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HomeMy WebLinkAbout0001 ELMWOOD CIRCLE - Health I Elttw dod Circle f� c6itat A '010-029 i �11 vt�o UPC 10230 g No�H1693 UAOfl[M tW r _ _ .�// � � TOWN OF BARN-STABLE LOCATION / SEWAGE# VILLAGE l t� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY JL M LEACHING FACILITY: (type)A'lm& (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetland exist within 300 feet o le ng ty Feet Furnished by 10 M 7V TOWN OF BARNSTABLE LOCATION_ i U1Q SEWAGE 94-3 86 VILLAGE ASSESSOR'S MAP & LOT0/f0, Jd�2 INSTALLER'S NAME PHONE NO. � �'la(t c x) SEPTIC TANK CAPACITY /GD6 D LEACHING FACILITY:(type) 1- Q�l. (size) /6®d NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: * DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No e c _ 32- a13 — 0 - � S'i ® -3 :—E= 3:5 ,r TO',,IN OF 7-.'.`:!STAr1LE ni 6 P"13: 17 1 ! lk AL ,M �• Ami PIP t� ' ..�41C ` ♦"'� '� �,,, ��'7 y� ; � its ,�! � v f r % i � 4 1 ; � ,�$ Iy��� / Off' 1 r ` � �.. t � .,. . �` '�` _ ., �� �, . 1 f http://www.sandwich.kI2.ma.us/forestdale/staff.htm 2/8/2010 D Win1L'f�ul ' m CD a Postage $ Ln Certified Fee tm 01_Postmark 6Q O Return Receipt Fee C Here p (Endorsement Required) Q 9 Restricted Delivery Fee (Endorsement Required) m vv" f'U Total Postage&Fees . M r05 Se tTo CD p �. a_ _ - �-✓_��:_L.l — O Street Apt.No., or PO Box No. G (� city,State,ZIP+4 n of l— y��1 O -2 � ,�'" :rr r�. /`/l7JJ Q) Cif Certified Mail Provides: la A mailing receipt o A unique Identifier for your mailpiece c A record of delivery kept by the Postal Service for two years Important Reminders: n Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile. o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorsemailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery': o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS.Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 �� m co F• L N� N rI Postage $ Ln I Certified Fee C 0) D rU N Postmarld's O O ReturnReceipt Fee Here W ti p (Endorsement Required) S OOj Restricted Delivery Fee 0 (Endorsement Required) m nJ Total Postage&Fees m CEI Sent To or PO Box No. W�//�� -----------------------1g• `' 0C=___ - City,State. '4 4� Certified Mail Provides: c A mailing receipt *A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years importnt Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail& � o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain;Retum Receipt service,please complete and attach a Return Receipt(PS,Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"RestrictedDefivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. if a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530.02-000.9047 i L �I SEND. OMPLETE THI ECTION ■ CompletD items.I j 2,and 3.Also complete A. Si ur item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse Addressee so that we can return the card to you. g. Recei ed y(Pin ed e) C. Date of Delive ■ Attach this card to the back of the mailpiece, Q a d f�0 or on the front if space permits. v ry D. Is delivery address different from item 1? ❑Yes ! 1. Article Addressed to: If YES,enter delivery address below: ❑No I 1�— / 3. Service Type ZCertified Mail ❑Express Mail ❑Registered )ff Return Receipt for Merchandise I (� 3� ❑ Insured Mail ❑C.O.D. ! 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service labeq . - 7 0 0 2 10 0 0 _.0 0 0 4 _6 6:83 14 3 3 PS Form 381 1,August 2001 Domestic Return Receipt 102595-02-M-1540, I UNITED STATES POSTAL SE RV �� °� "`�"^^ First f;asks Mai ° Postage`9 F969-Paid US?S..- Permit=Nd.G-40-- j • Sender: Please priJ an e, address. Zi 44n-th�s.=box� a cryyv�i T ; rn rn lt� m F F I C I A L E m -n Postage $ rJ Certified Fee a .�.J� p� t9 N Pgstinark t3 Return Receipt Fee Q Me t3 (Endorsement Required) . 7 -5 --- i- p Restricted Delivery Fee U) O (Endorsement Required) O H Total Postage 6 Fees $ � / ru Sent To � w�� C3 -----------�--(----2------------------------------- �----------- No. Street,Apt.No. or PO Box No. ,Sae, — C 3 ---State Z�e+� --------------- ----------- :�� �� Certified Mail Provides: o A mailing receipt n A unique identifier fortour mailpTece r- . o A signature upon delivery ` o A record of delivery kept by the Postal Service for two years Important Reminders: n Certified Mail may ONLY be combined with First-Class Mail or Priority Mail 1, o Certified Mail is not available for any class of international mail. w o NO>INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. n For an additional fee,a Return Receipt may be requested to provide proof of, delivery.To obtain Return Receipt service,please complete and attach a Return- Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece `Return Receipt Requested".To receive a fee waiver for. a duplicate return receipt, a USPS postmark on your Certified Mail receipt;is' required. '- � o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arti= cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,April 2002(Reverse) 102595-02-M-1133 J J i 1 1 i 3 ti r DATE: 6/9/99 PROPERTY ADDRESS: ----------------------- 1 Elmwood Circle ------------------------ Cotuit, Ma, ------------------------ 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 O /© 0 A 2. 2-1000 gallon leaching pits. 3. 1 -Distribution box Based on my inspection, I certify the following conditions: 4 . This is a title five septic system ( 78 code) 5. The septic system is in proper working order at the present time . 6 . Pit # 1 Waste water is 7" below pipe . 7 . Pit $ 2 Waste water is 6 ' below pipe . 8 . Pit #1 is 12" below grade . 9 . Pit #2 is 18" below grade . SIGNATURE:1 Name:__~ _ Company: Joseph_P. Macomber—& Son , Inc . Address: Box 66 -------------------- Centerville , Ma. 02632-0066 -------------------- Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY 9 JOSEPH P. MACOMBER & SON, INC. co� JU Tanks-Cesspools-Leachflelds N 6 1999 Pumped & Installed ro"OF N Town Sewer Connections® vw P.O. Box 66 Centerville, MA 02632-0066 i ,` 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY COX $ecre'a ARGEO PAUL CELLUCCI D.wTD B. STRI,': Governor Co-_: cc, SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART A CERTIFICATION Property Address: 1 Elmwood Cicle Narna of Owna. Tracey Jillson Cotuiitt Address of ownw: Same D" of lnspection:�9 Q / Prt Name of 4upector: a rrt) Joseph P. Macomber Jr. 1 am a DEP approved system Inspector pursuam to Section 15.340 of Title 5 (310 CMR 15.000) CornpanyNaaw: Joseph P. Macomber & Son, Inc. Ida.MN Address: Box 66, CPntPrVi 1 1 e, Ma _ 02632-0066 T, apt—Number:5 0 8-7 7 5-3-1 R A CERTIFICATION STATEMENT I certify that I have personally Inspected the &@wage disposal system at this address and that the Information reported below is true. accurats and complete as of the time of impaction. The Inspection was performed based on my training and experience in the proper Function ano maintenance of on- it s wag@ disposal systems. The system: lasses Conditionally Passes Needs Further Evaluation By the Local Ap roving Authority Fails trsspectoe'& Signatu / r Data: The System Inspecre: all subm hit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)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 ano the system owner Mall submit the report to the appropriate regional office of the Department ohfnv'uonmental Protection. The original should ba sent to," system owner and copies sent to the buyer, It applicable, and the approving authority. NOTES AND CONIMENTS i I revised 9/2/98 Page I of 11 Cd P(mlod on P."lad P.psr f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Elmwood Circle, Cotuit Owner: Tracey Jillson Data of Inspection: 6/9/9 9 INSPECTION SUMMARY: Check A, B, C, o/ A A. SYSTEM PASSES: l� i have not found any information which Indicates that any of the failure conditions described in 310 CMR 13.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: �vr r 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. Indicate Ye0,no,or not determined(Y, N, or NO). Describe basis of determination In all Instances. If "not determined", explain why not. The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was Installed within twenty(20) years prior to the date of the inspection; or 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 complying septic tank as approved by the Board of Health. 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). broken pips(s) are replaced obstruction is removed distribution box Is levelled or replaced - The system required pumping-more thanfour-times a yeardue to broken or obstructed pipe(s). The system will-pess-- inspection If(with approval of the Board of Health): - - broken pipe(s) are'replaced obstruction is removed I I revised 9/2/98 page 2orii r SUBSURFACE SEWAGE DISPOSAL SYSTE-M 1NSPECTION FORM PART A CERTIFICATION (continued) Prw-wAddraaa: 1 Elmwood Circle, Cotuit Ovvn.r: Tracey Jillson D"01 4up.c-tlort: 6/9/9 9 C. FURTHER EVALUATION LS REQUIRED BY THE BOARD OF HEALTH: Cond)dons oxlst which require further evaluation by the Board of Health In order to detormine If the system Is failing to protoct the public health, safety and the environment. 1) SYSTE3d W11-L PASS UNLESS BOARD OF HEALTH DETERMINES INACCORDANCE WITH 310 CJ.IR 16.343 (1)(a THAT THE SYS LS NOT FUNCTIONWG W A{.TANNER WH)CKYAUPROXECT THE PUBUC HEALTH-AND SAFETY AND THE DC BORMT: Cesspool or privy Is within 60 feet of surface water Cesspool or privy Is wlWn 60 foot of a bordering vegetated watiand or a salt marsh. 2) SYSTE3d WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUSUC WATER SUPPLIER. IF ANY)DETERMINES THAT THE SYSTE3 FUNCTIONWO W A!.TANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIRONJAENf: eo The system has a &optic tank and soil absorption system(SAS)and the SAS Is within 100 foot of a surface waist supply tributary to a surface watst supply. The system has a septic tank and &oil absorption system and the SAS I& within a Zone I of a public water supply wall. The system has a &optic tank and &oil absorption&y&tsm and the SAS 1& within 60 feet of a private waist supply wall. The system has a&optic tank and toll absorption system and the SAS Is less than 100 fist but 60 foot or mots from a private water supply wall,unless a well water analysis for coUlorm bacteria and volatile organic compounds indicates tha well It flea from pollution from that facility and the pro once of-ammonia nitrogen and musts nitrogen I& ►qv&J to or Iasi than 6 ppm. Method used to determins distance- (approx)mation not valid).- 3) OTHER WWI revised 9/2/98 Page Iof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Elmwood Circle, Cotuit °wear Tracey Jillson Data of Inspection:6/9/9 9 D. SYSTEM FAILS: You must Indicate either "Yes" or "No" to each of the following: _JLIZL I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination Is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup o(•"Wage irrtoiacilitywr•rfatem component dueKo an overloaded orcIogged-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 distr utlon f,Lox above outlet invert due to an overloaded or clogged SAS or cesspool. t �1►i g (e — � Liquid depth inn t>vi-9eespod s 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 less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the wall 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" 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 (eat of•$•Hibutary-io a ourfao"i;nk;"g•wate-oupplY ••• - --- the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area -IWPA) or a mapped Zone ll of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII i r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ProPanY Address: 1 Elmwood Circle, Cotuit owner: Tracey Jillson Data of Inspection: 6/9/9 9 Check if the following have been done: You must indicate either 'Yes" or 'No' as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. -None of the systemcoff-4 nts.kau&;b"n paatped+topatleast nvo•we&"arse the'rystem hasbaaasecsiuiag.ws.ul flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as pan 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 slgns of sewage back-up. The system does not receive non sanitary or Industrial waste flow. _ The site was Inspected for signs of breakout. All system components,4*cluding 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 baffle: or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C Is at issue, approximation of distance is unacceptable) 115.302(3)1b)i _ The facility owner.(and.or—paots,Jf difiarerlt infor "on on thA pfoper maintan �f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 l i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 Elmwood Circle, Cotuit Owrw: Tracey Jillson Date of Inspects«,: 6/9/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: 11b g.p.d./bedro Number of bedrooms(desig ): Number of bedrooms(actual):,': Total DESIGN flow t Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (q es 0r(a9):_;. If yes, separate lrtapection.required Laundry system Inspected es or no) I �(0I W08CAI)MS Seasonal use(yes or no): I _ (J �/ Water meter readings,if av liable (last two year's usage(gpd): s — 7/®+pl Sump Pump(yea or nc):7� Last data of occupancy: COMMERCIAUINDUSTRIAL: ''II Type of establishment: Ni Design flow: d ( Based on 15.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present:(yes or no)ATff- Non-sanitary waste discharged to the Titit9P system:(yes or no� ��((ff Water meter readings,if available: - Last date of occupancy: OTHER:(Describe). Last date of occupancy:_ GENERAL INFORMATION PUMPING RECORDS and sore inform 'on: fo UM Li 4& 6 System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM iTighSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous Inspection records,If any) I/A Technolog at . Attach copy of up to date operation and maintenance contract t Tank ! '�L—Copy of DEP Approval Othqr PROXI AGE o �l components, date instal(ed{if known)-and a2grce.•of4aforrnation: ` Sewage odors detected when,arriving at the site'(yes or no)zw revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropoexyAll: 1 Elmwood Circle, Cotuit O wr": Dou of Irspectioru Tracey Ji llson 6/9/99 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of co truc 'on:AMcost Iron PVC that(ex p In) Distance from �Ivate water su ply well or auction Ilne Id Diameter _ _• Cmments:(condition of Joints, venting, evidence of 4"kage,-etc.) Joints appear ti SEPTIC TANK: (locate on sits plan) Depth below grade:'f Material of construction:.L/Concrste_metal_Fiberglass _Polyethylene_other(explain) It tank is metal,list age 1s.age.confirmad by Certificate of Compllancs (Yss/No) Dimensions: r i �' ,����® J�j/<.0 Sludge depth: Distance from top o s.ludgo to bottom of outlet too orbaffle: Scum thickness: �J Distance from top of scum to top of outlet tee or baffler l (f Distance from bottom of scum to bottom of utlet tee or atfle:_� How dimensions ware determined: Comments: (recommendation for pumping, condition of Inlet and outlet tees or•batfles, depth of liquid level In relation to outlet invert, suucturb�-ntegrity evidence of leakage, etc.) PumD tank Pvar�4 ;riaa cr. _ Ti;Let otit -- tees are in 1 ift snows no GREASE TRAP: " (locate on sits plan) Depth below 9rade:A1y Material o!consvuc 'o /�,�concretmstaFiberglasaaJ�Polyethylene1bther(explain) Dimensions: Scum thickness: Distancs from top of scum to top of outlet too or batflo:" Distance from bottom of ac to bottom of outlet tee or.batfle:x441 Date of last pumping: Comments: (recommendation for pumping,condition of Inlet and outlet tees or baffles, depth of liquid level In relation to outlet Invert. structural integrity evidence of leakage, etc.) Grease revised 9/2/98 Page 7orIf f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropeMAddre": 1 Elmwood CIrcle, Cotuit own": Tracey Jillson Date of Irupection: 6/9/9 9 TIGHT OR HOLDING TANK;A/,Me(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade: Material of constructionAt&concretwvAmetaWAFiberglas*IAPolyethyleneaother(explain) ,fA4 Dimensions: tjW Capacity: /V gallons Design flow: gallons/day Alarm present Alarm level: Alarm In working order:Yes / NoA�4 Date of previous pumping: 4,W _ Comments: (condition of Inlet tee, condition of alarm and float switches, etc.) Tight or hutdilig Lanks are nor- re DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet Invert: �lJ Comments: (note-if level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) — — Distribution box has two laterals Nn ayidpnrp of enlir(c rarry aver PUMP CHAMB ER:4410— (locate on site plan) Pumps in working order:(Yes or No) AIA Alarms In working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) ump chamber is not present I revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Elmwood Circle, Cotuit Own": Tracey Jillson Date of Inspectw: 6/9/9 9 �� ,,��j SOIL ABSORPTION SYSTEM(SAS):,�'0Q6�y��V X_QA "4 (locate on site plan,if possible; excavation not required,locatlon may be approximated by non intrusive methods) If not located, explain: Type: - _- — —- - - leaching pits,number: leaching chambers, number: leeching galleries,number:_ leaching trenches,number,length: leaching fields, number, dime A}fons: overflow cesspool, number- Alternative system: Name of Technology: 6 Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to fine --ad -No signs of hydiattije f ii Or Gndi n nos Seils are dry . VugecdCtun is orma CESSPOOLS• (locate on site plan) Number and configuration: (l 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 Inspection) Cesspools are not rPgant Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of.vegetation, etc.) Cesspools are not nrPgant PRIVY:�i��i (locate on site plan) / Materjals of construc on: �� Dimensions: Depth o1 solids: Comments: (note condition of soil, signs of hydraulic failure, revel of ponding, condition of vegetation,etc.) Privy is not present _ revised 9/2/98 . Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFOR1dAnoN (contr&,od) PT0q.nyAd&"4: 1 Elmwood Circle, Cotuit 0%wr-W. Tracey Jillson cou or V'LP.C'6�: 6/9/9 9 SKETCH OF SEWAGE OLSPOSAL SYSTEM: Includs tl&s to atlaast two psrmansnt rslsrsnca landmarks or benchmarks louts all wills wlWn 100'(Locats whits publIc w►tsr supply comas Into hours) 0 revised 9/2/98 Poll 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Elmwood Circle, Cotuit owner: Tracey Jillson Dots of Inspection: 6/9/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Data website visited Observation Walls checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 3�Feet Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site (Abutting propert observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps cked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahre++ty & Miller Model M revised 9/2/98 Page 11of11 r `f•IT.nT�ntTfr'.T�\fflr J.A'n1.RT'AnlTl�R1\T•I1n/R/TI"t'11T MR.IJ M1V'n'.\I1.T .��-4'n-�..�. r-..., I TOWN OFBARNSTABLE BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL .SYSTEM INSPECTION FORM - PART D •- CEwrI FiCATION �_ h-•an-�••.-::.—r..n�.rrr��rn.-n.��rr�raw�rnr..-xt.�v'w.• ww+.r-r+�+�r�vrt►+w.�.mrnr� mnn�mr+.'.mm+.'...,•,.•..-r�•r•-• _..• �-TYPL OR PRINT CI.EARLY•- P110PERTY INSPECTED STREET ADDRESS 1 .Elmwood Circle, Cotuit ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Tracey Jillson PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber- Jr. COMPANY NAME Joseph P. Macomber & Son, Inc. COMPANY ADDRESS Box 66, Centerville, Ma. 0263.2-0066 strvvi Town or City Stat. LIP COMPANY TELEPHONE (508 )775 -3338 FAX ( 508 )790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that t)Ye information reported is true , accurate , and complete as of the time of ,inspection . The inspection was performed and any recommendations vegarding 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 : —/Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined 'in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* Tile inspection which I have conducted has found that the system fails to protect the }-)ublic 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 . ep Inspector Signatur r Date One copy of this &6rtification must be provided to the OWNER, the BUYER ( where applioable ) and the BOARD OF iiEAL1'li: If the inspection FAILED, the owner or op rator ahall u� p pgrado ' tho ayotem Within one ,year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 16 . 306 . partd • doc No.. ..33 Z . ,-o l Fa�.....(..J............... ...... _.._. THE COMMONWEALTH OF MASS ACHU ETTS + BOARD OF HEALTH ...... ---.._.OF...f3Clt,1.J..'.�✓�A0............................................. Appliratiuu -fur Dispaiial Workii Tonstrurtiuu Prrutit V/ Application is hereby'made for a Permit to Construct (P<) or Repair ( ) an Individual Sewage Disposal 10Sys ......1------------------- ----- ....--- •...0a-_C'a,:-t o' Location- d orLNo. 6ifere.a. -----------------•--•--------------•-•--•---•--•-•--- a7 r oar e J'�rW�t `' Address Installer Address Q Typ uilding �` Size Lot--- o` U---------Sq. feet U Dwellin No. of Bedrooms.................1`F'---3---------.----Expansion Attic (hp) Garbage' arbage Grinder (�� aer—Type of Building ---________________________ No. of persons-_----.-------_----------_ Showers ( ) — Cafeteria ( ) Pa Other fi_ ures ------------------------------ ---- ------------------------------ DesignW Flow-------------____0......._.............gallons per person per day. Total daily flow---- -_______.__-..__.._. .........gallons. WSeptic Tank—Liquid capacitv._/gallons Length---------------- Width................ Diameter---------------- Depth-.--.-----.-._. x Disposal Trench—No________________-.- Width-------------------- Total Length--_-_____-___--_--- Total leaching area--------------.---..sq. ft. Seepage Pit No........../----_____ Diameter....... - Depth below inlet.................... T tal leaching area..--_---._--_-_sq. ft. Z Other Distribution box (� Dosing tank ( ) Gh - ^C�-._ 9V 15 - 7 7 Percolation Test Results Performed by---------------- --------------------------------------------------------- Date--------------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--------�Y_0--------- ri Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ ------- - ----------------- Descrt tion of Soil---••--� f 'r r'�' = 1 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable_-------------------------------------------------------------------------..------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igne ------------- ----------•-- .--- -------------------- - ................................ Date Application Approved By.......-- ............ -• ......... --••-•-•. =......'L- ate --------------------- Date Application Disapproved for the following reasons:-•-•---•------•------------------------•--------------------_---------------------•--•-••-• .................... ..........................................-........................................--•-•--•-•--------•---------.....---.....---.......-•---------•------.---------------------------------------------- ------•---- ------------- Issued------ Date Permit No.._.._3_. -- Date No.......?..........:... Fink ..1.��................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF--- ?' ................................................ Appl ration -for Diapooat ork,s Tonmtrnrtton Vrruift Application is hereby'made for a Permit to Construct (y<) or Repair ( } an Individual Sewage Disposal Syst n at: // / Location- ddress or otf _ ��5'.. !� P" 4!/�?vIE . �a x..._.�'tic................. ......-��d?!•E'ft�r1�.. r.---•-No----.._..-- er Address Installer "' .,;y: Address p d Ty wilding `� � Size J<:of_�_d'_,,:........... ......Sq.-feet Dwellin No. of Bedrooms----------------- .. _ ---_-.__ Expansion Attic (?O) . Garbage Grinder (&a ier—T e of Building ____________________________ No. of persons............_.. -_ Showers Cafeteria _ Q Other fiWures --------------- ------------------------------------- -- --....------•---------- ----------------- ---- --- W Design Flow_____________�.? __-..gallons per person per day. Total daily flow._._ -� .........gallons. P4 Septic Tank—Liquid capacity- gallons Length---------------- Width................ Diameter-----.---------- Depth--- ------------ xDisposal Trench—No- -------------------- Width-------------------- Total Length----__--__-__..-_--. Total leaching area--------------......sq. ft. Seepage Pit No.......... ...:..... Diameter___-- �. Depth below inlet_..___:__;_:__..... TQt�al Machin ----------------sq. 1t. Z Other Distribution box ( Dosing tank ( ) lj ^r "✓ " 7 ' a Percolation Test Results Performed bY------------------------------------------------ .......................... Date---------•------------------------------ ,� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...... 0.--_.___.. rX Test Pit No. 2----------------minutes per inch Depth of Test Pit-----................ Depth to ground water_.....----_------__-.._. �! - '>r . O z; �- Descri tion of Soil-----.. _ .. ] ��" l s a !t " - ------' - --- ------ (xj ... all ---- :r ;�>l ----------------------- :-- :rr UNature of Repairs or Alterations—Answer when applicable...---_........... ...._---.-_-. ._--- _-.--------. . . ----------------------------------------------.-.-_--.---_-__-_---------------.-----_----._--___---_--_.-__-----:---___.--..__---_--.-_--_----___--.-__-------..-_.-=:--.-----.--..--_-.-_-_--___-_-_.._. Agreement: The undersigned agrees to install the aforedescribed Individual 'Sewage Disposal System in accordance with the provisions of Article XI of the Stafe'.Sanitary.Code—The,unders further agrees not to place the system in operation until a Certificate of Compliance.has been issued by the board of health. gnecf� � e° ... ------ �------- x ---- �r��� Application Approved BY----- ---- ­------------ -------- - - 1. 2P Date Application Disapproved for the following reas.'ons_------------_--------------------- _,._. rr. 4, Date PermitNo......................................................... Issued--=-------- --------- == Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........>.... ..t�s?.............OF.... f'l f //tG..........................`......:........ (9rrtifirate of f�rrut liaanrr THIS I �-'TO JERTIFA That the Individual Sewage�tDisposal System constructed 1 . or Repaired ( ) by------------------••-•Om:........ !T c. ,E at..................................................----- .............. 10---------------------------------------------------------- State has been installed.in accordance with the provisions of Art I f The Sanitary Code as described in the application for Disposal Works Construction Permit No.:__ ._...5- .-Z- ___. dated...... _ 7............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. ------..... 1 ......... Inspector----•-••. d THE COMMONWEALTH OF MASSACHUSETTS "BOARD OF HEALTH '... ...............O F......... ....................------------...................... No.-••-•-.`...... ilt FEE r ......... %Vivo rY'r �o�rnr i as rrinit Permission is hereby granted-----.. tom _^._-_-_ �_�`_......... .................. to Construct; (� r Re. air ( ) n Individual Sewa e Disposal System.— at No---------------h. ------- ................ ---- ----- ' Street as shown on the application for Disposal Works Construction Per _______ _4a. ted.... '. " - _-_._--_•. . a �" ..+p Board of Health DATE----- ��'5 --�-- ---------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 0 Q w woo Af A=35. 90 ,r, \ �r L07 v 2�srzvE > ( zo. 2 526917-2� i 49 / f / P2oPosGn `�� �. "5 , 00 Min/iivluA/1 .a"--ALF _, ..) ,,y 40 ` Z:>,47W 6- 22-77 .Z- C E e"r/F Y THAT -rA16 FOOA-Z�,A T/o/V /S 13E.I"G �-O r a 5140ern . IAJ _ GEORG£ , 8A,� A). 5' 7-A GE- C2 4► T`r 4 fi Z>6 co A, �. /S �/!J?" �'i 3�✓•�1_tea`' StfRV�yL .d try Z Al t TOWN OF BARNSTABLE LOCATION i ,�WOqZ SEWAGE # _3 VILLAGE {'- ASSESSOR'S MAP & LOT6/0r 432 9 INSTALLER'S NAME fa PHONE NO. � SEPTIC TANK CAPACITY j LEACHING FACILITY:(type) �.. Qom[. (size) /6®d NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER e'llew AJ L;:pi DATE PERMIT ISSUED: '• DATE COMPLIANCE ISSUED: '-��•�! VARIANCE GRANTED: Yes I R �- 6 - c _ _3.Z 13 - 0 �p No..........AppRaal, F>;a............._.............. 8t• T E COMMONWEALTH OF MASSACHUSETTS ,J- OARD OF HEAL7I-1 8r> "Da w OWN OF BARNSTABLE ApVtiratinu fnr Di-tipmial Works Tomitrnrtion rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....... Loan�on-Address -_-_•-----------------•------......or Lot No. .............. .!». ................................ •..... --........----••......................-•---•--- Owner p Address ----------•------------------------•---•-- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.._....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------------------------------------------------------------------------------------------------------•-------------------- W Deslgn Flow............................................G gallons Person Per day. otaai Y ow.. . .. ....................................gal Ions. WSePtic Tank—Liquid c Pacrty/ 6Ugallons Length___ Width________________ Diameter---------------- Depth................ i x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------1............ Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) •" Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ G% Test Pit No. 2................minutes per inch Depth of Test Pit-_-_____-...___----- Depth to ground water........................ P+ --•---•--•------------------------•-•----------------------•-------•-•-------••••-•-----------.-•---....................................... ....---- .......... 0 Description of Soil........................................................................................................................................................................ x U •-•-•••-------••-•-•----•--•-----•---•----------------•-----•-------•-------------------....-••-------------------------•----------------•--------•----••-----•-----•--••-•-•-----.............----••-- W ----•-•-•--------------------------------•-------••-----------------------------....-•--------••......---....... _l U Nature of Repairs or Alterations—Answer when applicable.- �!- ..._ ��®D.. d J� T ----------- i •-------------------------------•-•----------•---•--•-••------•--••--•-----•--•-----••........•-•--•-••-•-•-•--------------------•----------•---•-....--------------•••----•----•.........--••-•---•-•-. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ tal Code —The undersigned further agrees not to place the system in operation until a Certificate of Compli nee as een i d b the board of health. t s C Signed �� ..... 1e ------------------------ --------��J _!. Dare ApplicationApproved By .............. ' ---- ..--.................................................................. -----7-- /. ,! -"--7-Y Date Application Disapproved for the following reasons: ............................................................ .................................... ............. .. . ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- ecyy Date Permit No. ----------.1..�---- .- ...... Issued Date No................--....... FRx............................ r / THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allp iration for Di-nVw3ai Workii Tonitrnrtion rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 17 Location-Address or Lot No. .................... c' o - - :-� .................................. --•---------•-•-•-----•---•-----•--•-•....•------•-•-----....---•..........-•-------.....-----•--- Owner �6 Address 5 G Installer Address UType of-Building Size Lot............................Sq. feet 'Dwelling—No. of Bedrooms---N�____________________________________Expansion Attic ( ) Garbage Grinder ( ) a �� Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a d Other fixtures .. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/fir Ugallons Length---------------- Width--....._--_----- Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area__-_-___---•_-.-----sq. ft. Seepage Pit No-------/............ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- ........................... ..................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.__-..------_----_._.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ --------------------- ----------------------------------------------------------------------- -... --•-....... •... ••------------------------- ••••••...... ....... ODescription of Soil........................................................................................................................................................................ x _ _ ---•••-------- --------- ----------------------------------------------------•-------•-------------------..... --- -- ----------------- -•----D------------•-7.... -•••--•-------•----••_.---- U Nature of Repairs or Alterations—Answer when applicable.---.'_. %_��____--.-----���-----. �--/-:---- - ----'f Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environm-ental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as een is. ed/by the board of health. ��-77 1 Signed ...................... � .- .............. --------7-�.r:... T Dare Application Approved BY ........... -.-.-'!.../..s.:...... �.� Date Application Disapproved for the following reasons: ....................................................................................................................................... -------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ ........................................ q Date Permit No. ...........1-.�...-- 3 .�5.................. Issued Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CErtifirate of (foraylinure THYS TO CER�'IFY That the Individual Sewage Disposal System constructed ( ) or Repaired( `..`..L'.4 / wby ............. ..... . .. ... ........... ... ----------...---------------- -- - .... Insr.dler at ........ I .. ..0/ .-U/OQ.Q'...�//��I�' ��.�lJ..� r-------------_-------------......---------------------------......---------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 Uof The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......! lam---. ...g....... dated ............ ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............./... '' ll....'�-�. ....... _ Inspector - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �J �> TOWN OF BARNSTABLE No.. . 6 FEE........................ �i o ttL rk TomArttion rrrntit / --0 21 `u E!G.f�!/............................................................ Permission is hereby granted......_._..�/.............. .... ..... .. . to Construct ( )or Repair (k an Individual Sewage Disposal System atNo. . ..................... Street q 2 as shown on the application for Disposal Works Construction Permit No.l...�-�1.oar.�of Health Dated.......... 7..-_1,��..".�U - I ••......•--•.....---•-•-•--- -•----•-------- - --------------------------------------- DATE............. - ---•----------••--------------••-•----�S� FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS L r # E.F. Winslow j` B JOB INVOICE Plumbing & Heating 59890 8 Reardon Circle South Yarmouth,MA 02664 Phone 508-394-7778 CUSTOMERS ORDER NO. ATE ORDERED FAX 508-394-8256 e-mail questions@efwinslow.com ORDER TAKEN ev BILL.TO _ .DATE PROMISED D AM ADDRESS PHONE CI y Co JOB NAME AND LO—I ION i HELPER DESCRIPTION OF WOR ( F ❑CONTRACT ❑EXTRA QUANT. / DESCRIPTION OF MATERIAL USED PRICE AMOUNT J / ' �06 ca a cc 00 U HOURS LABOR MECHANICS AMOUNT @ ©g TOTAL J HELPERS @ MAT i �9 TOTAL LABOR /O 9 I hereby acknowled nat ge my sigure grants a C Ority to use Credit card numbers supplied at time of service or credit card numbers already on file. 1 I her knowledge y�satisfactory 00 le of the try escribed work. TOTAL LABOR IG E TAX ODATE COMPLETE� TOTA �C7 �7 ,93