HomeMy WebLinkAbout0200 GREENWOOD AVENUE - Health r - 200 Greenwood Ave
288-173-001r' Hyannis
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Co,A6C72Rb-- 2ro
No. �� vG Fee
T E COMMONWEALTH OF MASSACHUS TTS Entered in co put r:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
' 0(pprieation for Misposal 6pstem Coustrurtiou hermit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X) [:]Complete System ❑Individual Components
Location Address or Lot No. d2 b O C--t1tA+04 OWE, Owner's Name,Address,and Tel.Ng.
NY FAj(. 5,I-9pp- o`0006JEZ 1
Assessor's Map/Parcel , -9/t 7 —®® dcl 1 Fv 6--c- W.W QL A�
Installer's Name,Address,and Tel.No. .54V.>-qT7-ff1T7 Designer's Name,Address,and Tel.No.
d6¢dGWGbw f�.stZ �ldt'f LL-c—
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Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued "ofHealthg O Date a 3 a
Application Approved by Date
Application Disapproved y Date
for the following reasons
�y
Permit No. ' Date Issued
�r
No. ' �/i1� Fee f
T E COMMONWEALTH OF MASSACHUSETTS Entered in cons rater:
PUBLIC HEALTH DIVISION - OWN OF BARNSTABLE, MASSACHUSETTS Yes
-T i
01ppYication for 33isposai .pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X) ❑Complete System ❑Individual Components
Location Address or Lot No. A 6 O CP26ZNWo4 g uF_: Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel oZ�� [7 "®o i OP-b 6-r W.b2c;QL- Da,l3}_
Installer's Name,Address,and Tel.No. $O$-5(Z7-$g'17 Designer's Name,Address,and Tel.No.
Co<Py?O(b� 0k,17204Jef. (J-`-
� V St
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
,.Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Certificate of
Compliance has been issued b tj)d
' rd of Health.
� Date `All O 3
YApplication Approved by /; l Date
Application Disapproved by Date
for the following reasons
Permit No.' ' Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( by db(3O(A5" �(S�
at aon ('�67al }) AU 9 < has been const c d'n accord
with the provisions of Title 5 and the for Disposal System Construction Permit No.
�� /�
Installer C�p���1� Designer
#bedrooms Approved design flow /Vnf n /gpd
The issuance of this pe it hall not b construed as a guarantee that the system will 1 ttio{ as rdessi/gne{i4.1�'
Date Inspector_
No. 37-0 Fee _
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC EALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) = Upgrade( ) Abandon(k)
System located at loci &(Qoj oob kYAwj((
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construc ion�m st be co leted within three years of the date of this permit. l -
Date Approved by
,/
i
ate/
azo woo G�•.�,
James Bestford 4/6/00
200 Greenwood Ave
' Hyannic,Mass.
1
02601 1''
System consists of;
2-8 ' X8 ' block cesspools
This is a split system.
1
DATE:_4/6/00__—` —
PROPERTY ADDRESS: 2,0 Q Greenwood Ave _____
Hyannis wMass._--_
02601
On the above date, I Inspected the septic system at the above address.
This .system consists of the following:
1 . 2-8 ' X8 ' block cesspools. 00
Based on my Inspection, I certify the.following conditions:
2. This is not a title five septic system.
3. This is a sewage system. That consists of 2-8 'X8' block
cesspools.This is a split system. #1 Handles grey water and
a bath. #2 Handles bath.
4. The sewage system is in proper working order at the
present time.
5. System is about 40 years old.
SIGNATURE:..I
N a m e:_,Z,.P..,-Aos.Q ab t.r-JL�------
Company: Josnh_E-- Macomber & Son , Inc .
Address Box_6 6__ _______
Centerville L Ma__02632-0066
Phone:___508 775_3338_______
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
rOSEPH P. MACOMBER & SON, INC.
Tinks•Cesspools•Leachflelds
Pumped a, Instilled
: 1 ! Town sewer Connections
, P.O. Box 677 Cei
5•JJ38erv775•d 122632-0066
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENviRoNMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUH:
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
prop,irtyAddre; 200 Greenwood Ave Namaofow w James Bestford
Hyannis,Ma6766
02601 Address of Owner:
Date of kmgwct 4/
Name of Inspector:(Please Print) Joseph P.Macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: J P Macomb r & Son Tnc_
MaTing Address: Box 66 r-A n f e r v i l l a _M a c c 02632
Telephone Number: 5 0 8-7 7 5-3 3 3 8
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 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:
rz;
Passes
---_--Conditionally-Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date:
The System Inspecto shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)whNn 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 touts
system owner and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
10 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTviCATION'(oorrtlnueW
Pro%,.1yAddraaa:200 Greenwood Ave Hyannis,Mass.
owrowl James Bestford
Date of kupection: 4/6/0 0
INSPECTION SUMMARY: Check A, B, C, of D.
A. SYSTEM PASSES:
I have not found any Information which Indicates that any of the fallurs cond)tions described In 310 CMR 14.303 exist. Any hJlwe
criteria not evaluated are Indicated below.
COMMENTS:
B. SYSTEM CONDMONALLY 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 of repair,as approved by the Board of Health,wW pass.
Indicate yes, no, or snot determined(Y. N. or NO). Describe basis of determination In all Instances. if'not determined',explain why not.
^/ The • tic tank Is m• ni•ss the owner or operator has provided the system Inspector with a copy of a Certificate of
CompUsncs (anach•d)Indicating that the tank was In&U119d within twenty(20)years prior to the date of the 4up•ction: or
the septic tank, whether or not metal,Is cracked,structuratiy unsound, shows substantial InfUtradon or exNtretion, or tank
failure is Imminent. The system WW pass Inapsctlon 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 th distributlon box s due to broken or obstructed pipeW
- or due to •broken, settled or uneven distribution box. The system will pass nspect on If(with approval of the Board of
Health).
broken plpe(s)we replaced
obstruction Is removed
distribution box Is levelled or replaced
AtJO • The systsm(squired pumping-non dw-iour'tlmes io•yeardus to broken•a obstructed p)pe(s). The iystsm wiii-pu3v-
Inspection If(with approval of the Board of Health): • "'
broken pips(s)we replaced
obstruction Is removed
revised 9/2/98 hgc2ofIt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of kw4mmdon:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Ald 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 CMR 16.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH..WtLL.PRQIECT THE PUBLIC HEALTH.AND SAFETY AND THE 801 BONMEINT
Lb Cesspool or privy is within 60 feet-of 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 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 60 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 ;01.4 (approximation not valid).-
3) OTHER
This is a sewage system This is a split system.
1 Handles a bath and grey water_ #2 handles
ba f-b
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A 1
CERTIFICATION (continued)
P►opwtyAddrw: 200 Greenwood Ave Hyannis,Mass.
Ownw: James Bestford
Date of k-P--d°": 4/6/0 0
D. SYSTEM FAILS:
Yo;Amust indicate either"Yes" or "No" to each of the following:
AM I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure
Yes No
�/• Backup o+ravage inloiecili"0 y eter++oomponertt•due'to an overlwded ordegged-GA&w-ceaspod.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
.4
AAM-0 Static liquid level in th distribution box bove outlet Invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool Is less than 6" below Invert or available volume Is less than 1/2 day flow.
Required pumping more than 4 times in the last year No due to clogged or obstructed pipe(s).
Number of times pumped .
Any portion of the Soli 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.
4Z Any portion of a cesspool or privy is-wlthln a Zone I of a public well.
4/ Any portion of a cesspool or privy Is within 50 feet of a private water supply wall.
Any portion of a cesspool or privy Is less-than 100 feet but greater than 60 feet from a private water supply well 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 organio.compounds, ammonia 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 gpd or greater(Large System) and the system Is a significant threat to put
health and safety and the environment because one or more of the following conditions exist:
Yes No /
the system is wlthln 400 feet of a surface drinking water supply
JZ the system•Is-witWo 200{e+tol�tributar�rto�eu 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)
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 Infognation.
revised 9/2/98 page 4orli
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i z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART S'
CHECKLIST
ProperyAddr.s 00 Greenwood Ave Hyannis,Mass.
Owner: James Bestford
Date of Inspection: 4/6/0 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 systemacompoaants warwbaan poa4md4opstJaast two.aweaks asb aad%dw-system haeoasceivinywa+d flow
rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this
Inspection.
As built plans have been obtained and examined. Note if they are not available wi N/
_ 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,-o eluding the Soil Absorption System have been located on the site.
�VdAlj . The opZ
Rial
manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles
or tees, of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System orrthe 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)
(I5.302(3)(b))
_ The facility owner.(and.^^._..upan±s.Jf diffaraw trom.wwner).werayrnuidad with InfoLumtiomon*.hprnp_•Maio: ,^^ ^f
SubSurface Disposal Systems.
i
revised 9/2/98 Page 5of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(con*woM
Props Add *". 200 Greenwood Ave .Hyannis,Mass-.
Owrw: James B.estford
D+u of Inspection: 4/6/0 0
SKEToi OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locate all walls within 100' (Locate where public water supply comes Into house)
pdoM txi,'a„c� pp
Ali
\14'
I
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revised 9/2/98 Pat#10of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertYAddro": 200 Greenwood Ave Hyannis,Mass.
Owner: James Bestford
Date of Inspectkm: 4/6/0 0
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 00 g.p.d./bedro M.
Number of bedrooms( esi n .i' Number of bedrooms(actual):
Total DESIGN flow . .
Number of current residents: 2
Garbage grinder(yes or no):-
Laundry(separate system) es or&:_; If yes, sepamte.Inspection.required
Laundry system inspected or no)
Seasonal use(yes or no): p
Water meter readings,if available(last two year's usage(gpd): O" 7 01 D10
Sump Pump(yes or no):
Last date of occupancy:�V
COMMERCIAL/INDUSTRIAL
Type of establishment: //1g
Design flow: 41A gad ( Based on 15.203)
Basis of design flow Aw
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no) A44
Non-sanitary waste discharged to the Title 5 system 1yes or no)Nl _
Water meter readings,if available:
Last date of occupancy: A14
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORD and urce of i or ation:
� -- � Z,� .BMW" >*- ,�.► sue.
System pumped as part of inspection:(yes or no)_.eW
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
AM 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)
AJ, I/A Technology etc. Attach copy of up to date operation and maintenance contract
V_ Tight Tank /CAAr Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed{if known)-and source of4wfermation: ./�,�- •�
Sewage odors detected when•arriving at the site:(yes or no)
revised 9/2/98 Page 6orll
* SUBSURFACE SEWAGE DISPOSAL S-STEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Greenwood Ave Hyannis,Mass.
Owner: James Bestford
Data of lrupectiort: 4/6/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grader
Material of constructio : cast ron4/040 PVC 416other(explain)
er�iy4r %yr D DB
Distance from BrMate watet4pT well or suction line
Diameter -y_
Comments:(condition of joints,venting,evidence of leak"e,•etc.) —
JQints afar t i vented-
ht No e1ri dc4nr-c of l®akage.
System
SEPTIC TANK
(locate on site plan)
Depth below grade.
Material of construction:jLAconcrete metal*,4FlberglassA*1 Polyethyloneo6tother(explain)
If tank is instal,list age M Js.age-confirmed by Certificate of Compliance (Yes/No)
Dimensions: JJA
Sludge depth: 1 _
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness: AM
Distance from top of scum to top of outlet toe or baffle:
Distance from bottom of scum to bottom of outlet too or baffle: AO
How dimensions were determined: AAA
Comments:
Irecommendation for pumping, condition of inlet and outlet toes or-baffles, depth of liquid level in relation to outlet invert, structural-integrity,
evidence of leakage,etc.)
Septic an is not prPGPnt-
GREASE TRAP• V,
(locate on site plan)
Depth below grade:/
Material of consA14- :.tIconcreto$!! met&14�&lborglasrV,*Polyethylenerlother(explain)
Dimensions: AN
Scum thickness:
Distance from top of scum to top of outlet too or baffler
Distance from bottom of scum to bottom of outlet too or baffle:44,
Date of last 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.)
Grease trap i c not p-rnSQnf
revised 9/2/98 Page 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARVC
SYSTEM INFORMATION(continued)
PropertyAddria": 200 Greenwood Ave Hyannis,Mass.
Owner: James Bestford
Date of 4tispec':4/2 6/0 0
TIGHT OR HOLDING TANK:ANfdTank must be pumped prior to, or at time of, Inspection)
(locate on site plan)
Depth below grade:A14
Material of conatruction:f��l concrete VAmetai v'�FlberglassA' Polyethyiene,edother(explain)
AM
AJA
Dimensions:
Capacity: A� gallons
Design flow: gallons/day
Alarm pressnt
Alarm level: IM Alarm in working order:Yss fA No/�
Date of previous pumping: Ablf
Comments:
(condition of Inlet too, condition of alarm and float switches,etc.)
Tight nr hnl ai ng tanks are not pFesent. _—
DISTRIBUTION BOX4V?1
(locate on site plan)
Depth of liquid level above outlet Invert:_
Comments:
(note if level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) —
Distrihutinn hnx is HoF present
PUMP CHAMBERA'Ve,
(locate on site plan)
Pumps in working order:(Yes or No) /1�
Alarms in working order(Yes or No).:�
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Pump c`hamhar i c not
revised 9/2/98 Page 8ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
P,opeortyAddress; 200 Greenwood Ave Hyannis,Mass.
owner: James Bestford
Dace of Inspection: 4/2 6/0 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: tV
leaching trenches,number,length;
leaching fields, number, dime r [one:
overflow cesspool,number:
Alternative system: IV
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,level of pondInA4 damp,soil,condition of vegetation, etc.)
o signs of hydraulic failure
or pon ing Soils are dry.Vegetation is normal
CESSPOOLS:
(locate on site plan) l
Number and configuration:LZ
Depth-top of liquid to inlet inve :
Depth of solids layer: 1
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater: did
inflow(cesspool must be pumped as part of inspection)
Did not Pump inflow oW sspool _ Nnt r6-kzr1Pr1
Comments:
(note condition of soil, signs of hydraulic failure,.level of.pending,condition of.vegetation, etc.)
Same as ahnvp, �
PRIVY: klvel
(locate on site plan)
Materjals of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
Privy is not nrPCPnf ,
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
i' PART C i
SYSTEM INFORMATION(condrxHd)
P,opertyAd&"s:200 Greenwood Ave Hyannis,Mass.
own«: James Bestford
Dau of Inspection: 4/6/0 0
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwate(/&t Feet
Please Indicate all the methods used to determine High.Groundwater Elevation:
Obtained from Design Plans on record
�/ Observed Site (Abutting propert observation hole, basement sump etc.)
determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_zChecked pumping records
Checked local excavators, Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Musl be completed)
Used water contours Map.
Gahrety & Miller Model
12/16/94
revised 9/2/98 page it oftl
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TOWN OF Barnstable BOARD OF HEALTH
SUI)SURFACR SEWAGE I)ISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
•.•rn-r••.-: •—r.ta�.-rnmr.+n•rtn+n rwa+es�rr+Wort.ar-n•trnvea.tsrnnr•earn+aa���e+w�n�� �n v+-i.-r�•r.-ter—..A
-TYPE OA PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 200 Greenwood Ave Hyannis,Mass. '
ASSESSORS MAP, BLOCK AND PARCEL 0
OWNER' s NAME James Best-ford
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son In(!".`
COMPANY ADDRESS Box 66 Centerville,Mass. 02632 .
Street Town or City state EIP
COMPANY TELEPHONE ( 508 775 - 3338 FAX ( 508 ) 790- 1 578 .
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaY system at
ID
his 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 .
Check one ;
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 the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have con tcted has found that the system fails to
Protect the public 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 .
"r
Inspector Signature Date ell)
ne copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided i•n 3.10 Ch1R 16 , 306 .
partd .doc