HomeMy WebLinkAbout0051 EDGEHILL ROAD - Health 51 Edgehill Road
Hyannis P
A = 287 113
o
0
OAT E ;12/3/03-----
PROPERTY A0ORESS 51- Edgeh.iii Road _-----
_ { cu�nn.�-s•_/zo2t, ('l a-3-s. ———— ���
-- - - - -------------------
On the above date, I inspected the septic syslern--•al the above address,
Tnis system consists of the foll,owing; _ `gyp �1
1. 1- 9500 ga-�.�on ze/?t.ic tank.
REC !4r ED
2. 1-Lutz i&ut.ion Sox.
3. 5-500 ga.'ion ieach.iag chamgezz, ( .in ze2.ie-) JAN 0 6 2004
Baseo on my inspection, I certify the following condlllons:
TOWN OF 6ARNSTABLE
4. 7h.ia .i.s a t.itie rive 3e/2t.iC ZyZ.te'm. (95 Code) HEALTH DEPT,
5. The �3e/2t.ic hyztem .i.6 .in /zao/zea wo2k.ing oadea
at the /2ae,3ent time.
6. Aii 5 o� the 500 gaiion chamgeaz aae /2aezentiy d2y.
• SIGNATUR
Name _ P . -Macomber_Jr .
- - - - - - - - - MAP :.._-._,•-.,•�,,,,�...�.,,
�ompany : )Q�Zph Son, Inc , PARCEL , 3
° ooress --@Qys _66. ----- ----- LOX - -
- - -C.eA;QcxLL Le,_ :1a _Q-2.632- 0066
?^one : 508 . 115 • 3338
This CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY
r
JOSEPH P. MACOMBER & SON, INC.
T anxs•Cesspools-l.eachllelds
Pumped & Installed
Town Sewer Connections
P 0 Box 66 Centerville, MA 0263?-0066
775.3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
o
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: ..51 Cdgeh.iii Road
yanni.612o,z , azn.
Owner's Name: Pa Aic.ca Gu e.e ive2
Owner's Address: Same
Date of Inspection: 1213103
Name of Inspector: (please print) jo.6e12h P. Macoml~ea ;,z
Company Name:g. ,Aacomle2 9 Son Inc.
Mailing Address:
Cen eltz) e, a.3-6. OZ632
Telephone Number: 5 0 8-7 7 5-3 3 3 8
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of 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 toSection.15:340 of Title 5(310 CMR 15000). The system:
i Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: XLvx/A Date:
The system inspector shalks6mit a copy of this inspection report to the.Approving Authority(Board of Health or
DEP)within 30 days.of completing this inspection.If the system is a.shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the.time of inspection andunder.the conditions.of use at:that
time.This inspection::does not address how the-system will perform in the::future under,the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION (continued)
Property Address: 51 Edye. liite . Road
Kyann.i.sRoa , Nazz.
Owner: %abt ic.ia giattive2
Date of Inspection: 1213103
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syste,m.Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.30 or i'n 10 CMR 15.304.exist.Any failure criteria not evaluated are indicated below.
Comments:
The zeR.t.ic .sy.Ztem .ins- .in /2)tope2 wo2k.iny: o/zde2 a;
the Rae,3eni .tame.
B. System Conditionally Passes:
AZO 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.
*'le')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:
If/1� 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
approvalrof Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
V 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:
. i
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A
CERTIFICATION(continued)
Property Address: 51 Edgelz.i-Pi Road
yanni 3po2 , Ma.6.6
Owner:. 1 a t t i c.i a Gu i e u v
Date of Inspection:/213/0 3
C. Further Evaluation is Required by the Board of Health:
4)0 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.
A. 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:
,616 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..ofa
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 watersupply.
The system has a septic tank and.SAS and the SAS is withinf 50 feet of a private water supply well.
ly? 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 supplywell**.Method used to determine distance Zi. j�
**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:
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Page 4 of 11
OFFICIAL,INSPECTION FORM—NOT FOR,.VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:51 Edgehi ei Road
yann.czpo2 , Nazz.
Owner: %a.t/tic.ia Cu. iivea
Date of Inspection: 7213103
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to.each of the followingfor all inspections:
Yes No /
Backup of sewage into facility or system component dueto overloaded.or clogged SAS or cesspool
rDischarge:or,ponding of etfluent.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 dueto:an overloaded or clogged SAS or
cesspool
/Liquid depth`m�sspeel'is less than 6"be ow invert or available-volume is less than'h•dayflow
P� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped C� .
y 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
y portion ofa-cesspool orprivy•is within•a Zone l of a:public well..
y 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.] .
Al (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 1.0;00.0 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
_ Ithe system is within 400 feet of a surface drinking water supply
L14e 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:51 Ed yehi-ei /2o ad
yann.c3/2o2 , ass.
Owner:Patz.icia Gueiive2
Date of Inspection: 1213103
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?
Were all system components
l�&,tluding the SAS,located on site?
t _ 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
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
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Page 6 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C At
SYSTEM INFORMATION
Property Add ress:5I edgeh.iii Road
uannizpnR ahb.
Owoer: PaLaicia ku.Ulyalz
Dsttc of lnspcctlon: 97/3/0 3
FLOW CONDITIONS ,...
RESIDENTLIL
Number of bedrooms(design): Number of bedroom)
,
(actual):
DESIGN flow based on 310 C�M,K'�15,203 (for example: 110 gpd x N of bedrooms);/W
,
Number of current residenus: a—
Does residence have a garbagc grvsder (yes or no):
Is laundry on a separate sewage systcm (ycs or no): (if yes separate Inspection.required)
Laundry system inspected (yes or no):
Seuonal use: (yes or no):
Water meter readings, if available (last 2 years usage(gpd))l?002-245, 250 gat onz_67 y. 92 C%D
Sump pump(yes or no): Wd-- 2003- 177, 150 ga teon,3-486. 99 Gl D
Last date of occupancy: S/22•i.nk.Pe2 dyZtem .ih /2ite,3ent.
COMM ERCIAULNDUSTRIAL
Type of esublishment: •Ah
Design now(bued on 310 CMR 15,203); d
Buis of design now(seats/personVsgft,etc.): ^ .0,
Grcue trap present (yes or no): A14
Industrial waste holding tank present (yes or no):,M
Non-saniury waste discharged to the Title 5 system(yes or no): .l1/� )
Water meter readings, if available:
Last date of occupancylust; 42
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:None ava i—Ragie
Wu system pumped as pan of the inspection (yes or no): _
If ycs, volume pumped: 9_gallons —Mow was quantity pumped determined?
Reason (or pumping:
TY t OF SYSTEM
J//Septic unk, distribution box, soil absorption system
Singlc cesspool
F Overflow cesspool
/U, Privy
Shared system (yes or no)(i(yes, attach previous Inspection records, if any)
Innovativc/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank X4 Atucb a copy of the DEP approval
/t/o0ther(describe): At
�2proximatc aec of all compon ts, date Installed(if kno d source of information:
Wcrc sewage odors detected when arriving at the site (yes or no); .
J
6
Pt<gc 7 of I 1
OFFICIAL.INSFECTiON-FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SU S' IZFXCE SEWAGE I)ISPOSAL SYSTEM INS.rECTION FORM
PART C
SYSTEM. INFORMATION(continued)
froperty Address: 5 9 EdGeh.;RP
fftia nn�4 gQ.17 /rJn.c c,
Qwam%a .i ra U
Dstt of Ins:pcction:
r•'
BUILDING SEWER Q-0cait cn site plan)
Depth below gn4e:.,.�.---
Mstcrials.o(constrvctlomAb ;tut Iron �9 PVC other(expitttn): '
Distance frorn.privstt wsttF sr apply well or suction lilts: d't
Comments(on condition of jousts,venting,cvldonte
o in a: 64. &eak e. The 4-h
e 2oug e noo
SEPTIC TANK: e(lIate on site plan)
DV1h below grade: _
atcrial.oiconswction: concrctcwJd tnewl�g!�fiberglass,!&Polytthyknc.
I l tstdc is mcWl list,age, is age conftrmc.d by a crtiticatc of Compliance ayes or noj&h(attach a copy of
Sludge dcpth y 112.-fs—
Dis.tttnct trom top of sludge to bo ioni of out., tee or
Scum thicltricss:�� —
Distance from top of scum to top of Outlet tee or bafflee:-la-A —
D.isWee from.bonom of scwm to bottom of outlet tee o ba:Pflc: 4a---
How w.crc dimensions detertmtned:
Co:mrrtcats(on.purn.ping.revo.rtunendations, Wot and outlet tee or ba.fllc condition,structural integrity,liquid levels
--ads related toout-e.t inycrt,evidcncc'QrJt&lSegc,etc;), In het & out�e teee a2
k'l uffl,/?. .the �e. t cc, tank. ev
.era P ace. e tank cis 2a
o ea aye. Liquid -et-vei at .the .out e y�, n?1A�2lb !',6 5 9"
GREASE TRAK Flocatc on site plank r�
Depth below grndc:-V�
Material of construction &conerctc tnctal�4fibcrglass Qpolyethylcno�, ,other
(explain); .
Dimensions;
AW
Scum thit;Mew
Distance from top of`scum to t.op of outlet he yr baffle: A
Disunce from bosom of scuAn to bottom of outlet tee or baffle:
Date of lut ptun,parsg:, _„r,
Comments(on pumping recommcndali:pns, inlet and outlet tee or baffle condition, structural Integrity, liquid levels
as related to-otrtict invcrl, evidence of:Iealca:ge,etc.}:
y2eaze 41taI2 J*.i nnf 'nna4an� L
.. 7
Page 8 of I I
OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS
'SI BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 57 Edgeh.i-e-e Road
Owner:
Date of Inspection:
TIGHT or HOLDING TANw (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: l _
Material of construction:41 concrete metal j -ftberglass�AJ polyethyleneAO other(explain);
Dimensions:
Capaciry: gallons
Design Flow: gallons/day
Alarm present(yes or no): XW
Alarm level: 214 Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
Ziaht oid.in zankz a/ce no pae sen .
DISTRIBUTION BOX: —Z—/(if present must be opened)(locate on site pla
n)
n)
Depth of liquid level above outlet invert: �f
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.):.
x ha-3 .ive za eta z o eve epee
oven. No ev.idernce of .leakage -in.to o2 ou o e ox.
PUMP CHAMBE "locate on site plan)
Pumps in working order(yes or no): ,d
Alarms in working order(yes or no):
Comments(note condition of pump chamber,.condition of pumps and appurtenances,etc.):
Pump cham e2 4-6 no /?2eaen
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Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL..SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued):
Property Address: 5 7 Edgeh ii 2 Road
y—an n.izRo zi azz.
Ownerpa.t,z icier Guii ive z
Date of Inspection: 7213163
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
5-5 ,
If SAS not located explain why:
Type
kl leaching pits,number:
a 'leaching chambers,number:6i OV 6'j94'
/! leaching galleries,number:.
A�V leaching trenches,number,length: C>
tileaching fields,number,dimensions:
overflow cesspool,number:0 � c9r4
innovative/alternative system Type/name of technology`�1 � /"lh
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
Loam 2e
o ae
d,zy. Vegeiat ion ins no zma-e.
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Cezz o0V},$PRI (locate on site plan)
Materials of construction:
Dimensions: A _
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
l a.iv .ins
9 .
Page 10 of 11
OFFICIAL INSPECTION FORM.-NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)'
,'XF
Property address:
51 edggh i to Road
yanniz j2o2 h, 15la6 � .�
Owner: %a.zt.¢.i c i 1213103
Gu.�-UVTZ
Date of Inspection:
SKETC r E-DISPOSAL SYSTE nt reference landmarks o
Provide sketch of th josal system cl �din ties to at least:two.permane ar r
benchm kS.Locate all wells wi 100 feet.Lo a��wh re public water supply enters.the building.
j q
f}
03 y
A
77
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0
M67-
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10
_ TOWN OF BARNSTABLE
LOCATION71
ssjo�.✓TG�l�A'°� �SEWAGE #
VILLAGE eklix ASSESSOR'S MAP & LOT
i
INSTALLER'S NAME&PHONE NO; C7%'M
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS. !�
i
BUILDER OR OWNER
PERMITDATE: �O°�COMPLIANCE DATE: �oZ
Separation Distance
Maximum Adjusted Groundwater Table to-the Bottom of Leaching Facility Feet
Private Water Supply Well and Le Facility (If any wells exist
on site or within 200 feet of leading fkility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
4
i
r
r
i
iq�
L
Peed
0
DE
� � #1�/
Page I I of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued).
Property Address: 51 Fc1gPhi DL i? hat
'Q'i 4 7Q-0 -4,-g ch 3 S.
Owner: I)n f n i r i n r, Q Q Gve2
Date of Inspection: 17/ 3/()3 ;..
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
F
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained (Tom system design plans on record • If checked, date of design plan reviewed:
C Observed site (abutting property/observation hole within,ISO feet of SAS) �`�
Checked with local Board of Health-explain: Q�`� k AV, +a1;?7- s?41b
'Checked with local excavators, installers• (anach documentation)
Accessed USGS dambase•explain:hi;tp://down, p.a zn.6;taeie. ma. u.b.
You must describe how you established the high ground water elevation:
Laed: gahzel/j R1'Z%QPea Rade0. 97.1Z, 612 a?nl!ud 1,161104 04eiza1.i^n6 czPauo Aen Oeve�.
U,3ed:IISGS; Detez OF
lL,6ed: IISG a.tea
5-5oo gaiion r
ieach.ing .chamgea.a.
-eel
Groundwater: Feet Below Bottom of Pit Nigh Groundwater Adjustment 1.. ) 8 ft per Fnmptcr Method
T?terefore,the vertical.separation distance between the bonom
of the leaching pit and the adjusted groundwater table is1
feet.
11
rr -r-n-1TT-m.•nTrs-�r.Zrr..r..r.:sr.*e1-arr:Trs*srrl m-lv:*•�ifsTer.mn .. .T'mrra^.�..:,r--..�•. _..,t
t.• TOWN OF Barnstable WARD OF HEALTH
SUI)SORFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
•.•—•.•-r••^.: —r.na^-.rn.r.nm•rt:ra:r�rr.r.rTra�T�•.r—•.�r,urrtes.rimr— -*+care nrmrns-.rs�er� rtmn•�mr�nZtvtr•nmrtr.•.—rrrr--:. —..�
-TYPZ OR PRINT CUARLI'-
PROPERTY INSPCC7'ED
STREET ADDRESS 57 Edgehiii Road Nynnn1.4nnnf� Mn. A-
ASSESSORS MAP , BLOCK AND PARCEL # 287- 113
OWNER' s NAME Pa.t2.ccia Gai-eive2
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAME Joseph P. Macomber V ion Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street To" or City scat• LIP
COMPANY TELEPIiONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1-578
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 ,
r
Check one ;
Sys.te_m PASS-ID
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 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 'acted has found that the system fails to
protect the i)ublic health and the environment in Accordance with Title
5 , 3.10 CMR 16 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection. form ,
Inspector Signature . ilate d
ne copy of this c.ification must be provided to the OwNER, the BUYER
( where applicable And the 130ARD OF HEALTH,
* If the inspection FAILED , the owner .or""op.erator shall upgrade ' the ayetem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CFIR 15 .-305 ,
partd . doc
• •N .
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/93. Z/ . I60
CERTIFIED PLOT PLAN
�. ` �:f .'F rr d,,,���I11 LOCATION
EDV I S ..LE . .. . ........ .... DATE .. .. . P. .
4`I EL, EY w PLAN REFERENCE .3��NG„ GoTS,
Ho. 26501 d /¢/�?�p ��S/S s lqN�/ -o ✓
t CERTIFY THAT THE �� !-ST�^�G.�t.v� 71an/ .
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REQUIREMENTS OF THE TOWN OF
WHEN CONSTRUCTED.
DATE QCf 4R4
yC//«/A h ¢� P�977ZIC//-7 Cc,LL
REGISTERED LAND SURVEYO
fee
'V OF BARNSTABLE
• •�' �
LOCATION ��SEWAGE # er`off
�!LLAGE ��""` .�� l ASSESSOR'S MAID&
INSTALLER'S NAME&PHONE NO.
li
SEPTIC TANK CAPACITY ra o a
LEACHING FACILITY: (type) (size
NO.OF BEDROOMS
BUILDER OR OWNER G!i
PERMITDATE:` — 060000MPLIANCE DATE: -',e--2 'O O
Separation Distance Bet een e:
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) _ "`d Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) - Feet
Furnished by
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No. �.�� �a"•O Fee `oez,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
. Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE.,MASSACHUSETTS
Application for Migogal *.pgtem Congtruction Permit
Application for a Permit to Construct(X Repair( &)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot Owner's Name,Address and Tel.No.
H is ort William & Patricia .Gulliver
Assessor'sMap/Pazcel yann P P.O. .Box. 152, Hyannisport, MA .02647
Map 287 Lots 113-1 2 & 3
Installer's Name,Addr ,and Tel D sign s Address and Tel.No.
�1. l. i�Ison Associates, Inc.
P.O. Box 486, Barnstable, MA 02630
508 375-0327
Type of Building: +1.39 AC
Dwelling No.of Bedrooms Lot Size+60548.4 sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 550 gallons per day. Calculated daily flow 709 gallons.
Plan Date Number of sheets 1 Revision Date
Title Subsurtace 6ewage Disposal Design
Size of Septic Tank 1500 Type of S.A.S. Gailiesitrench
Description of Soil P-7461: A-0-18"; B 18-48"; C 48-72" layered coed.sand and gravel
C2 72"-144" coarse sand - no water. P-7462 A&B 0-30"; C 30"-144" med. to coarse
sand, no water.
Nature of Repairs or.Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to pla a they ra
tion until a Certifi-
cate of Compliance has been iss by this Board of He lth.
Signed Date
Application Approved by Date q f K— d�
Application Disapproved for We fol wing reasons
Permit No. 9 mo , A-lt rj Date Issued
---------------------------------------
41
405
��(,�^�•— � ` , Fee jyGL—
No. /
4 Entered in cbm uteri
- _ THE-COMMONWEALTH OF MASSACHUSETTS• p yes
BLIC HEALTH DIVISION -`TOWN OF BARNSTABLE., MASSACHUSETTS
Zipplication for nitpoOar *p5te' Coftgtructiott ermit
Application for a Permit to Construct(X Repair(a)Upgrade'( �j Abandon( ) El Complete System ❑Individual Components
Location Address or Lot 5® e d es d o.
' i iam a ricz Gulliver
Assessor's Map/Parcel 1 Hyannisport Ma �287 Lots 113-1 2 & 3
p.0, BOX 152, iHyanIllSport, MA 02647
t. Installer's Name,Addr ss,and Tel o. D sig er s Addres and Tel.No
��/�of ` i. wi'9 son associates, Inc.
L.�� P.O. Box 486, Barnstable, MA 02630
508 375-0327
Type of Building: ++1.39 AC
Dwelling' No.of Bedrooms Lot Size+60548.4 sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures 550
Design Flow gallons per day. Calculated daily flow 709 gallons.
Plan. Date Numb of sheets 1 Revision Date �,
Title Su5surlace sewage isposa Design
Size of Septic Tank Type of S.A.S. a les t:rencn
Description of Soil P-7451: A-6--18"; B t8-48"; a 48-72" layered med.sand and gravel F
C2 72"-144" coarse sand - no water. P-7462 A&B 0-30"; C330'--144" med. to coarse
sand, no water.
Nature of Repairs or Alterations(Answer when applicable)
1 C
1
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 is by this Board of
Signed Date
Application Approved by Date 1 Y— D6
Application Disapproved for a fol wing reasons tt -
Permit No., :�L Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(X )Repaired( )Upgraded( )
Abandoned )b William & Pau ul Paula Gliver
at �0 :8-m-c Vernon Ave., yanni.sporr- has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Nlo.. -�
Installer dr//v9 �e'� G Designer g �fA.
The issuance of this permit shall notfb:c� guarantee
strued as a e that the y ste will funct' n a4e n
g
lst ed. J
Date I g Inspector
5
6
---� ------------------------------------
No. -4,20— Fee - c.)
1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
MiopoOar *pOtem Construction Permit
Permission is hereby granted to Construct(X )Repair( )Upgrade( )Abandon
System located at 50 Mount Vernon Ave., Hyannisport ,
1 h
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
/comply with Title 5 and the following local provisions or special conditions.
provided:Construction must be completed within three years of the date of t rmit.
Date: / '".� �"Gam, Approve Y G�
i
1
LOCAT ON SEWAGE PERMIT NO.
VILLAGE
21 ->i i-s ?d r )
INSTA LLER'S NAME /i ADDRESS t
e U I L D E R OR OWNER
DATE PERMIT ISSUED .___ -7lp
DATE COMPLIANCE ISSUED
—�
� �—
� n
n
/ V
O `V
r�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
W ............OF........1.3.AR..J.UZ.l.A.R&Lr....................................
Appliration for Ui4#niial Workii Towarnr "nn autit
Application is hereby made for a°Permit to Construct ( or Repair ( an Individual Sewage Disposal
System at
................_... ...r 4..... ................................•.........
Location-Address or Lot No.
1�.. G G-t�.K i' Gl
rr Owne n Address
..............................................................
a ----•.........-•-•--• •_Y. -1�....... ... O n ..------•..... ..................................
Installer Address
d Type of Building Size Lot--_K B. ............Sq. feet
U Dwelling—No. of Bedrooms..................................._..__.._...Expansion Attic ( ) Garbage Grinder ( )
j
p., Other—Type of Building ............................ No. of persons....____;�..--------------- Showers ( ) — Cafeteria ( )
Other fixtures .-----•--•--•-•--------------- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter.--------------- Depth................
..... Width.................. Total Length Total leaching area_._.....--....._._._s ft.
x Disposal Trench—No. .............. g g q.
Seepage Pit No--------/----------- Diameter-__- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_--__-_--____--..._----.
Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........................
�4 •-•••------------------ - -
ODescription of Soil---------•-•-S ---•-•----------------------------•-••----------------------•- ---- -- -•-•-•••----------------------------.-----
x
V ----------------
•---------------------
:------------------------
•---------------------------------
-------------------------------------------------------------------------------------------------------------------y�------------------------------------------------------------------------------------ '
U Nature of Repairs or Alterations—Answer when applicable----------R_ P--, O_ ,.4na.1fLD:Py
---------------------------------------=---•-------------------•-----------•---•--...................--•---......---------------....-----------------------------------------------------...........----
Agreement: 4
The undersigned agrees to install the aforedescribed Individual,Sewage Disposal System in accordance with
the provisions of'TT I,:, y g g' p y
S of the State Sanitary Code—The undersigned further rees not to lace the system in
operation until a Certificate of Compliance has been ' sue y the oard of h alth.
Signed ... _-
------•----•-----•---------•------- --•------- ---- ----------•-Da a .....------•-
�� �y / ate
Application Approved BY •-•-Y,�� = / - • ------------------------------ ill P ? .
I '
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------•.••...
---------------------------••----••-•-----•-••-•• .........=..................................................................................................................................----------
Date
PermitNo.. ...................................................... Issued_•-`I1---------••---p......--•-................................................ ,.
Date
I Y
Q g "n` . ..............................
Fps
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-----. ....................... ...OF.........................................................................................
,
AVV iraffou for BiBvaa al IVV: Tonlitr Linn ramit
Applica is herebyad'e af1dt to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 61
�
................. ., ,._/s..t--- ----.-----------------•------..---------------------- ----•----- .......................................................
Location- dress or Lot No.
................. -- -f._ ........................ ..................................................................................................
W Owner Address yf
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—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.
Septic Tank—Liquid capacity............g to s P, Length---------------- Width................ Diameter................ Depth................
Disposal Trench—ko...................... Wi th.................... 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.........................................
aTest Pit No. 1________________minutes per inch Depth of Test Pit------_............. Depth to ground water........................
f� Test Pit No. 2............_<-nin utter p��inch Depth of Test Pit.................... Depth to ground water.__________.____.__.___.
Descriptionof Soil........................................................................................................................................................................
U •----------- , yz ) --------------------• .....................................
W ---•--------------------------------------------------•-------------------------•--------------------------------------------------------------- --/.A.".
UNature of Repairs or Alterations—Answer when applicable..___...........................................................................................
'S
Agreement:
The undersigned'agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of I TT L of the State SanitVbee!
e— The un ersigned further agrees not to place the system in
operation until a Certificate of Compliance hasu .�y th boar
Signed_...... •• •---- ----- ------------------•---•-•--•.....
41
Application Approved BY ' ..... .......................
--------------------
-----------------
Date
Application Disapproved for the following reasons---------------•----------•-••-------•------------•------------...-----------------------...-•--••----......._.._
-•----------------------------_----------......----•-----------------------•------._.-•-_-••--••-•---•--•----•-•-••••-•---•-.-------------------•-------------------------------------------------------
/ Date
PermitNo......................................................... Issued_...................................2�
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
VW.°' ............oF.......... 4�/V��'4 Vie-
......................................................................
Tntifiratr of TompliFanrr
THI:SWJ TO�CERTIF�-Y i DT Individual Sewage Disposal System constructed ( ) or Repaired ( )
by -----.-----...•••-• ----•...
• ..-••- -------- -------- --•-----------•----• --••----------------------•-------._......•••-•---••---•--
has been installed in accordance with the provisions of j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No___ �� ___J�.�9............. dated----------......................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED. AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
� inspector
DATE ...................... THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT s
.................. .....OF.--.. ... .... . ........ ......... .........
NFEE...................••••.
fit
Permission is hereby grante ------=---------------------------••--•-------------------------•-------------------------..-•-------------+...........
to Construct,,(. r pair ( ) an I i rage,, , pso Syst rli Al � ^1!/ `
atNo.--------. --•••-••-- ........--••--••-•-••-•..............:...............•----.._.._..--•---•-•------------------------•------.........................................................
Street
as shown on the application for Disposal Works Constructio >t o.__-_... ..... .d.......... ...............................
�
Board of Health
DATE. '
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
/ - VJ0' Sf ffA *r A *W. . ZrVAV
JedVe JOCaEr 4ff&yd1A1j> 0",fttsi
TOP OF FOUNDATION
JV.17N CeATAW SA9A0Z:-.
CONCRETE COVERS
Mu
L
LA. 4"CAST IRON 9W
MAN *V
ti OR SCHEDULE 40 4"SCHEDULE 40 PV.C. (ONLY) LEACHING TRENCH MREQ.
MIN.4IN
of PIPE A 9. MIN .
*D. A PITCH 1/4441 pER.FT PIPE- MIN. MAX.
1/8"- 1/2" WASHED STONE
PITCH 1/4"PER.FT
2"04
k 1p tly
•wo
4#@
GAS BAFFLE---,&.
Popr
INV R INVERT INVERT
EL.10.-.TA?�.. C.I I di 6i, t 24
K 4 ♦1%; SEPTIC TAN 4
,0
glow cle
I.A INVERT M .
Q,* 1cZ%
GAL.. INVER
w 40
........... BOX
;%
PEA EL D'STANVER-i-/ Prewtt 50OGaI.Leach 3/4 1 V2,
�av ;C7 'r) REG. Chamber WASHED SMNE
*N Ell-flY . 0
RUSHEELF J)S-p .. i
§7 -297 1
I H
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Pl- - Ze.>
Alp
4b 4
4, /46/1, er- S�0
PROR LE Or
P_ GROUND WATER TABLEII
SEWAGE DISPOSAL ' SYSTEM
TYPICAL CROSS SECTION
SOIL LOG
NO SCALE LEACH I NG TRENCH .
E
DATE TRA NO SCALE-
TEST HOLE I TEST HOLE 2 �*Af,CO~. 3Y.5w
1" A/
ELEV. DESIGN - DATA :
ELEV.
WASHED -36
✓
9rl
r Jf MAX,
NUMZER OF BEDROONIS SMINE A 11
Jf"s-Solt_ &qr,so., 'TOTAL ESTIMATED FLOW . . . . GALLONS/DAY
4
/4',V 7.4 Q
&Z. all-cl 4 A. BOTTOM LEACHING AREA ... SQ.FT./TRENCH11
aon. ? 1-3. C:;[•c:
t= .24
Z41r,4z 85.AJ* - I',
SIDE LEACHING AREA -TIf3
EA SO.1 i./TRENCH//, Cr,t=r
Atep, GARBAGE DISPOSAL . .44/0"f..(50% AREA INCREASE)
ro
TOTAL LEACHING AREA REA . SO.
s4pa> ck I
17,
T RATE ef'M- 'PER. INCH
PERCOLAi ION
LEACHING AREA PER PERCOLATION RATE
y
top.,
•
-ER r"BLE
ip GROUND W4
13xl &Z 0.4-p 44 APPROVED
34- -ZvcN J er, BOAPD OF HEALTH
"_Ae, ...........
"90. . .WATER ENCOUNTERED
DATE . . . . . . .
71---
A ENT OR INSPECTOR
I �_ Gr_
4�14 Imppe AO
ESSED
J,* JA/ WITH BY :
4;pw- IS& 15
. ..e. .Aqv • BOARD OF HEAL:1-4
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00 . . . . . . . .
3*
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wale' Q1
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