is a significant threat to pL
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system Is within 400 feet of a surface drinking water supply
the system•IswitWo 200 taetol♦-triiKA*rtr•do+ourfaud waiMsurply•... --
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area:IWPA)or a mapped Zone 11 of a pubi
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 16.304(2). Please consult the local region
office of the Department for further info4nation.
revised 9/2/98 page 4orn
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 263 South Main Street Centerville,Mass.
Owner: Kate Whouley
Date of Inspection:4/1 2/0 0
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No ,
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system sompoawas ha►sAwan puw%pad4ocatJeast two%veWw an&A re'system hasbaaovaceWA9gw seal slow
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 system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,,d luding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum.
The size and location of the Soil Absorption System on•the site has been determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b))
_ The facility owner.(and.occupants,lf diffarant from ow:nerl.+Kere prmidad.awiih lnfatmatioacn thA prnpor rna' ta.,a&W ,.f
SubSurface Disposal Systems.
t
'I revised 9/2/98 Page 5of11
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION
Property Address: Z4.3 South Main Street Centerville,Mass.
Owner: Kate Whouley
Date of Inspection:4/1 2/0 0
FLOW CONDITIONS
RESIDENTIAL:
Design flow: //b g.p.d./bedr m.
Number of bedrooms d si )• Number of bedrooms(actual):•
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) Was or no :_; If yes, sepwatelnspection.required
Laundry system inspected (ya or no)
Seasonal use(yes or no): ��/6c.7y/d f�i
Water meter readings,if available(last two year's usage(gpd): 5 — - & .G� 6 J
Sump Pump(yes or no): ���
Last date of occupancy:!
CO M M ER CIA L/INDUSTRIAL:
Type of establishment: ./>/¢
Design flow: XIA aad Based on 15.203)
Basis of design flow —
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or nou'21
Non-sanitary waste discharged to the Title 5 system: (yes or not #
Water meter readings,If available: /l�
Last date of occupancy:—&&
OTHER:(Describe)
Last date of occupancy: 10
GENERAL INFORMATION
PUMPING RE ORDS and our �f_i�ormati ru +� f ���
System pumped as part of inspection:(yes or no)
If yes, volume pumped: /mod lions
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
AJb Tight Tank 4.4 Copy of DEP Approval
Other 4A
A OXIMATE AGE of all components, date installed{if known)-and source of4nformation: 1
Sewage odors detected when arriving at the site:(yes or no)dla/
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA
PART C
SYSTEM INFORMATION(continued)
PmWtyAddreu: 263 South Main Street Centerville,Mass.
own«: Kate Whouley
Date of 4-P—tI'on: 4/1 2/0 0
BUILDING SEWER:
(Locate on site plan)
iJ
Depth below grade:
Material of construction:_cast Iron 40 PVC mother(explain)
Distance from pate water supply well or suction line/ `t
Diameter V
Comments: (condition of Joints, venting, evidence of
Joints
system is v n
SEPTIC TANK: AXV YOIW4��
(locate on site plan)
Depth below grade: /concrete
Material of construction: J&ot&I4—JFiberglass Ad)Polyethylene4/Aother(explaln)
If tank is fnetal,list age Is.ape.c�o�nfrmed by Certificate of Compliance (Yes/No)
Dimensions• e6 1rr _V"e"'V-11Eh,
Sludge depth:
Distance from top of sludge to bottom of outlet tee o►bafflr.�
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bolt of outl t tee or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of,liquld level In relation to outlet Invert, structuroHntegrity,
evide e c of I akkage, etc.) Pumpth _ Inlet
and oulet tees are in ace.T a tank is structurally sound and
shows n
of inspection,
GREASE TRAP:
(locate on site plan)
Depth below grader
Material of con3tructionAJ�concretv(dmet&I4Wberglsss4Aj Polyethylenoi/�other(expiain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:.A&�e
Distance from bottom of scjjrn to bottom of outlet tee or baffle:41W
Date of lest pumping:
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert, structural integrity,
evidence of leakage, etc.)
GreaS . TRAP Ts NnT PRFCRNT
revised 9/2/98 Page 7orII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA
PART C
SYSTEM INFORMATION(continued)
P.opertyAddress: 263 South Main Street Centerville,Mass.
Owrw: Kate Whouley
Dow of kupecdan:4/1 2/0 0
TIGHT OR HOLDING TANK:AA:eC4fTank must be pumped prior to, or at time of, Inspection)
fiocst• on site plan)
Depth below grads:-
Material of construction:,jJr�concreteJl�metal1l1Fibergla&&V Polyethylene aother(explaln)
Dimensions: Wly
Capacity: eVd gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm In order:Yes V
Date of previous pumping: 4,4
Comments:
(condition of Inlet tea, condition of alarm and float switches,etc.)
Tight nr hnl inn tankg Are i3At=F pewit.
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet Invert:_
Comments:
(note if level and distribution Is equal, evidenoe of solids carryover, .(dance of le kage Into or ut of hox, etc.) —
Distr ' box No evidence of solids
-Ca y over.No evidence ot ieakAq6
box,
PUMP CHAMBER:12dIiL°.
(locate on site plan)
Pumps in working order:(Yes or No)—!izly
Alarms In working order(Yes or No)__"
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
umg chamber is nnf pi-event
revised 9/2/98 PsetIof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C I I
SYSTEM INFORMATION(continued)
Property Address: 263 South Main Street Centerville,Mass.
Owner: Kate Whouley
Date of Inspection:4/1 2/0 0
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type: ,
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields, number, dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology: Titie Five ( 78 Code
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to fine sand. No signs of hydraulic failure or
ponding. Soils are dry. Vegetation is norma .
CESSPOOLS: v�
(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(cesspool must be pumped as part of inspection)
o
Cesspools are not present.
Comments:
(note condition of soil, signs of hydraulic failure,level of pending,condition of,vegetation, etc.)
esspoo s are not present.
PRIVY: /W'W'
(locate on site plan)
Materjals of construction: Dimensions: i1L9
Depth of solids: )54
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
Privy is not present.
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C j
SYSTEM INFORMATION(candr"041
PropenyAd&*": 263 South Main Street Centerville,Mass.
Own *. Kate Whouley
D+tu of 4iaPec%; ":4/1 2/0 0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at mast two permanent reference landmarks or benchmarks
locate all walls within 100'(Locate where public water supply comes Into house)
Ck
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revised 9/2/98 Pate 10of11
f
o SUBSURFACE SEWAGE DISPOSAL SYSTVA INSPECTION FORM
PART C 0 N
SYSTEM INFORMATION Ic"Wrtwd)
PropwtyAddra": 263 South Main Street Centerville,Mass.
Own«: Kate Whouley
Data of Insp.ction: 4/1 2/0 0
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date wobsits visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Collar
Shallow wells
r
Estimated Depth to Groundwater AP Feet
Please Indicate all the methods used to dotermino High Groundwater EJovatlon:
Obtained from Design Plans on record
bserved Site (Abutting property bservatlon hole, baeemeat sump etc.)
-- _
Determined from local conditions
Chocked with local Board of health
_Chocked FEMA Maps
��/Ch.ckod pumping records
hocked local excavators,Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Myd be completed)
Water Contours Map.
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page It of it
i
1•Rrsne•n.—ntTrr:T— rnr mr•a.mrrrl+n+en.Isrrr.TTR•r�IrlTnTn+rA7.seTa7l.+'�'en�rtsT � �.'.T-.r•
TOWN OF Barnstable BOARD OF HEALTH
31113SURFACF SF.WA(;E DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
.•••TT'I�T••.••.:.—T.tif.-.TTTTITI'R.'.TIT11rRT1/Tlr"f11T.r5•iT�tTr't 1T1T1TRt�tiR1-Il.l�ft�l7 t11A •TrT'T�'1r�..II
-TYPL OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 263 South Main Street Centerville,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Kate Whouley
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME J.P.Macomber` & So4• -Inc.
COMPANY ADDRESS Box 66 CEnterville,Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate, and
Omplete as of the time of .-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one: t
System PASSED ;
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe environment as defined in 310 CMR 15 . 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 tcted has found that the system fails to
Protect the i-)ublic health and the environment in accordance with Title
5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITE
RIA of this inspection form .
Inspector Signature Date
copy of this certification must be provided to the OWNER, the BUYER
:)wne
here applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or•t~operator shall u d
within one year of the date of the inspection , unless allowed ort required
he m otherwise as provided in 3.10 CMR 16 . 305 .
partd .doc
r1
PROPERTY ADDRESS:263_South_Main_Street__
_-02632 -
----------------
On the above date, I Inspected the septic system at the above address,
This .system consists of the following;
1 . 1 -1000 gallon septic tank.
2. 1 -Distribution box.
3 . 1 -1000 gallon precast 11ea hin
Based on my Inspectlon, cl cer` ifV473 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. The waste water is 62 inches below the ivert pipe
to the laeching pit.
SIGNATURE:•f
Na m e:_1 ------
Company: Joae.2h_P_ Macomber & Son , Inc .
Address; Box 66
--------------------
Can tervilleL Ha_-02632-0066
Phone:---508-775-3338
------------------
w
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P, MACOMBER & SON, INC.
Tinks•Cesspools•Leichflelds
Pumped L Instilled
Town Sewer Connoctlons
P.O, Box 66 Centervllle, MA 02632-0066
775.3338 775.6412
UOI1MONVVEWULTIA OF
SACHUSETTS w ,
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Comtnissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Pr.p."Address:263 South Main Street NameofOwner Kate Whouley
Centerville,Mass. 02632 Address of Owner.
Nata of meo Inspector:
4/12/00 Joseph P.Macomber Jr.
Name of kispectw:(Please Print) P
I am a DEP approved system inspector pursuant to Section 15.340 of.Title 5(310 CMR 15.000)
company Name: J.P.Macomber & Son Inc.
Mailing Address: BOX 66 Centerville,Mass- 02632
Telephone Number8—7 7 5—3 3 38
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector s Signature: i✓ --/ Date:
The System Inspecto7all's,bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to'"
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND CONIMENTS
revised 9/2/98 Pagel of11
M
�1 Pnnled on Recycled Paper
TOWN OF BARNSTABLE
LOCATION,= S- />7,a - SEWAGE #
VILLAGE_�� /�ZVALE ASSESSOR'S MAP S& LOT
INSTALLER'S NAME. PHONE NO. C'O>'u ST CO,
SEPTIC TANK CAPACITY 1/OO Z'
LEACHING FACILITY:(type) R/7- 000 (size)
NO. OF BEDROOMS /�Y��JJ PRIVATE WELL O - PUBLIC WATER
BUILDER O OWNE d UL
DATE PERMIT ISSUED: �6
DATE COMPLIANCE ISSUED:
O�
VARIANCE GRANTED: Yes No
.�.,
� �� vL�.
��
.�
..9e
��°
_.�
•
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
ApplirFation for Disposal Works Tonstrurtion thrmit
Application is hereby made for a Permit to Construct ( ) or Repair (P an Individual Sewage Disposal
System at:
... 3..........S007tN.....:!!�y!�1.4)....----............................. ...........- ...........................................
Location-Address r Lot No_ o
... ........... . ....................................................... ....... ...........................................................
owner Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................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........................
19 ••••-•-•--•--•----------•----•---•--------•-----••--•••----•-------••----•---•--•-----------••--_-_.._.
O Description of Soil......
-- _O--2------S.Lfia------•-----.-Z.-..�Y------c LEA ` -----S°o.'J ---......
---....
------•----=--------..........._..
x
W
UNature of Repairs or Alterations—Answer when applicable_N?w'`�-.-.--_---�(&TIw� QLsSm�oL t�lr is0
rJY�`� \ OCo G R
P'=^-'D........ -------4...• ------�c?>.--.-Ew�!�...f------: C�C t't'----,k�..... -N.....- .....................A.. Z- •-•S(�..
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 Compliance has been issued by the board of health.
Signed ---------------- -- W'`0 .�--------------------------- �
Application Approved By .---..-_
Date
Application Disapproved fort e following reasons
.................................................---- --- --- -------------------------------------------------------------............................................
w' ® Date
Permit No. --- ------------------- Issued .................. .�---- --?(9-----------------
GDate
0 No.._r._s•='••----�=--- - Fps.. .:.........._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applira#ion for Diipnsal Works Toustrnrtinn priinit ,
Application is hereby made for a Permit to Construct ( ) or Repair (q an IndividualT Sewage�Disposal
System at:
Location-Address or Lot No.
----.. 1s_?��v......`.-----•--•--------------•---•--...-•-•-----•------- ..............
...ay.....C..---------------------..-'#-'------•--------....-•------...
Owner r— Address
w t.... .. .....
`n------=1�!�. P.c�_,_�Soy ....i. ......................
Installer Address
Type of Building Size Lot....................:.......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder, ( )
aOther Other—Type of Building ............................ No. of persons...._.....--.--.........---- Showers ( ) — Cafeteria fixtures .. -----------------------
wDesign 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.--------.----.----- Depth to ground water..---...............--..
rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit...---.............. Depth to ground water........................
9 -------------.................................................................................................................................................
0 Description of Soil -S a.-Z - `.. = �`� c_�C�... ...... -�----5 .��
x
V .....-----•-• ----•--•-•---------------------•---•---------------------•------------••-----------•-------•----•-----. -----------------•-------•------------•------•-------•------------•---------
IV
--------------------------------------------------------------------------------------------------------------------•------------ .........
U Nature of Repairs or Alterations—Answer when applicable._--'�--�-r"` ......... i C��sSAOoL
........................................... -------------
i?.!^).---•-•.a!JT .......�- 00o----- •--- . t t .......................
Agreement: ` 4 Sta±-LS
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 Compliance has been issued b<: the board of health.
Sig
ned --------------- �- 1
Da
l vre
b
11,,a I
Application Approved By ------ -- -tt��i�.!/17 ./!�!�t. C --
--------------------
Dare
Application Disapproved for�e following reasons- -----------------------------
---------------
', ....... ...... ................... ...q_j0""
-------- -'`�
Dare
Permit No. ----- - - ------------------ Issued ............. � �---------------- +
1 Dare
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
` TOWN OF BARNSTABLE
C�er#ifi.c�zte mf C�IIm�ltttrcce
THIS IS TO CERTIFY, That the
�Individual
Sewage Disposal System constructed ( ) or Repaired
by-------- tC L.. --------(b ST.._.....eo/_�_'+ ...... ""' alter----------- ----------------------------------------------- ----------------------------------------------------------
at ....-- .-----_ 2(3----------------5_ m � -------5 .............................................. ........._..............
has been installed in accordance with the provisions of TITLE 5. f The State Environmental Code 6 des Zed in
the application for Disposal Works Construction Permit No. _ � t'7 dated ------_..- .� ��.....`'`/- ..--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BVC1ONSTRU r}('AS A GUARA�+TEE T AT HE
SYSTEM WILL FUNCTI , N SATISFACTORY.
DATEr� G .--------------------------------------------------------------- Inspector ------- ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE FEE. �-
.......... .......
Permission is hereby granted..... ....... ...... t.....tea c"-----------------------------------
to Construct ( ) or Repair ((I an Individual Sewage Disposal System
at No.....z -1---.....�>1M e i -------• 1'4z.u►-....................L
--------------------- ---•------ -•---
Street /}f
as shown on the application for Disposal Works Constructio ermit No .�,L__._�..v ate��i..____ - ��j .1 .......
r -- ------------- - ..............
Board of Health
DATE................. ( ...�[ -�1(�......................................
FORM 365oa HOBBS 11 WARREN,INC.,PUBLISHERS