HomeMy WebLinkAbout0054 GROUSE LANE - Health 54 Gr ,6s6 Lane . �
268-257 Hyannis
4
I
U TOWN OF BARNSTABLE p
LOCATION S 7 G R® V Se I- A lVe SEWAGE # 7 7— 3/3
VILLAGE UJ e3f 11V A &^II—S ,X-rASSESSOR'S MAP & LOT.7,6 a - *,U7
INSTALLER'S NAME&PHONE NO. J<P M A C U m ReR--S'd,�
SEPTIC TANK CAPACITY /v O O
LEACHING FACILITY: (type) 'L6 O/=Leta C&-A&4Mze)1- S'00 G A b
NO.OF BEDROOMS ✓?
BUILDER OR OWNER
,PERMrrDATE: COMPLIANCE DATE: f rI
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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.�,�-
i k'
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No. A Fee $ 5 0. 0 0
THE COMMON E LTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TO N OF BARNSTABLE., MASSACHUSETTS
2ppYication for Mi.5pogal *pttem Couttruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) []Complete System XX Individual Components
Location Address or Lot No. 54 Grouse Lane Owner's Name,Address and Tel.No.
l es-r nr�isport,Mass . Estate Of Doris M Rynearson
Assessors arce
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Desi ner's Name,Address and Tel.No. — —3 3 3 8
J.P.Macomber & Son Inc. J.T.Macomber & Son Inc.
Box 66 Centerville ,Mass . 02632 Box 66 Centerville,Mass . 02632
Type of Building:
Dwelling g)io.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(TO)
Other Type of Building $ES No. of Persons 1 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 31110 gallons.
Plan Date 6/ Q/a 7 Number of sheets Revision Date
Title
Size of Septic Tank i nnn Type of S.A.S.
Description of Soil
Loamy sand to medium sand
Nature of Repairs or Alterations(Answer when applicable) Adding two 500 gallon chambers
to an existing septic system 4W e) 1-,-e-f a 5PvNe-
Date last inspected: 6/1,8/9 7
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 issu,96 by this ear of alth. 6/1 9/9 7
Signe Date
Application Approved y - Date i;
Application Disapproved for the following reasons '
Permit No. Date Issued G--
TOWN OF BARNSTABLE p
LOCATION S� g o V S� L' A 41 SEWAGE # 7 rI 3/3
VILLAG / S,0,0 ASSESSOR'S MAP & LOT S
INSTALLER'S NAME&PHONE NO. J-P A/1 A G U M
SEPTIC TANK CAPACITY UO
LEACHING FACILITY: (type)�!�/4 I=LoI� C/fA/i1f3�iCt�+ze)�- �a� G/Q G
NO.OF BEDROOMS 3
BUILDER'OR OWNER
PERM DATE: COMPLIANCE DATE:
Sepazation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Witer Supply Well and Leaching Facility (If any wells exist Feet
on'site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands.exist Feet
within 300 feet of leaching facility)
Furnished.by
50. 00
-No. Fee
THE COMMON LTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TO N OF BARNSTABLE., MASSACHUSETTS
Appfication',for Miopaai *pgtem Congtruction permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System YJIndividual Components
Location Address or Lot No. 54 Grouse Lane Owner's Name,Address and Tel.No.
West Hyannisport,Mass. Estate Of Doris M Rynearson
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. 508_775-3338 Dsgpte:'�jVame,Address and Tel.No.
J.P.Macomber & Son Inc. t' Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass . 02632
Type of Building:
Dwelling X)-No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder�1-10)
Other Type of Building RES No. of Persons 1 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3�1 1 0 gallons.
Plan Date%. 6/1 8_197 Number of sheets Revision Date
Title
Size of Septic Tank 1 000 Type of S.A.S.
Description_of Soil
Loamy sand to medium sand
Nature of Repairs or Alterations(Answer when applicable) ' dding two 500 gallon chambers
to an existing septic system 7 ,W Stow'
Date last inspected: 6/18/9 7
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 issu by this oo e-alth. i
Signe o / Date
6/19/97-
Application Approved Date
Application Disapproved for the following reasons
i a 4
Permit No. k'` - • Date Issued e—
. 1
————————=------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE-, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )UpgradedTXX)
Abandoned( )by J.P.Macomber & San Inc.
at 54 Grouse Lane West Hyannis Ort Mass . ha been construc ed in ac ord e
with the provisions of Title 5 and the for Disposal System Construction Permit No 0 g dated
Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & Son Inc.
The issuance of this pe t sha cn�ot be construed as a guarantee that the system wil�unctionn as designed.
Date `' / Inspector
No. /� ^✓ ! �J --------------------------Fee $ 50. QQ
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mioogal *proem Congtruction Vermit
Permission is hereby granted to Construct( )Repair( )UpgradeX(XX)Abandon( )
Systemlocatedat 54 Grouse Lane West Hyannisi3ort,Mass.
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Cons ction mus b'e com�I ted within three years of the date of t ' pe• 't.
Date: ~ ! / ! Approved b
i
CERTIFICATION Or SKETCH AND AMILICATION FORA DISPL._
WORKS CONSTRUCTION PLR.�,11'I' (W1'I'IIOU'1' DESIGNED PLANS)
I Joseph P. Macomber Jr., that tlw application for disposal works
construction permit signed by rtt, �:: tad 6/19/97 , concerning the
property located at 54 Grouse Lane West Hyann; sp r+. meets all of the
following criteria:
• There are no Nvetlands within 300 fcct of the proposed septic system
• There are no private wells within 15U feet of the proposed septic system
• The observed groundwater table is fcct or greater below Ili(;bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED
DATE: 6/19/97
LICE D SEPTIC SYS'rEiil INS"I'AL.LIER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed s;stem. Also if the licensed installer posesses.a certified plot plan,
this plan should be submitted).
8
n e
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i
Cornmornvealth of M=achusetts 7
ExecutNe'Office of Em lfonmental Affolfs
Department of
Environmental Prote Ji Qom
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wluiarn F.weld y Cone
Argoo Pau! Glluccl o �� `9�9� g.svuhs
Cornmr.brw
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION Y
PART A
CERTIFICATION
Prop.rty Address 54 Grouse Lane Uke- }�a ml S'�70`r'_t5r_ Addze„of owner.
t,.Do of inspeotlon:6/4/9 7 YlvWLS at dltlemnt)
NameofinsP- Joseph P.Macomber Jr.
Company Name,Address and Tel hone Number.
J.P.Macomber & Son Inc . 508-775-3338
Box 66 Centerville ,Mass . 02632
CERTIFICATION STATEMENT
I oW%W that I have personally inspected the"wage disposal system at this addrese and that the information reported below is true,aaurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper Atacdon and
maintenaaos of on-site sewage disposal rystaau. The rysum:
_. Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails ✓ Q /
Inspector's 8lgaaturrr ��/�" ( GL l�r. v Dates 61, 7_/
Tla Systam Ias shall submit a copy of this inspection report to the Approving Authority within thirty(30)ds�ys of completing this
inspection If the system is a shared gstam or has a design flow of 10,000 gpd or greater,the inspector and the system ownar shall submit the
report to the appropriate regional office of the Departmant of Environmental Protactioa.
Toe original should be seat to the system owner,zd ooplas sent to the buyer, if applicable and the approving authority.
LNSPECTION SUMMARY: Rt)A l ! 1'-313
Chack A. B, C, or D: I S su P® 0 617 4 7
A).SYSTEM PASSES: Co/4 L.
I bave not found any laformatioa which Indicates that the system violates any of the tai)ure critarii as d4dued in 310 CUR 15.308.
Any Liture crit.aria not evaluated are (adicated below.
B) SYSTEM CONDITIONALLY PASSES:
�U Oas or more system compaaants used to be replaced or repaired. The system, upon oompletion of the repUcament or repair, peaaa
iarpectioa.
Indicate ao,or not determined(Y. N, or ND). Dascsibe basis of datermiaation in all `w. If*not determined',explain why act)
The septic tank is mrt&L cm:ked,structurally unsound, shows substantial intlltmtioa or asnitmtioa,.or teak failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a poaforming septic tank as approvd
by the Board of Health.
(reylted 11/03/95) 1
Om Winter Street . Boston, µasaachuaetts 02106 a FAX(617) $56-10-49 a Telephone(617)292-55M
t� rr m d an Rrrcyc4d r.pv
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (ooatlauad)
Propartymdr..s 54 Grouse Lane West Hyanni sport,Mass .
Owaer7 Kings Highway Real Estate
Date of buPectloas 6/4/9 7
B)SYS= CONDITIONAUY PASSES (oontinud)
&&,t, Sewsp backup or breakout or ho static water lsvel oboarrad is the distribution baa is&a to broils or obstructed pipe(,
or due to a bro"a, settled or uaevan distribution ban. The syvt=win pass iaspectiaa if(with approval of the Board of
brokaa plpe(s)are nplaosd
obetructlon is removed
dLtr{butioa bats is levelled or replace
/Jo The system required pumpiay mon than four time.a year due to broken or obstructed pipe(s). The system Will Pau
iaspeuiaa if(with approval of the Board of H"Ith):
broken pipes)are replaced
obstruction U removed
C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTEr
_Xz' Conditions exist which require Authar evaluation by the Board of Health in order to deurmias it the system is Uling to pra.ect the
public health, safsty and the anviroament.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAYETY AND THE ENVIRONMENT
�Q Gaapool or privy [r within 60 feat of a surface water
Cwpool or privy L within 60 feat bf a bordering vegetated wetland or a salt massh.
I) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF APPROPRIATE)
DMXRMWES THAT THE SYSTEM 19 FUNCTIONING IN A MANNER THAT PROTECT THR PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT.
The gstam has a wptk tank aad*oil absorption system Lad is within 100 lest to a surLce water supply or o-Lb+tar7 to •
4 surface water ripply.
The system hu a wptk tank and&OU absorptioa system sad is within a Zone I of a public water supply well
The system has a septic tank and coil Absorption system sad V within 60 feet of a private water supply will
The system hu a aap(k tank and Sol absorption s7*tam and is Las than 100 lest but 60 feet or more from a private water
supply w4 ualoa a well water analyels for coliform b.ctarL and volatile or&Laic compounds indicate*that the Well is tree
4vm pollution from that facility and the prwace of ammonia altroeaa and dust*aitroQaa Is egUAl to ar Las than 6 ppm
3) ,O/THER
(revised 11/03/95) _
3
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A
CERTIFICATION (continued)
Property Address: 54 Grouse Lane West Hyanni sport ,Mass
Owner: Kings Highway Real Estate
Date of Inspedion6/4/97
D) SYSTEM FAILS:
Yo must indicate ei;r,er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined 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 y
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
x/ Discharge or ponding of effluent to the surface of the ground or surface waters.due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the+distrilbution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the 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 I of a public.well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is I'ess than 100 feet but greater than 50 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 organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as 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
public 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
/7 the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
SYSTEM FAILS
The septic system is in failure because the blockcesspool
is in the neighbors yard. Cesspool must be pumped and filled
in with clean sand. A new title 5 septic repair must be done under
(revised 04/25/97) Page 3 of 10 the 95 code .
SUBSURFACE SEWAGE DISPOSAL 6YSTEM INSPECTION FORM
PART B
CHECKLIST
PsoperVAddrees: 54 Grouse Lane West Hyanni sport,Mass .
for;I Kings Highway Real Estate
Date ct Inepeatba:6/4/9 7
Cheeks if the following
have bean dons:
ZP=ping information — requested of the owner,oocup&at, and Board of Health.
Nona of the System components have been pumped for at least two weeks and the rystam has been receiving normal Oow rau
during that Perms. L-rg++ vob m«of water have not bees introduced into the system reoaa b,or u part of this inspnxioa
-"buik plans havo bean obtained and--mined Note if they are not available with N/A.
ZThe tacMV or de elling eras inspected for signs of sewage back-up.
The does not receive aoa.saaitary or industrial waste Ilow
The site was inspectad for signs of breakout.
xx�u Sy"iam oomPoneac+, azctuding the Soil Absorption System, have been located on the dts.
septic tank man hoist were unr4vared,opened,and the interior of the septic tank was ins
P peeled for condition of baSlea.or
Use,matarial of construction, dit:uiisions, depth of liquid, depth of sludge, depth of satin.
�Tha site and location of the Soil Absorption System on the site has been detesminad based on eodsting information or
aP by aon.intruaive methods.
Tha fU'&d4=i"tV7o'wn" (aid occupants, if different from owner)were provided with information on the proper malatenaaoe of Sub`
Surface Disposal Syatam.
(revised 11/03/95) 4
I V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL: J
Design flow:_MLF.p.d./bedroom for S,'.S
Number of bedrooms: J
Number of current residents: d
Garbage grinder (yes or no):-42
Laundry connected to system (yes or no):_�_11 1_
Seasonal use (yes or no):
Water meter readings, if available (last two (2) year usage (gpd): ._��(�
Sump Pump (yes or no): tgg7- 7 '3md gA�lavS = j�Di S,1 ,�
Last date of occupancy: gb
COMMERCIAUINDUSTRIAI:
Type of establishment:
Design flow: A14 allons/day
Grease trap present: (yes or no)A�4
Industrial Waste Holding Tank present: (yes or no),LY
Non-sanitary waste discharged to the Title 5 system: (yes or no)•A2-
Water meter readings, if availab e:—W/) _
Last date of occupancy:
OTHER: (Describe) A20
Last date of occupancy:
ti
GENERAL INFORMATION
PUMPING RECORDS a d sourc of of rmauon:
�
System pumped as part of inspec for, (yes or no)—j6b
If yes, volume pumped: �/`� allons
Reason for pumping:
TYPE Oj SYSTEM '
_k/ Septic tank/44h46ti�Aoil absorption system
_tea Single cesspool
===i Overflow cesspool
Privy
Shared system (yes or no) (if yes, anach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other _
APPROXIMATE AGE of all components, date instaNed (if known) and source of information:
Sewage odors detected when arriving at the sne: (ves or no)
(reviaod 04/25/97) Page 5 of 10
SUBS'.: . NCE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 54 Grouse La t West Hyannisport,Mass .
Owner: Kings Highw,:.,.-, �eai Estate
Date of Inspection: 6/4/97
BUILDING SEWER:
(Locate on site plan)
Depth below grade:i /
Material of construction: iron K'r1 C: J_ other (ex lft ain) _
Distance from on ate w ter supply well o t;.ur 'Ine U
Diameter
Comments: (condition of joints, venting, e;:.,.: _e of leakage, etc.)
J n ::_._.. _ G-:q ntin is done throu h the vent stack
in side t e house o t),e = .of Vent.
SEPTIC TANK:eddN
(locate on site plan)
�r
Depth below grade:
Material of construction: Zconcrete r: :: _J i ,erglass _Polyethylene _other(explain)
If tank is metal, list age�[4 Is age conLr _enificate of Compliance 0/9 (Yes/No)
Dimensions: . �6" 02��;
Sludge depth:
Distance from top of sludge to bonom of o.,:. ; ;an or baffle
Scum thickness:_
Distance from top of scum to top of
Distance from bonom of scum to bonom or baffle
How dimensions were determined: _
Comments:
(recommendation for pumping, cond�il`r, 1�tlet�teS or b�f PesT,d�pt ofjigj�j� e�ip relation to outlet invert, $tructural
integrity, evidence of leakage, etc.) 1_. J .•YY Inlet tees and
baffles are in place _-eve at outiet invert
Tank ; G struntural lw .r. ..�__—'Tank shows no signs o ea age.
GREASE TRAP:AI We—
(locate:on site plan)
Depth below grade:l9
Material of construction,Zconcrete _ r.e.. _' ,r;lass _Polyethylene _other(explain)
— 4 —22 ..----
Dimensions: ilia
Scum thickness: A>II,
Distance from top of scum to top of ouila
Distance from bottom of scum to bonom of or baffle:A!zt
Date of last pumping:
Comments:
(recommendation for pumping, condition ...,J outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
Grease Trap is not pr' ' . -
(revised 04/25/97) page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddreea: 54 Grouse Lane West Hyanni sport,MasS .
Owner. Kings Highway Real Estate.
Date of twpecu=6/4/97
TIGHT OR HOLDING TANKWM)P(,
(local•on site plw •
Depth below Vw1*:.A?A
Material of ooasesudioa.(L�oo�se��jt+IJ'itPlf�otba�(aplaia) -
Dimensions:
capaciq
Design
Alarm evok llons/da�y
Alarm 1evaL• N�
Comments:
(condition of inlet toe,condition of alarm and float switch",etc.)
riglit or not presen
DISTRIBVIION BOX&We
Gocats an site plan)
Depth of liquid level above outlet invert: A.)rQ
Commaats:
(note if level and distribution is equal,evidence of solids carryover,•vkknoe of leakage into or out of boa,etc.)
Distribution box is not present
PUMP CHAMBER: /e—
(locate on site plan)
Pumps in working ordar.(yes or no)�
comments:
(note condition of pump cbambar,condition of pumps and appartanances,etc.)
Pig rhambPr is nnt, present
(revised 11/03/95) 7 `
C
SUBSURFACE SEWAOE DISPOSAL SYSTEM WSPECTION FORM
PART C
SYSTEM INFORMATION(oontlnued)
Pow+trAdr..s54 Grouse Lane
West H annisport,Mass
Owaart Kings Highway Real Estate
DLie of 1mp'°UQQ6/4/9 7
SOIL ABSORMON SYS= (WA _z
Oocate oa site pla:4 If pot& ;somratioa not rsquirad,but may be approzbutad by aandatruaiw methods)
If mot docmind to be premA ssplalw
Type;
6"him p4 number.J.
6"bla �
66AIn sal6ri6s.
L"hWjtr+aclas,numbar,kagth:—
hLchini meld., nu—be r, °
wsatow oa:syooL aumberG
Commamt.:(mots ooadidan of.oil,aips of hydmulie tanur,3evei of poadla&oonditioa of a.8wt.tioa.ete.)
NonP Of the 9hOvP gre rr sPnt
CEWPOOL6
pocats an sets plea)
NamDsr Lad aoaii�watiori ,
D.ptb of liquid to ialst in 10
oHd /P� 1tl f'i�l) �0d1—� �114✓�
Depth of as lyar.
Depth of sera iy'sr
Dims Skw of""POOL.1SLta:iaL of oaastructba:
Iadiatiaa of Qound�atar:_ ./ .►Ji?
b%aaw(oaspool a"be P M*La part of inspection)
esspoo an es e.:was e wa er. a eave -
Cammaats:(noes oonditioa of soil,dins of hydraulic ww%I"of poadLv&oomditioa of red.tation,eta)
um sand : No signs of Hydraulic failure or
jnn., r j ;QW All irngQ+.q+j ^r j G normal CPS omi e e cess-
pool is. in the neighbors yard.Must upgrade to 95 .code .
PRIVY:A�if/e
aocst.maw PIAW
DeY+t•riLla oonst�tiaa_ .!>/� Dimeaaions:_ !�>r9
pth of
Cammante:(note=dWO'of soil,51P+of bydraulio tal2w.,level of pond4 oond}t;oa of repution,•etc.)
Privy is no presen
(revised 11/03/95)•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
SYSTEM INFORMATION (continued)
Property Address: 54 Grouse Lane West Hyannisport,Mass .
Owner: Kings Highway Real Estate ,
Date of Inspection: 6/4/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
I --- ---------
- ---
---`—
..-.......
----- .
1 _ I
(Ae
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOS.:\L SYSTEM INSPECTION FORM
P,,i\'T C
SYSTEM INFOR:,t:\TION (continued)
Property Address: 56 Grouse Lane West Hyannisport,Mass .
Owner: Kings Highway Real Estate
Date of Inspection:6/4/9 7
Depth to Groundwater,�'�LFeet
Please indicate all the methods used to determine High Groundwater: .:!eva(ion:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, base : -nt sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
2'Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Ground..<:.er Elevation. Must be completed)
We have installed new system at 26 Grouse Lane #87-389
- 33 Grouse Lane # 79-549
46 Grouse Lane # 92-535
67 Grouse Lane # 86-1285
No water encountered at 121 at any of .these locations .
(revised 04/25/97) Pag. :.J of 10
f
•nw..r..-n•r�„r• rwran.•ns���.�n.+�rwn�e++rw►�n+�,u n�w��n�•e+ .�-r..+---..- ..
TOWN OF Barnstable UUARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 54 Grouse Lane West Hyanmisport,Mass .
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Kings Highway Real Estate
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & SQrw ,Inc ,
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE (508 1 775 - 3338 FAX ( 509 1 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system a
this address and that the information reported is true , accurate , and
complete 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 :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
IlealLh 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.
XXXXXXXXXXXX System FAILED*
The inspection which I have con cted has found that the system fails tc
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 .
Inspector Signature Date 6/4/97
One copy of this ce tification must be provided to the OWNER, the BUYER
( where appl ioablo ) and the BOARD OF HEALTH.
+ If the inspection FAILED, the owner or operator shall upgrade ' the ayetem
within -one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 . 305 ,
partd . doc
W I
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF E ONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualificatigns as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the - ton of Water Pollution Control
I,