HomeMy WebLinkAbout0502 PITCHER'S WAY - Health 502. Pitcher'a Way
Hyannis P
A 291 020
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SEWAGE INSPECTIONS
LOCATION 502 Pitchers Way DATE 11 /1 6/02
VILLAGE Hyannis,Mass. ASSESSOR'S MAP & LOT
-INSFkFET.OR Joseph P.Maccomber Jr.
SEPTIC TANK CAPACITY NONE 5 ' X7 ' block cesspool with a
LEACHING FACILITY: (type)1000 pit overflow (size) 2500GLS.
MNO. OF BEDROOMS 3
BUILDER OR OWNER Mark Thompson
OWNER MAILING ADDRESS
•Same
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TOWN OF BARNSTABLE
LOCATION �-5W ��CDI��� �I .Y SEWAGE #
VILLAGEy/39k/VS72M AC, ASSESSOR'S MAP & LOT O .;�-6�
INSTALLER'S NAME & PHONE NO.�___
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) I 5' e-
NO. OF BEDROOMS PRIVATE WELL OR ATERBUILDER OR OWNER ; Jq � �i� , 6t f'L /7
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
,
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SEWAGE INSPECTIONS
LOCATION 502 Pitchers Way DATE 11 /1 6/02
VILLAGE Hyannis,Mass . ASSESSOR'S MAP& LOT
-INSPECTOR Joseph P.Macomber Jr.— i
SEPTIC TANK CAPACITY NONE 5 ' XV block cesspool with a
LEACHING FACILITY; (type)1 000 pit overflow
(size) 2500GLS.
NO. OF BEDROOMS 3 I
BUILDER OR OWNER Mark Thompson
OWNER MAILING ADDRESS
Same
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DATE : 11 /16/02
PROPERTY ADDRESS: 502 Pitchers Way
---------- yoka
Hyannis,Mass.
------------------
02601 -._
DEC 1 0 2002
TOWN OF BAi=ZNSTABLE
HEALTH DEPT.
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -5 ' X7 ' block cesspool MAP
2. 1 -1000 gallon precast leaching pit. ( overflow) 6 'X9 ' PARCEL : �2
Based on my inspection, I certify the following conditions: LOT
3. This is not a title five septic system.
4 . This is a sewage system that has had a 1000 gallon leachirigq
pit added as an overflow.Under the 78 code)
5. The leaching pit is presently dry.The stain line on the pit
is 42" below the invert pipe.
'6. The sewage system is in proper working order
at the present time.
SIGNATUR
Name :— J .— P . Macomber Jr .
-- ------------------
COrripany : Joseph P-- Macomte-r & Son , Inc .
Address :__BQx _ti6 -_---_--_-__
---G-en-�2zv_tl- .,-Ma-_QZ-632-0066
Phone: 508- 775- 3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH!P, MACOMBER & SON, INC.
Tans•Cess pool s•LeachfleIds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632.0066
775.3338 775.6412
r\
,per
-\ COMMONWEALTH OF MABSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 502 Pitchers Way
Hyannis Mass.
Owner's Name: MarK Thompson
Owner's Address.Same
Date of Inspection: 11 /16/02
!Fame of Inspector: (please print)JoseAh P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc.
Mailing Address: Box 66
l enf'eYVI 1 1 P -Maw 02632
Telephone Number:5_08-77 — 8
CERTIFICATION STATEMENT
I certih that I have personally inspected the sewage disposal system at this address and that the information reported
below is true. accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
2pptoved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15-000). The system:
`y_j�/Passes
f Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
_ ,Fails
Inspector's Signature: !, Date:
The system inspector sha mit a copy of this inspection report to the Approving Authority(Board of Health or
DE?)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authoriry.
Notes and Comments Drywell for the laundry is being omitted.
Laundry is now going into the sewage system. I
''This report only describes conditions at the time of inspection and under the conditions of use at th~ at `""
time. This inspection does not address how the system will perform in the future under the same or different--
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 502 Pitchers Way
Hyannis,Mass.
Owner: Mark Thompson
Date of Inspection:11 /1 6/0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A Sys Passes:
_ ) I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
,The sewage system is in proper working order at the present
time_ Dry well for laundry has been omitted Laundry now
goes into the sewage system.
B. System Conditionally 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 or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
:L/d erhe a tic tank s metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,ex. ibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
/14 If � Observation of sewage backup or break out or high static water level in the d' tribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properr) Address: 502 Pitchers Way
Owoer: Mark Th6mpson
Date of Inspection: 1 6 02
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,,safety or the environment.
i. System Hill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public bealtb,safety and the environment:
Ud Cesspool or privy is within 50 feet of a surface water
A2 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless.,the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
�0 The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or rributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 104 feet but 0 feet or more from a
prtrate water supple well, Method used to determine distance 1,
' This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nirrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are rriggered. A copy of the analysis must be anached to this form.
3. Other. _
This is a Sewage System nnnGi GtG of 1 _0 X7 ' hl ne-k
c-Pss nnl and 1 —1 000 qn 1 1 nn precast l eacbing as an oviar-flow.
Tha nagrnnnl arrti as a sea t; n tank_ Contains 6A waste
in place and allows-.the effluent tp pass over to the
leaching pit.
3
Page 4 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:502 Pitchers Way
Hyannis,Mass.
Owner: Mark Thompson
Date of Inspection: 11 f 1 6/0 2
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
:Zackup of sewage into facility or system component due to 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 th d' tribution bo bove outlet invert due to an overloaded or clogged SAS or
_ t� cesspool
squid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
f times pumped
y portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
/water supply.
,/_ /any portion of a cesspool or privy is within a Zone 1 of a public well.
!/Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
r
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ _!�the system is within 400 feet of a surface drinking water supply
t�e 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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
.,age : of
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
S UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address 502 Pitchers Way
Hyannis,Macc
Owner: Mark Thompson
Date of lospectioo: , 1+ r1 ti
Check if the following have been done You must indicate "yes"or"no" as to each of the following:
yes No
Pumping information was provided by the owner, occupant. or Board of Health
_Zwere and of the system components pumped out in the previous two weeks
_ ✓ Has Use system received normal flows in the previous two week period ?
✓ Havc large volumes or water been inrroduced to the system recently or as part of this inspection '
Were as built plans of the system obtained and examined? (I(they were not available note as N/A)
was the faciliry or dwelling inspected for signs of sewage back up?
was the site inspected for signs of break out ?
1z— Were all system components,�luding the SAS, located on site
Were t h c4l c tic anholes uncovered, opened, and the interior of the tank inspected for the co.^.Ci::o.-.
c'!ne baffles or tees. material of construction,dimensions, depth of liquid, depth of sludge and depth of scum '
_ Was the facilirry owner (and occupants if different From owner)provided with information on the proper
:rnaintcnance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based or:
Yes n0
!•' Existing -information. For example, a plan at the Board of Health.
G' _ Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of disc=^:c
s ,nacceptab1c) ()10 C►vA I5.302(3)(b))
S
Page 6 of 1 I
,R'
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 502 Pitchers Way
Hyannis,Mass.
Owner: _Mark Thnmpc;on
Date of Inspection: 11 1 6/0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 15.203 (for example: 110 gpd x H of bedrooms):- X)0
Number of current residents:
Does residence have a garbage grinder(yes or no): A49 _
Is laundry on a separate sewage system (yes or no): (if yes separate inspection required) f
Laundry system inspected(yes or no):
Seasonal use: (yes or no):0
Water meter readings, if available(last 2 years usage(gpd)): 2001 —2002=71 , 250 gal lons=1 95. 21 GPD
Sump pump(yes oran
Last date of occupancy:
COMMERCLALJINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15,203):— i? gpd
Basis of design flow(seats/persons/sgft,etc
Grease trap present(yes or no): &(4
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):Ad
Water meter readings, if available: 4114
Last date of occupancy/use: Z34
OTHER(describe): tiA
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as pan of the inspection(yes or no):
If yes, volume pumped: _gallons -- How was quantity pumped determined? .G19
Reason for pumping: ,/a¢
ZIE OF SYSTEM
Septic tank,distribution box, soil absorption system
Single cesspool
Overflow zssspool t A)dr
Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank &!d Attach a copy of the DEP approval
4��Other(describe): _ 1160
App oximat age of all components, date installed (if known)and source of information:
' �6�
Were sewage odors detected when arriving at the site(yes or no);a
6
Page 7ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 502 Pitchers Way
Hyannis,Mass.
Owner: Mark ThQmT_aop
Date of Inspection:
4" Cast iron pipe from the
BUILDING SEWER(locate on site plan) house to 4" Orangeberg pipe
_ 90 to the cesspool. Sch. 40 4"
Depth below grade: / PVC pipe from the cesspool
Materials of construction: cast iron /00 PVC ,,'other(explain): to the l ear-hing pit.
Distance from private water supply well or suction line: lel*'-,,A
Comments(on condition of joints, venting, evidence of leakage, etc.):
jc)i nts appear ti c1ht- _ No Pvi r3PncP of 1 PakngP ThP system is vented
through t__ llh'•e house vents.
SEPTIC TANIIdlocate on site plan)
Depth below grade:
Material of construction:A�Aconcrete,64 meta fiberglass,r�olyethylene
/lJiQ other(explain) 'WIN
If tank is metal list age:/t�4 Is age confirmed by a Certificate of Compliance(yes or no):, (attach a copy of
certificate)
Dimensions: 11A
Sludge depth: A/W
Distance from top of sludge to bottom of outlet tee or baffle: ,d,9
Scum thickness: A?4_ .
Distance from top of scum to top of outlet tee or baffle:
Distanee from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: A
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage, etc.): - ,
Septic .tank is not present Main cesspool should be pumped every
1 �_1 R mnnthG r'ecGpnnl i s structlira 1 1 y crninrl at thi S t i mP T i qui d level
� in the cesspool is 18" below the outlet pipe.
GREASE TRAP (locate on site plan)
Depth below grade:&_0
Material of construction:eAconcrete/I,0metaW/A fiberglas44/,�polyethylene.�other
(explain): A,0
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 4 i4
Distance from bottom of scum to bottom of outlet tee or baffle: "1�4
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present.
7
Page 8 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 502 Pitchers Way
Hyannis,Mass.
Owner:Mark Thompson
Date of Inspection: 11 /16/0 2
TIGHT or HOLDING TANK6?t 2(mnk must be pumped at time of inspection)(]ocate on site plan)
Depth below grade: AM
Material of construction: concrete AA metal V,4 fiberglass&t/ polyethylene !��other(explain):
A)14
Dimensions:
Capacity: Ali gallons
Design Flow: AX/ gallons/day
Alarm present(yes or no): x14
Alarm level:_A Alarm in working order(yes or no): 4,4
Date of last pumping:_A.�ly
Comments(condition of alarm and float switches,etc.):
Tight or holding tanks are not present
DISTRIBUTION BOX /e-(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
rii st-ributi on box is not Present
PUMP CHAMBEW21LI.(locate on,site plan)
Pumps in working order(yes or no): t 9
Alarms in working order(yes or no): 11r9
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Pump nhamhpr is not present
8
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Page 9 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) t:
Property Address: 502 Pitchers Way
T1.yannis,Mass.
Owner:Mark Thofn2 son
Date of Inspection: 11 1 6 02
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not a tired
1-5 'X7 ' block cesspool an- 1 -1000 gallon precastr e8hing pit.
In series.
If SAS not located explain why:
Located- See page 10
YTYP �
leaching pits, number:
leaching chambers, number: e)
40 leaching galleries,number: Cd
i O leaching trenches, number, length: 0
At & leaching fields, number, dimensions: Q
XF overflow cesspool, number:6
ZF innovative/altemative system Type/name of technology:AY& f0FV 4 7�
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
Loamy sand to boney fine sand.No signs of hydraulic failure
orpnndi n4-8'oi. re dr .The leac ing pi i -antly dry .
The stain line ..in the pit is 42 below -
Cast iron in l, co r-`to grade in driveway.
CSSPgOI,$: cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: .
Depth;top of liquid to-t let invert:
Depth of solids layer:
Depth of scum laver. rL
Dimensions of cesspool:
Materials of construction: e
Indication of groundwater inflow(yes ot*no):
Comments (note condition of soil, signs of hydraulic failure, levq;o f o din ,condition of a elation, etc.):
Same as above.The liquid level is 18 Iie�o� the out vlt pipe.
PRIVY (locate on site plan)
Materials of construction:
Dimensions: /f�j►
Depth of solids: --
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.);
Pfivl
is nGt present -
Pf jr IO of I I
OFFIC!,, INSPECTION FORM- NOT FOR VOLVNTtiRY ASSCSSMF,, -:
S085URfACC SEwnCE DISPOSA-L SYSTEM INSPECTION FOB„
PART C
SYSTEM INPORM.aTION (conalnvc0)
502 Pitchers Way
.is, as 97—
Mark T n 'dTr—
�r r OI Inipici 00: 1 6 02
SK-'TCH OF SEwnCC DISPO AL SYSTCM
AO ,Orr itri(h Of inr rr..r Ir oilporrl Iylicm IncIVO(n; II(J 10 II It(ll (w0 Ptrm4ncnl fc((rant< It1a
to(ur iu ..rni -.1h.A 100Irn LOcm what pvbI't w"" IVpPIy (Alan Ihr bvilo n(
•
5az TITC�tfs way �}�an�cs
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01
3 �
WO*�!
10
Page 11 of 11
- .r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 502 Pitchers Way
Hyannis,Mass,
Owner: Mark Thompson
Date of Inspection:1 1 /1 6/o 9
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 9feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record - If checked,date of design plan reviewed: NA
YES Observed site(abutting property/observation hole within ISO feet of SAS)
NO Checked with local Board of Health-explain: NA
yF.S Checked with local excavators, installers-(attach documentation)
yFS Accessed USGS database-explain: http; //town, barnstable,us.ma.
You must describe how you established the high ground water elevation:
Used: Gahrety & Miller ModP1 _ 12/16/A4 Ground water elevations
above sea level.
Used; USGS: Observation well data. June 1992
Ysed: USGS: Technical bulletin 92-000-1 Plate #2 Annual ranges of ground
Moundwater elevations. January 1992
Leaching
Pit 'eel
Groundwater. 1:eet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
All,W '
Therefore, the vertical separation distance between the bottom-,
of the leaching pit and the adjusted groundwater table is
A
feet.
11
`"T.1T^A'R�'1'T' . lr'.- ITP.•TrIT•"•.T•�PT:TrTi'1•'1 iTs1Z:1Y'�'i�TL.T� .�� ��..._. �..,,
TOWN OF Barnstable WARD OF HEALTH
SUIISURFACF SF.HACF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I•.•—••s•�•..-•. •—r.ur.^.-.rn.r..—n'n:*Ti err.rr.rrrTr-.'—•.��i.-+ri.-nrrr TT+rrR..-'+s rrr�nrnarrw•+er� n•n.r�+smatser.r'�r+n•.—.rre•-•r•�. A
0 -TYPE OR PRINT CLEARLY- -
PROPERTY INSPECTED
STREET ADDRESS 502 pitchers Way HyannisM)ass
ASSESSORS MAP , BLOCK AND PARCEL
OWNER ' s NAME Mark Thomp' on
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr
COMPANY NAME Joseph P. Macomber &won Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Strest Town or City State t I P
COMPANY TELCPHONE ( 508 ) 775-3338 FAX ( 508 ) 790-1-578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of .-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site- sewage disposal systems .
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 16 - 303 , Any failure
criteria not evaluated are ns- stated in the FAILURE CRITERIA section of
this form ,
System FAILED$
The inspection which I conducted has found that the system fails to
Protect the 'public health and the environment in accordance with Title
5 , 3.10 CFIR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature - Date
copy of this certification must bepOnd
Where applicable ) and the 130AIlD 01r 11LAL1°vided to the OWNER, the BUYER
* If the Inspection FAILED , tht owner or" 'pie rator shall upgrade ' the system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 ChIR 55 . 305 ,
partd . doc
31
pp
No.JFee--- - --�---
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applicat ion-*r Vell Cootruct ion Permit
Application is hereby made for a permit to Co ruct ( ), Alter ( ), or Repair ( an ' dividual Well at:
------------------------- - ----
Location — Address Assessors Ma and Parcel
JJ M
Owner Address
Installer — Driller Address
Type of Building
Dwelling—�ZQ—_t��_✓_--------------------
Other - Type of Building No. of Persons--------------_____---_____
/bi
— — —— —-- —___ -- --
Type of Well-_7_= c uc L
--_-------------------=----------------- Capacity----___--------
Purpose of Well--11-`-J --x - -------- -_
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certifigate of CompDance has been issued by the Board of Health.
�,�
Signed - -�- --
date p
Application Approved By- —(� _/D - -/ �-
_--__—_-=_ date
Application Disapproved for the following reasons:-----------------------______________:______.____—_______ ___--
----------
date
Permit No.-- - ------ ----- Issued-----_------ date -- -
BOARD OF HEALTH
TOWN OF BARNSTABLE .
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
b ` �__ �, = - ___-- - -- —--------------------------------------------- -_----------- -- -
y___-____ - Installer
has been installed in accordance with the provis`ia>Pts of the Town of Baiv�tstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. Dated---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----------—-=___- —__ ----- Inspector—_-- --- -— -
♦ t`Y +
No.--- i2= x _ Fee 1 -�----
- -- - -
' BOARD OF HEALTH
TOWN OF BARNSTABLE
ZippYitation' -forWell Con.9tructionpermit
Application' is hereby made for a permit to Construct ( ), Alter ( `), or Repair ( )an individual Well at:
Location — Address Assessors Ma and Parcel
----------------- --------------- -- - — — —--
_� Owner Address
------------ -------------- --- - -------------
_ Installer — Driller Address
Type of Building
Dwelling --------------------------------------
Other Type of Building -- - - - - No. of Persons--------------------------------------- -
Type of Well-_ ?-`-?r�=� a'' ----------------------------- Capacity--------------------------
Purpose of Well----- --------------------------�
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed--_.--_--=-'�,..-.-----�'------ -��':l�i -,�------------- ----
�� _ d-t
Application Approved By-------�0_�'
date
Application Disapproved for the following reasons:---------------------------_---____---------_------_________—__—_______�_�_
-------------------------------------------------------------------------------------
date
~ - Issued
Permit No.--------�-�'�---�-!-----------------
v� �-�s- s
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate Of Compliance
THIS•IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
by----------- ----- - may:;= :-------------------------
----- - - = - -- ---- -
Installer
at- --- i_ c1- - - I i,+-�" -1 �-----------------------------
, d•�'r •��-=�= - -- - --- - ---Y
has been installed in accordance with the provisions of the Town of B stable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. Dated-----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------------------------------------------------------------------------- Inspector-------------------------------------------------------------------------
BOARD OF HEALTH'
TOWN OF BARNSTABLE �
Well Con5truction3permit
No. ----�AI-- a Fee-
Permission is hereby granted -=------------------------------------------------------------------ ---------------
to Construct (>e)°, Alter ( ), or Repair ( ) an Individual Well at:
Street -
as shown on the application for a Well Construction Permit
No.----------------------------------------------------------- - - - Dated
--------------
- r
90ard of Health
DATE----___________-------______------------------------____--