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0943 PHINNEY'S LANE - Health
943 PHINNEY'S LANE,HYANNIS A= 252 085 i I � i I D D { 1 a VV 4 V s I I I YOU WISH TO OPEN A BUSINESS? For Your Information: . Business certificates[cost$40.00 for 4 years]. A business certificate ONLY REGISTERS YOUR NAME in town(which you must do by M"G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI.,367 Main St., Hyannis,MA 02601 (Town Hall)and get the Business Certificate that is required by law. �, DATE:_(v s Fill in please: d4 .�=� " APPLICANT'S YOUR NAME/S: 2' Ee �� y BUSINESS YOUR I E ADp, SS: Tt PHONE # Ha e Number Z 10� Z x.,errearrrT- _ NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS �C f� IS THIS A HOME OCCUP 0 ? E NO r ADDRESS OF BUSINESS ' /1 m A3Wd L NUMBER S a 2S [Assessing] When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St.-(corner of Yarmouth Rd.&Main Street) t sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING MIS E '07eFFICE This indivi b n oMUST COMPLY WITH HOME OCCU anyp+;it �rtt as, n to this type o siness. UU lI Aut orize g e* RULES AND REGULATIONS. FAILUR d ENT OMPLY MAY RESULT IN FINES. c ; 2. BOARD OF H ALTH This individual h n' r % f the permit requirements that pertain to this type of business T. Authorized Signature* COMMENTS: VMDbUS-MATERIAL-S REG 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS:, a THE ip� Building Department Services .� Brian Florence, CBO o* Building Commissioner �= 200 Main Street,Hyannis,MA 02601. www.town.barnsiable.ma.us Office: 509-962-4038 Fax 509-790-6230 _ Approved:d/g - 0`f,S • Fee: 3 S Permit#: rc 9 HOME OCCUPATION REGISTRATION �-C) 20I V n � , None: Qey. ►_ " 1�" ( Phone Address: ��, tt''� ` ( meu S Ln TK 4 ©•uJL3 Name ofB,:,. s:(2�v—C �(_ CO Type of Business i '� Map/Lot:O5 a—V tS t - o R\rr;NT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation .within single family dwellings,snbj ect to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the•dwelling. there shall be no increase in noise or odor,no vim al alterati.ou to the premises which'would suggest anything Diner than a residential use;no increase in traffic above normal residential volmnes;and no increase in air or groundwater pollnticEL After registration with the Building Inspector,a costommy home ownpation shall be pemitted as of right subject to the following conditions: • -The activity is carved on by the pm=pert resident of a single famrly residential dwelling Mit,located wifhm that dwelling unit. •'" Such use occupies no more than 400 square feet of space. ■ There are no extemal alterations to the dwelling which are not customary in residential buildings,and there is no'outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. ■ The use does not involve the prodnction of offensive noise,vrbration,smoke,dust or other particular matter,odors,electrical disturbance,head glare,lnmmidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flamable or explosive materials,in excess . ofn=;;l household quantities. ■ Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no at56or storage or display of materials or.equipmei#. ■ .There are no commercial vehicles related to the Customary Home Occupation, other than one van or one pick up track not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containmg-Fhe Customary Home Occupation. ■ No siga shall be displayed indicating the Customary Home Occupation. • If the Cbstomary Home Occupation is listed or advertised as a business,the street address shall not be included • No person shaIl bg employed in Ihe,Customary Home Occupationwho is not a pemmenf resident of the dwelling unit, I,the undersigned,ha read tfie above restrictions for my home occupation I amregistering. Applic Date: Homroc.dor Rcv.06120116 . . , . 1 9 Date /�/[ TOWN OF BARNSTABLE ,TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: `.- BUSINESS LOCATION: IYIypy MAILING ADDRES 4� a 4 ,� " � �AL AMOUNT: ° TELEPHONE NUMBER . - R !'•C.� :, CONTACT PERSON: Y} EMERGENCY CONTA T TELEP ONE NUMBER: X - -�,u�7� MSDS ON SITE? Ln TYPE OF BUSINESS: Dkt-4,AMO , INFORMATION / REC MMENDA IONS: Fire District: i i Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/ Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals(Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives.(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar IPCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, �Cfa faint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes pp a Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initial J U z- g ti�U�o� w AD s S F . ; �.. �� {1`�. -.,,,' d � �� ,�� \ W 1 � /P, -eL S' �;.. DATE-:r_7/12/96 PROPERTY ADDRESS: 943 Phinneys Lane [f�I ! V � 7 Centerville,Mass . AU F l 1936 02632 H DEPT. TOWNRNSTA' E. LL 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. 2-1000 gallon leaching pits. based bn may Ins;xectlon, I certify the following condltions: 3 1 . This i ;"�a�T' Zt�ley// e./sept 'c"`'system. ( 78 Code ) 2. The set' c syst�l" conditionally passes. 3 . The newest -pit is not,-functioning. 4. Pipe ;leaves, .side- of..tank is uphill in the septic tank. S . . A distribution box„should be installed and new lines ran from the septic tank to the distribution box and news lines from the distribution box to the two Pre Cast leaching pits . SIGNATURE: Name: J. P .Macomber Jr.. Company:* om an J. P.Macomber & Son •Inc . Address:--B-e-x-bb-----=.�- -,-- --Cente'r_v.-1i'1(e M,a-ss02632 P h o n e:---5Q8__Z7-5=-3338------- .THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-CeupoolrLeachfleld: ..Pumped 4 Instilled Town Sewer Connections P.O. Box 56 Centerville, MA 02632-0066 775.3338 776-6412 � 1 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Coxe GOMM( g—"Y Aryeo Paul Celluccl David/.B.�S{tru�hs tL Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddress: 943 Phinneys Lane Centerville,MA. Addresaofowner. Johanna Dacey Date of Inspection: 7/12/96 - (If different) 100 West:`Main Street Name of Inspector. Joseph P.MAcomber Jr. ``°` Hyannis,Mass. 02601 Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 508-775-3338 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: Casses onditionally Passes — Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's signature: ���yf'X' Dste: 7- l! J� The System Inspector s submit a copy of this inspection report to the Approving Authority 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 the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A] SYSTEM PASSES: �I eI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components used to to replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Winter Street • Boston,Massachusetts 02106 a FAX(617)556-1049 • Telephone(617)292-SSW Prinled on Recycled Paper r 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F'U!Ltd PART A CERTIFICATION (oontinued) 943 Phinneys Lane Centerville,Mass. owner Johanna Dacey Date of ltwp-oi.ior,: 7/1 2/96 BJ SYSTEM CONDITIUNALLY PASSES (continued) Sewage backup or breakout or huh static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced A/0 The system required pumping more than four 6 es 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 C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: —ZleZ_ 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) Sizi'i'L.'XIWILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. A2Q The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is leas than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for ooliform 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. 9) �OTHER r (revised 11/03/95) 2 lil SYSTk:hI i'AI1:5: . {,±r;� 157r!? 'T'F,,;,`.,,'ai'- I have determined that the system violates one or more of the following failure criteriaas defined in for this determination is identified below. The Board of Health should be contacted to determine what wiil bu mess""y to corrwt tho failure. ruiulNnent due to an overloaded or clogged SAS �b Backup of ra waero uuo f::ci.': r R}WV- Static liquid le e! ;_; t!.; .. outlet invert due to an overloaded or clogged SAS or cesspool. Ad Liquid depth in cesspool is few tr-1 ti" i eioµ invert or available volume is less than 1/2 day flow. _"D Required pumping more than 4 t&ues in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil /"sorption System, cesspool or privy is below the high groundwater elevation. iJ is i00 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or prig) t , Any portion of a cesspool or privy is within a Zone I of a public well. xnter supply well. Any portion of a cesspool o.•privy is less 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 FAIIS: The system serves a facility with a design (low of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment to=,ause one or more of the following conditions exist: dLoj the system is within 400 feet of a surface drinking water supply the system is within Lihl i0tu triLuu:,ry to u 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 uwuer or oporuwr of uny 9 _r. . ..ra. d f, y uao full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please coneu It the local regional office of the Department for further information.. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddr"&- 943 Phinneys Lane Centerville,Mass . Owner. Johanna Dacey Date of Inspeotlow 7/1 2/9 6 Check if the following have boon done: . ,Pumping information was requested of the owner, occupant,and Board of Health. one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates d ' that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. built plans have been obtained and examined. Note if they are not available with N/A 2TThe facility or dwelling was inspected for signs of sewage back-up. ;�e system does not receive non-sanitary or industrial waste flow The site was inspocted for signs of breakout. X`AllsysteM components,licluding 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 battles or tens, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. zThe size and location of the Soil Absorption System on the site has been determined based on existing information or ap =Lmated by non-intrusive methods. X1Ae facility owner(and occupants, if different from owner)were provided with information on the maintenance o proper f Sub. Surface Disposal System. a f (revised 11/03/95) 4 SUI)SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION i 943 Phinneys Lane Centerville,Mass . , Johanna Dacey ' 7/12/96 FLOW CONDITIONS . RESIDENTIAL: Design flow:.Y aalllgas x..-A Number of bedrooms: `?� Number of curreat rZd ents: Garbage grinder(yu or no):_ip Laundry connected to ayetsm tr v3 or to): S Soasonal use(yw or no):A&L " n Water meter roadin,^s, if available: �i7 Last date of occupancy:--��2Ki COMMERCIAI./INDUSTRIAI: Type of establirbment: M4 Design flow:��;'lor 'Wzy Grease trap present: (yw cr no) ltf Industrial Waite :,:.k ;•ray a:t, (ye: or no) / Non sanitary wuste d.k0i r7 to the Title 5 system: (yes or no)AO �i`ukr meter A)A- Last date of oocup•an:;v: � OTHEIL(Dascrit.a) , ...,j� Lust date of"Cu GENERAL INFORMATION PUMPING I 'Ci):'. n of info inat' n. �, System pumped a:i part of uupection: (yes or no)dZ If yes, vvls:r,e pu:ucsd: V ens Reason for TYPE, 0 j�Septic Yti3c i , absorption system . 00 Str,j�e 910 ' O•.urf:ow Ally Privy S"-tA .yi. V 4.—"�; ('W yam, a(wch previous inspection rocords, if any) Other --pouezats, date installed(if known) and source of information: Sewage odors detoctod when arriving et the site: (yes or no) _ (revised 11/03/95•) 6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) ropertyAddress: 943 Phinneys Lane Centerville,Mass. wner: Johanna Dacey ate of Inspection:7/12/96 EPTIC TANK:l Pa)9/0G �p�G �r9•i°/� ocate on site plan) epth below grade:1� aterial of construction: concrete _metal _FRP _other(explain) imensions: � ludge depth: istance from to�sludge to bottom of outlet tee or baffleTt2g � , cum thickness:_ istance from top of scum to top of outlet tee or baffler.) istance from bottom of scum to bottom of outlet tee or baffle._./1+�ele, omments: ecommendation for pumping, condition of inlet and outlet tees or baffle,. depth of liquid level in relation to outlet invert, structural �rity, evidence of leakage, etc.) . Pumped tank qypU—t3jo to thrae year 141 A+. & Q;,+T:A+ e.e �z'e in place ;Liguid leyal o autlPt inVAr;b...„s_51tt •The •s'ep:Ljo tanlr2 REASE TRAP. /I/ovte , ovate on site plan) epth below grade:,," aterial of constrortion,jZ ,:oncrete _metal _FRP _other(explain) imensions• cum thickness: istance from top U't scum to top of outlet tee or bahle:!V/9_ istance from bottom of crom f- honour of outlet tee or bafle--)V& r omments: ecommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural tegrity, evidence of leakage, et • ` revised 8115195) 6 TIGHT OR HOLD1NU TANK:_dd!yYC_- (locate on site plan) s Depth below grads:AJfl MatarL,J .. N1 ,: P athar(espLiu�) . AIA, Dimeniions: A24—,—., Capacity: Design flow: _,_gallois/day Alarm levcl: �_., Comments: (condition of inlet toe, coudition of alarm and float switches, etc.) A)Cj N^,.,10-14rr� DISTRIBUTION BOM_A�We (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (n)ts if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) A distribution box. should be installed. One pit is dry and not receiving any wa er. ine leaving +he side of the septic tank is uphill in flow. Install box and diver jSg}�+r .gira_lly to Park 1Par+hi-ng it PUMP CSAMBEIL' (locate on site plan) Pumps in working order:(yes or no) %! Comments: (note condition of pump chamber;condition of pumps and appurtenances,etc.) (revised 11/03/95) r DISPOSAL.SYSTEM INSPECTION FORM INFORMATION (continued) Property Addreoa 943 Phinneys Lane Centerville,Mass. Owner. Johanna Dacey ' Date of I►wpoutic.w 7/1 2/96 SOIL ABSORVI'ION (locate on aite pLiu, i.; -.vation not ruquu..t, bui a ay be approximated by non-intrusive methods) 1 If not determiiy.i t:: '.. TYPe: Leaching pits, number: .x+ leaching chambers, number: leaching galleries, number;= leaching trenches, number,length:� leaching fields, number, dim ions ___......._.-_.._...�_ overflow cesspool, number: a Comments: (note condition of soil, sigma of hydraulic failurv, level of ponding, condition of vegetation,etc.) Sand loam 11 medium sand 111-1 _97Lgns, pf hydraulic failure or ponding: All ireg.P. t8,t.i.On—i-S—nntma1 - Dj_S.tr_i butt nnYmnat ha i na+.All arl - nna =i t i q dry_ nist i}a>atls��aa wJ-11—dix"t--water en>l�'11y to Ga-h, 302abi pit. CESSPOOLS: (locate on site plan) Number and configuration: Aa _...._-- 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 insp&cticn) OA Comments: (note condition of soil, signs of hydra:,lic fl:ilure, level of ponding, condition of vegetation, etc.) 'Id C0VMy,1P1AJrS PRIVY: (locate on site pL.:,) Materials of construction: Dimensions: Al Depth of solids: Comments:, condition of so signs of hydraulic failure, level of ponding, condition of vegetation,etc.) oLlBrl/T� (revised 11/03/5,5) g l ' SUBSURFACE SEWAGE DISPOSiL..SYSTEM INSPECTION •FORM PAkT 8 SYSTEM INFORMATION continued SKETCH OF SEWAGE L_SPOSAL SYSTEM: include ties to at least two permanent references landmarks. or benchmarks locate all wells within 100' Hyannis Water Company 775-0063 "., ter,,..A, bw ij b . s h2uu, �.1-7 b. -��-,,h all LS nth ',s DEPTH TO GROUNDWATER 21 !+ depth' to groundwat r �'✓ hod o.f determinion :or aproxiym,at�o� f • �;�is ' • S EWA G E PERMIT NO. l0 CAT ION �1 s. VILLAGE r INSTA LLER'S � . NAME ; ,& ADDRESS S U I L D E R OR OWNER DATE PERMIT ISSUED ` DAT E COMPLIANCE j„� SUED } do 4 .Sr r .70 cr 7 V 1 I 1� � G �'y b Sb'ly ��1 THE COM MONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications 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 21 A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the -ion of Water Pollution Control _ aura ri+vn 0r:►1A iF1 tii�+vai►u btdirr+ a►w•r.v rVAM rAha u •+ � iit `�'` h..:srh-r•:-::.—T.1IT.-.�TTITRTI'R.'tf►IT.{li•fRl9fTP'RR'r-.l'IriVi'R'7Df11t19•T777rRS7r7�R{ Ititt7l I•I'T'••1T•-11•�.•� -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS _,94� Phi rrAyn Tana (:anteryi l 1 jjQMA ac ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Johana Dac&may PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber .Jr. , COMPANY NAME J.P.Macomber & Sonw'Ihc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City state EIP COMPANY TELEPHONE ( 0 ) FAX ( 508 79O 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 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: •' , XXXXXXXXXX System PASSED Conditionally 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 3101, CMR 160' 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which 1 have. conducted 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 . Inspector Signature Date 7/1'7/96 . ':a-�rrsr�xsrrs—�rsoclr �-t. . , ' One copy of this certification must -be provided to the .OWNER, the. BUYER (where applicable) and the D9ARD OF HEALTH. * If the' inspection FAILED, ' th�e owner or" operator shall upgrade ' the system. within o•ne year of the date of the inspection, unless allowed or required otherwise as provided in 310. CMR 16 , 306 � ' . . . ,, partd.doc TOWN OF BARNSTABLE LOCEa !OiY'J�� VILLAGE ( � �� ASSESSOR'S MAP & LOT H °S NAME&PHONE NO. - SEPTIC TANK CAPACITY e ��� (size) fed �¢fi LEACHING FACILITY: (type) D`�"'"� � � NO.OF BEDROOMS _ cRERNf MATE: � s COMPLIANCE DATE: �f 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 leachin ac' ' Feet Furnished by - " 07, r7 CU s � �1 . U) VIC y i i TOWN OF BARNSTABLE LOCATION � � /OX � SEWAGE # f VILLAGE ASSESSOR'S MAP.& LOT INSTALLER'S N4►'iFe/&P� SEPTIC TANK CAPACITY 1066 4 YID LEACHING FACILITY: (type`—a t�S (size),• 7 NO.OF BEDROOMS "1 ; BUILDER OR OWNER QAh r9�J�4 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: ar Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility. (If any wells exist on site or within 200 feet of leaching facility) Feet Edge'of Wetland and Lea hing Facility(If any well ds exist within 300 feet le n ty) Feet Furnished �.:,`,C % �i Q - Jr UO p J � 1- 4 -LO �C-AT ION SEWAGE PERMIT NO. �H VILLAGE I N S T A LLER'S NAME a ADDRESS s UILDER OR OWN ER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED o © j a �n • �i iv a No.91 ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH . ............ ..........OF...,B.��,y�T. -----•------------................................ ApplirFa#ion for Bhipasal Works Tonotrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: A • actin -Address p � o.Lot o. pN Cov7�n� it/!z iY C /VTg UL�F Own A dress ----•------------ .l �4t ...Hire./...&....-1J Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms_.......................................Expansion Attic e) Garbage Grinder Other—T e of Building -.-.-.----.-.... s.... No. of persons....... Showers — Cafeteria a YP g P ( ) ( ) a Other fixtures -------------------------------• - W Design Flow.............................................gallons per person er ;dons. WSeptic Tank—Liquid capacity-------- ngt ................ Width................ Diameter................ Depth........... x Disposal Trench—No...................... Width_- ............... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- D' t �A) /`'... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Test Results Arformed b .PercolationY-------------------------------------•-------------•--------------------- Date........................................ Test Pit No. 1................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........................ a ........... ---------------------- •-•....................... •...... -----------•---------------------------- •---------------------- •-•----------..._---••-- 0 Description of Soil.................................................................................................................................................------•-•-------••---- x ---------------------------------------------------------------------------------------------------------=----------------------------------------------------------•-------------------•--•-----_...-- U Nature of Repair or Alterations—Answer when applicable-1_ 'Sh?34 _-_-__10,PO..---�Ij�--.--dl/ o.... � . o.... x,cT! , 91:" ................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL1112 5 of the State Sanitary Code— The undersigned further agrees not to place the.system in operation until a Certificate of Compliance has been ' ued by the bo,3d o iealth. Signed .. _..t�, . �........... Date Application Approved BY--- --- ----••----• . --•-------•-- - D to Date Application Disapproved for the ollowing reasons:-------------------------•-•---•-----------------------------------------------•------•---------.........------ .............................................._.....-•---•--............................................................................................................................................ Date PermitNo....... S_..` ............................ IssuedL....................................................... Date AIM No (V........ Fuic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..A.W.W6ZA0.1-4Z- ............................................................. Appliration for Dhipatiat Works Qlott�strurtiott JIrrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at. !.x ...........................................................................................;...... ........ <-eili a n Address ................................. ....Aa pgeza ............ --- ............ .S e ... .. . ... .... A Owndyes .. '*R'r.. . . ................. . .... ..... Installer Address Type of Building -3 Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........................................Expansio Attic Garbage Grinder <'O) Other—Type of Building —----------- No. of persons persons.___.__ ................... Showers Cafeteria Otherfixtures ......................... ................................................................ .............................................................. Design Flow...........................................gallonsper personWidth......._.._._... ................gallons. �n Septic Tank—Liquid'capacity...... per ................ Width.......... ..... Diameter..._......___... Depth................ Disposal Trench—No. ....... ........... Width_ ........... Total Length.....................Total.leaching area....................sq. ft. Seepage Pit No_____________________ D* P�q)- ---7...... Depth below inlet._.._..._..__.__.___ Total leaching area..................sq. ft., Other Distribution box ( ) p I Dosing tank ( ) Percolation Test Results fierformed by.......................................................................... Date................... .......... Test Pit No. 1................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._____......_...._....._ ............................................................................................................................................................. .0 Description of Soil........................................................................................................................................................................ 7--------------*----------------*--------------------*------------------------"I'll---------l-l""I'l""I-111-11Ill-l-,-"""""",-,I------------ -----------------*------*--------------------...........................................................................................................................................................Z------------------ U Nature of Repair or Alterations—Answer whe2 _pplicable./o /'9'049 '7 ...................... . ------------------------------------------....... .................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T IS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been, ued by the boed 9&;health. 01 Signed. ... .. ----------------- ---------------------------- Date--.00*o Application Approved By..- ... ................. ............................................................ ------ ill ........... .... Date Application Disapproved for the, ollowing reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo....... ------------------------------ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL TOU64 T ....................... .....1.........0 F.........P.4i: -.7 ................� ............................ (girtifiratr of Toutphattrr THIS LY TQ CERTIFY That the Individual Sewage Disposal System constructed or Repaired .....sc� by.................A .4% ...................................... ---------- ------- ------------------------ --------------- Installer at........................................................................................................................................................ —............................................ has been installed in accordance with the,provisions of TIME of The State Sanitary Code as described in the Ca application for Disposal Works Construction.Permit No......................................... dated__....__.______________________________________ ter THE ISSUANCE OF THIS Ci6RICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. A AT ATE -------................................. Inspector..—. ................... THE COMMONWEALTH OF mAqSACHUSETTS BOARD OF HEALTH ........... ..................0 F.,44 1.5�0....................................... 4*-W4 1 0#1 ......I.......... FEE.&--� 0hipmal World TDonstrudion Prrmit Permission is hereby granted....14-444-p4l....4...."WAA----------------------------........................................................ to Construct rk,#Repair (41C<an Individual Sewage Disposal Sys I tern t7zj,c at NO-4.14j. ATE Street as shown on the application for Disposal Works Constru tion Pe knit No.....(-RSt- ted -- I> A- a -- ................................. . .... ........ ......... .... -------------------- ----------------------------Board of Health DATE------. .............................. 46c, 'FORM 1255 A. M. SULKIN, INC., BOSTON pl1e� OAT E:,_7/_23/98 PROPERTY ADDRESS: •843 Phinneys Lane —ree1 � ite �% le,Mass . 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 . 2-1000 :gallon leaching pits, ; Based bn my In5oactlon, I certify the following condltlons: 3 . This is a title Five Septic' System':"'(` 78 Code ') 4 . The -septic system is in proper Working order at- the present time. 5 .. The septic tank was pumped for maint. purposes only. SIGNATURr: Name J P Macomber Jr_ ' PMaco �berCompany: ` & Son' *Inc .. _ —Address: '�.' A' J __Cen_ttrvijtAE sj,:_02.632 ` tow, ' 30 pq g • _ Qf Phone:__;508J]-538------- -1 HEAD' 46�6 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY 60SEPH P. MACOMBER & SON,. INC. Tank&-Ces4p,00l&-Leach(1elds Pump+d & Installed _ -Town Sewer Connections P.O. ao'x 66' Centervilld,MA 02632.0066 77.5-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS l/ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO-TECTION ONE WINTER STREET, BOSTON, MA 02108 617.292.$500 WILLIADI F.WELD TRUDY C( Govemor Sccrc ARGEO PAUL CELLUCCI DAVID B.STRI Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissi( PART A CERTIFICATION Johanna Dacey Property Address: 943 Phinneys Lane Centerville Address of Owner: 100 West Main Street Date of Inspection: 7/23/98 ' Mass. (If differenO Hyannis,Mass. 02601 Name of Inspector: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.Macomber & Son INc. Mailing Address: BOX 66 Centerville,Mass . 02632 Telephone Number: 5 f1 R_7 7 S—'j3 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accuratt 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 se age disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fail Inspector's Signature: Date: 7 2 3 9 8 The System Inspe shall submit a copy of this inspection report to the Approving Authority 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 the system owne and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: }I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: One or more system components as described in the `Conditional Pass" section need to be replaced or repaired. The system, upor completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. 10 The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of t_ Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection;,of M the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Dap• 1 of 10 DEP on the World Wide Web: hnp:1twww.m8pnet.sta1e.ma.us/0ep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 943 Phinneys Lane Centerville,Mass . Owner: Johanna Dacey Dale of Inspection: 2 3 9$ BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 611 The system required pumping more than four 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 Cl 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: &Q Cesspool or privy is within 50 feet of a surface water &D Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. r I 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) 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 to 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 IZ14 (approximation not valid). 3) OTHER (roviaed 04/35/07) F:go 2 of 10 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 943 Phinneys Lane Centerville,Mass. Owner: Johanna Dacey Date of Inspection: 7/2 3/9 8 D) SYSTEM FAILS: You 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 No , ,�/' Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. 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 dis ibution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in Gs4&p l is less than 6" below invert or available volume is less than 112 day flow. _ Y Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped D . 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 less than 100 feet but greater than 50 feet from a private water supply well w4h 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. E) 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 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. (rsvSssd 04/2S/97) Page�3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 943 Phinneys Lane Centerville,Mass . Owner: Johanna Dacey Date of Inspection: 7/2 3/9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes N-i� Pumping information was provided by the owner, occupant, or Board of Health. ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal 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 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. L All system components,&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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. ZExisting information. Ex. 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) (15.302(3)(b)J (revised 04/25/97) ?&go 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propeny Address: 943 Phinneys Lane Centerville,Mass . Ohner: Johanna Dacey. Date of Inspection: /23/98 FLOW CONDITIONS RESIDENTIAL: Design floN.,, g.p.dkedroom for S.A.S. Number of bedrooms: Number of current residenls:� Caroage grinder (yes or no).� Laundry connected 10 system (yes or no).2—b Seasonal Ives or no1.� h r QGCJ ater meter rcad�ngs, if available (Last two f11 Year usage lgpct: r Svmp Pump ryes or no):, '.as[ date Of occupant)- COMMERCIAUINDUSTRIAL: Type of establishment:_ Design flow_ VA gallons/day Crease Irap present: (yes or no)AO industrial Waste Molding Tank present: (yes or no)." Non sanitary haste discharged to the Title S system: (yes or no)—N.20 Water meter readings, if available._ Last date of occupancy: OVA OTHER: :Descobei l,Jq Last date of occvpan GE-NERAL INFORMATION PU:HPINC R�EC10RD�eno source of information. System —Pumped as pan of inspection: (yes or no) if Yes, volume pumped: allons l/ � Reason for pumping Jyl� sMIC1s ,1�y�hs• TYPE O TEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or not (if yes, anach previous inspection records, if any) VA Technology etc. Copy of up to date contractl Chher APPROXIMATE AGE fall components, stall (if nOwn) and source of information: _Q111Q1D�iJ� T X S �4 3 oe" Se-age odors detected when arriving at the site: (yes or no) aIV/) f , tr ws.•d 0�/1S/171 ➢400 S of 10 r SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddress:943 Phinneys Lane Centerville,Mass . Owner: Johanna Dacey Date of Inspection:7/2 3/9 8 BUILDING SEWER: (Locate on site plan) Zf Depth below grade:, /� Material of construction: _cast iron Y 40 PVC_ other (explain) Distance from private water supply well or suction line �14 Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) Joints appear tight Nn esdrience of iaaka. System is vented through the �ho use vant SEPTIC TANK:1' ?i`�t V-5 (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass —Polyethylene _other(explain) If tank is metal, list age &s,4 Is age confirmed by Certificate of Compliance&e4L(Yes/No) Dimensions: TVbWX ',OY wwe' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bolt of outlet tee or baffle: How dimensions were determined: s Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity„evidege of leakage etc.) Pum tank Inlet & outlet t aY"e in pll.ace; The septic tank is structurally no signs or leakage. GREASE TRAP:,V�e (locate-on site plan) Depth below grade:AO Material of con struction:41 concreteXAmeta WAF ibergl as s4/h PolyethyleneVAother(explain) Dimensions: Scum thickness: AM Distance from top of scum to top of outlet tee or baffle:-X& Distance from bottom of scum to bottom of outlet tee or baffle:�� � Date of last pumping: r 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 is not present — (rwi&ed 04/25/91) Pay• 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 943 Phinneys Lane centerville,Mass . Owner: Johanna Dacey Date of Inspection: 7/2 3/9 8 TIGHT OR HOLDING TANK:A&—e-(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: RJR Material of constructon;VA concrete-'imetal4A Fiberglass&APolyethylene4l&other(explain) 4 Dimensions: A14 Capacity:_ ,4 gallons Design flow: gallons/day Alarm level: Alarm in working orcleAV LA Yes;4g No Date of previous pumping: _d)A Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or hoiding tanks are not present DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet inven: /1 _ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or,out of box, etc.) Distribution box has two laterals of equal flow.No evidence o heavy solids carry over•No evidence of leakage-,into or out of the distribution box STi4 per/ Al �� �STr•a uT�sa, PUMP CHAMBER:—A&Y, (locate on site plan) Pumps in working order: (Yes or No)_ZJ-41 Alarms in working order(Yes or No)_,g�& Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump chamber is not present. (r.vio•d 04/25/37) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 943 Phinneys Lane Centerville,Mass . Owner: Johanna Dacey Date of Inspection: 7/2 3/9 8 / SOIL ABSORPTION SYSTEM (SAS): Y (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:, leaching chambers, number:, leaching galleries, number: leaching trenches, number,length:—d leaching fields, number, dimensions: 0 overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy boney sand to medium fine sand;No signs of hydraulir, failure or pondinq;All yRgPtat; an i�_ normal. CESSPOOLS:., &V (locate on site plan) Number and configuration: d Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: ti. Dimensions of cesspool: Materials of construction: 44 Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Cesspools are not present Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not present - PRIVY: (locate on site plan) Materials of construction: Dimensions:_ ti Depth of solids:_ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not present (rovis*d 04/25/97) Ys9. 8 of 10 SUBSURFACE SE%'.'AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propeny Address: 943 Phinneys Lane Cdnterville,Mass . Owner: Johanna Dacey Date of Inspection: 7/23/98 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) • Li' I ;r —Woo r O �Aj x 01 1- 4 (e.v1••0 WWII) Y•9• � of 10 r SUBSURFACE SEWAGE DISPG:,-L. SYSTEM INSPECTION FORM Pi:,i!T C SYSTEM INFOR'•l .TION (continued) Property Address. 943 Phinneys Lane Centerville,Mass . Owner: Johanna Dacey Date of Inspection: 7/23/98 r Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting grope bservation hole, basemcr:t'sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groun< 4,1,cr-Elevation. Must be completed) Used water contours map. Gahrety & Miller Model , 1 2/1 6/94 (revised 04/25/97) P49. '160f 10 J ti j s•nnn r•—n.•rsr"r'rrn:mt•nmr.s-rn+r.nnrnr.•r.•fmnrrnnim nrrwa+TOWN OF 130ARD OF HEALTH SUIISURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D.•- CERTIFICATION \— �•••n'17•:-:: -�•..n^•1.T1VRrw.•rrlRi r�TrJR1an'trrr..-•R•t�vrwrY mrmrT'�AfJ.ealvlv*►��s rem n'a.irrlr►stP•rrrm++t:+ai-rr•r+-� -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS _943 Phinneys Lane Centerville,Mass . ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME Johanna Dacey PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Scrfi- Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632. street Town or City :tat t! COMPANY TELEPHONE (508 1 775 3338 FAX ( 508 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system 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 o site sewage disposal systems , ne : :2�steui 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 o: this form . System FAILED* The inspection which I have con acted has found that the system fails t 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 Date7/23'/98 J One copy of this certification must be provided to the OWNER, the BUYER ( where appl icabl e ) and the DOARD Or,11HAL1'11. * If the inspection FAILED, th'e owner or• *o orator shall u P pgrado • tho system. within o•ne year of the date of the inspection, unless allowed or required otherwise as providdd in 3.10 CHR 16 , 306 . partd .do, t w 7 - � s THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby 1 authorized to use the title CERTIFIED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. r S. 1995 Acimy, Dirccior of the l)' ion of Water PUItutio 1 Control