HomeMy WebLinkAbout0059 PINEY ROAD - Health Cotuit _
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`DATE: 2./27/02
PROPERTY ADDRESS: _59 Piney Road
. Cotuit,Mass.
--
02635
WY1_
.
------
On the above date, I Inspected the septic system at the above address.
This system consists of- the following: RECEIVED
1 . 1 -1000 gallon septic tank.
2 . 1 -'Distribution box. MAR 0 7 2002
3 . 1 -1000 gallon precast leaching pit. 6 ' X 10 '
TOWN OF BARNSTABLE
Based on my Inspection, I certify the following conditions: HEALTH DEPT.
4 . This is a •title five septic system. ( 78 Dode.
,5 . The septic system is in proper working order art
the present.
6 . Waste water is 62" below the, invert pipe• of the leaching pit.
7. Pumped the septic tank At time of inspection.Heavy scum and
solids .layers were -present.
SIGNATURE:-J J.
Name:-J_p _ Macomber J.r------_ „
Company: Jos ej2h_P . Macomber-& Son ,: Inc . `
Address: Box 66
__Centerville , Ma ;_02632-0066
Phone: 508-775-3338 rrt
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
Y ,
JOSEPH P. MACOMBER & SON, INC. ,
Tan ks-Cesspools-Leachflelds,
Pumped & Installed
Town Sewer Connections
P.O. .Box 66 Centerville, MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
`DEPARTMENT OF ENVIRONMENTAL PROTECTION
i -
TITLE 5 ,
OFFICIAL INSPECTION FORM =NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION•
Property Address• 59 Piney Road
Cotuit,Mass.
Owner's Name:Mrs. Stanley Burgess
Owner's Address: Same
Date of Inspection: 2
Name of Inspector: (please print) Joseph P.Macomber Jr.'
Company Name: J.P.Macomber & Son Inc.
Mailing Address:Box 66 rentPrvi 1 le,
• s
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is rrue, 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
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
r Z/asses
'Conditionally Passes^
Needs Further Evaluation by the Local Approving Authority
� Fail '
Inspector's Signature: Date:
The system inspector shall mit a copy of this inspection report to the Approving Authority(Board of Health or
DEP) 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 .
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
`'time. This inspection does not address how the system will perform in the future under the same or differeoE``—�
conditions of use. f
f
Title 5 Inspection Form 6/15/2000 page I
I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:59 Piney Road 4 r
Cotuit,Mass.
Owner: Mrs. Stanley Burgess
Date of Inspection: 2/2 7/.0 2
Inspection Summary: Check"A,B,C,D or E/ALWAYS complete all of Section D
CA. System Passes:
,141 1 have.not found any inform�,Anv
hich indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 R 15.304 existailure criteria not,evaluated are indicated below.
Comments -
`The septic system is in proper working 'order at_t] e_
nrPSent" t l mP_
M
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-approve&by the Board of Health,will pass.
Answer yes,no or,not determined(Y,N,ND)in the, for the followingstatements. If"not det
explain. ermined please
410 The septic tank is metal.and over 20 years old* or the septic tank(whether metal or not is structurally
unsbund, exhibits 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:
Observation of sewage backup'or break out or high static water level in the distribution 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); R
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): t
broken pipe(s)are replaced
obstruction is removed
ND explain;
2
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 59 Piney Road
o ui , ass.
Owner. Mrs. Stanley Burgess
Date of Inspection: 2/2 7/0 2
C. Further Evaluation is Required by the Board of Health:
VQ 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.
1. System will 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 health,safety and the environment:
We 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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
40 The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water-Supply or tributary to a surface water supply.
Wd The system has a septic tank and SAS and the SAS is within a Zone 1 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 100 feet bit 50 feet or more from a
pr'yate water supply well.". Method used to determine distance
L
"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.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM —NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
.CERTIFICATION(continued)r
Property Address: 59 Piney Road
-Cotuit,Mass
Owner: Mrs. Stanley Burgess
Date of l nspection:2/2 7/0 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
��Dackup of sewage info facility or system component due to overloaded or cIogeed SAS or cesspool
ischarge or ponding of effluent to the surface of the ground or surface waters due town overloaded.or
/clogged SAS or cesspool
_J Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS of
cesspool
iquid depth'-in cesspe4 is less than 6"below invert or available volume is.less than 'h day flow.
. Required pumping more than 41imes in the last year NOT due to clogged or obstructed pipe(s). Number
of times
pumped
�y portion of the SAS,cesspool or privy is below high ground water-elevation.
y portion of cesspool.or privy is within 100 feet of a surface water,supply or tributary to a surface
ater supply.
,Any portion of a cesspool,or privy is within a Zone 1 of a public well.
i/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.]
Xf) (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. s a
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"fior"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no� ..
vthe system is within 400 feet of a surface drinking water supply• `
e system is within 200 feet of a tributary to a surface drinking water supply
the systenn 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
A
Page 5ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 59 Piney Road
Cotuit,Mass.
Owner:Mrs. Stanley Burgess
Date of Inspection: 2/2 7/0 2
Check if the following have been done. You must indicate`des"or"no"as to each of the following:
Yes No/�
J Pumping information was provided by the owner, occupant,or Board of Health
ere any of the system components pumped out in the previous two weeks?
7__ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
— Were as built plans of the system obtained and examined? (If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up
-21— Was the site inspected for signs of break out?
Were all system components iCuding the SAS, located on site?-,
— Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum ?
�— Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information. For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
k
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 59 Piney Road
o ui , ass.
Owner:Mrs. Stan ey Burgess =
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL �1
Number of bedrooms(design):—d—. Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd.x#of bedrooms): w,
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system-(yes or no):4.0 [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):�
Water meter readin s> if availa b'
le(last2 yearsusage(gPd)):2000-39, 000 gallons=106.85 GPD
Sump pump(yes or no): 2001 -36.UUT gallons=98. 63 GPD
Last date of occupancy: # r
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/s ft,etc.):
Grease trap present(yes or no):_&�/
Industrial waste holding tank present(yes or no):.1-0/7
Non-sanitary waste discharged to the Title 5 system(yes or no):X—#
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL-INFORMATION
Pumping Records. )�
Source of information: A) �7
Was system pumped as part of the inspection(yes or no): LS-
If yes, volume pumped: i,!VD gallRns--How was uan ' ump�d determined?171►94Y)i6�Z
Reason for pumping: 6lwe "s wX
TYP F SYSTEM
eptic tank,distribution box, soil absorption system:
2QSingle cesspool
Overflow cesspool
Privy '
y Shared system(yes or no)(if yes,attach previous inspection records, if any)
Q Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Ab Attach a copy of the DEP approval
All)Other(describe):
' pprox�im a age of all comp n nts, da installed(if known)) source information:
,ftWere sewage odors detected when arriving at the site(yes or no):,!:e19
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C _
SYSTEM INFORMATION(continued),
Property Address: 59 Piney, Road
Cotuit,Mass
Owner: Mrs. Stanlet Burgess
Date of Inspection: 2 2 7/0 2
BUILDING SEWER(locate on site plan)
Depth below grade: -
� w .
Materials of construction cast iron 40 PVC mother(explain) W,4
Distance from private water supply well or suction line: J6
Comments(on condition of joints,venting, evidence of leakage,etc.):
Joints appear.. tight.No evidence of leakage.System is vented
through the house vents.
SEPTIC TANK: locate on site.plan) 'i&'d QA �I M
Depth below grade:.
Material of construction-_concrete W meta Let-)fiberglass4 L41 polyethylene.„
40—other(explain) Ald
_
If tank is metal list age: is age confirmed by a Certificate of Compliance(yes or no):,f (attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: Q
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: Q
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Pu�,� a�j�ne dsD� red
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as.related to outlet invert, evidence of leakage, etc.):_
tPumri the septic tank every 2-3 y arc; Tnl et X -c) rtl Pt tPPS
a're_in place-The tank is. stru rt-iral_`I'y Gnrrnd and ahnws nn '
evidence of leakage.Pumped the 1. at time of inspection. 4
GREASE TRA H1 (locate on.site plan)
Depth below grade: V ;.
Material of constructionstl?Lconerete t 41 metal 4 fiberglass�olyethylene40 other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
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.):
Page 8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Piney Road
Co ui ,Massa
Owner: Mrs. Stanley Burgess
Date of Inspection: 2/2 7/0 2
TIGHT or HOLDING TANIGGi<J'V—(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: VA.
Material of construction:AM concrete AM metal tI4 fiberglass .tli4 polyethylene,eO other(explain):
Dimensions: A119
Capacity: A gallons
Design Flow: AN gallons/day
Alarm present(yes or no): gJ4
Alarm level: '/x Alarm in working order(yes or no): 40
Date of last pumping: X4
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX: Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: '411)
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.):
Distribution box has one lateral.No evidence of solids
carry over.No evidence of leakage into or out of the
box. -
PUMP CHAMBERV-Ve.(locate on site plan)
Pumps in working order(yes or no): IfI14
Alarms in working order(yes or no): J P
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Pump chamber is not present.
8
r
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 59 Piney Road
Cotuit,Mass.
Owner:Mrs. Stanle Burgess
Date of Inspection: 2 27 02
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required)
1 -1000 gallon precast leaching pit. '6 ' X 10 "
Waste water is 62" below the invert pipe.
If SAS not located explain why:
Located; See Aacre .10
Type
aching pits, number:
.16 leaching chambers, number: -87
le leaching galleries,number:
R leaching trenches,number, length:
c7 leaching fields,number,dimensions:
Xy overflow cesspool, number: _,
XT_ innovative/alternative system Type/name of technology: z�/7i V i G
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp-soil, condition of vegetation,
etc.):
Loamy sand to sand.No signs of hydraulic failure or ponding
Soils are dry.Vegetation is norma .Was a wa er is62" below -tne
invert pipe.
CESSPOOLStup_V0- (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool: Al
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
GSnools are not present
PRIVY.t�i "locate on site plan) .
Materials of construction: mil!
Dimensions: AO
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Privy i G not present
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:59 Piney Road
cotuit,lylass. `
Owner: Mrs. S an ey urgess
Date o(Inspectioo:2/27/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system includini ties to at least two permanent referen e I dmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buil in .
tN
i
�. X. i r 1
Has; not been pumped in
four years
J r
10
Page 11 of I 1 "
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 59 Piney Road
o ui ,Mass.
Owner: Mrs. Stanley Burgess
Date of Inspection: 2 27 02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine-the high ground water elevation:
Obtained from syst tans on record • If checked, date of design plan reviewed: 4laz
e Observed site(abut ro erryI bservation hole within 150 feet of SAS)
4/0 hec ced with local Board of Health-explain-
Checked with local excavators, installers- (atl,ach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Jsed; Gahrety & Miller Model 12/16/ 4 Ground water PlpyAtinn .ahnye
sea level_
Jsed; ObservatJon wa1•1 rJAt-a June 1992 11S S
Jsed; USG
92-000-1 Pla # un
Leaching
Pit 'cc(
-
Groundwater.Ali,`eet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the,bottom
of the leaching pit and the adjusted groundwater table is �
feet.
11 + .
'rnnr.—nre�e—..Tr�:rnrmr•nrnrrnen ati+rir.�r::•n-rermri�+rrerrtrn rsrrntiu+�a�rrvsa•e+ rn-rs—r��r—r—:..--..—...`
Barnstable l
TOWN OF Barnstable OF IIEALTII
F -�R SUDSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM = PART D..a- CERTIFICATION I
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 59 Piney_ Road Cotuit,Mass. '
ASSESSORS MAP , BLOCK AND PARCEL
OWNER' s NAME Mrs.' Stanley Burgess
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAMEJ.P.Macomber & Son Ince-'
COMPANY ADDRESS Box 66 Centerville,Mass.02632
street Town or City State LIP
COMPANY TELEPHONE (508 ) 775 - '3338 FAX ( 508 790 - 1578
A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is
p 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 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con acted has 'found that the system fails to
Protect - the htiblic health and the environment in accordance with. Title
5 , 3.10 CMR 15 . 303 , and as specifically noted. on PART C - FAILURE
CRITERIA of this inspection form ,
3 r 1 .
Inspector Signature Date ifs
ae copy of this certification must be provided to the OWNER, the BUYER
here . applicable ) and the BOARD OF HEALZ'll.
* If the inspection FAILED, the owner or"o� orator shall u p pgrade ' the ayetem
within one ;year of the date of the inspection , unless allowed or required
otherwise as provided in '3.10 ChJR 15 , 305 ,
partd .doc
. TOWN OF BARNSTABLE
LOCATION /fie SEWAGE #
VILLAGE C®re/ /,� ASSESSOR'S MAP & LOT 6
INSTALLER'S NAME & PHONE NO. p MA CQA4 eA fi SOA-1
SEPTIC TANK CAPACITY /. D DO
LEACHING FACILIT•Y:(type) 7- _ (size) / ®O 0
NO. OF BEDROOMS .`Z PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: Ll/
DATE COMPLIANCE ISSUED: -7 3S ! 'Y
VARIANCE GRANTED: Yes No L�
4 �
`` �
� � �
3�` � �
�o , a'�
�i
� -
��
' Q $ 30.00
Fr�s..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 1?03 q �a 1
Allp iration for Diopoittl Wor1w Towitrnr#inn Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair XXN an Individual Sewage Disposal
System at:
59 Piney Road Cotuit
....................•-•------•--......-•----•---------......---------------------------••---....•. ------•----•--•--------•-----•----------•-----•...-----•--..............-------•••-------------•--
Location-Address or Lot No.
Stanly_Buraess
----------•---•--•---•--••-------•------ ----•----•-----------•------•-------------•-------------......•----•-•--------•----------------•--
Owner Address
W J.P.Macomber Jr.
Installer Address
UType of Building Size Lot_.........................Sq. feet
Dwellings No. of Bedrooms.................2.........---------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ..................... ...... No. of persons....................-------- Showers ( ) — Cafeteria ( )
Other fixtures ......................_--- ... . .
W Design Flow............................................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-------------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date--------...............................
Test Pit No. 1................minutes per inch Depth of Test Pit....--.............. Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -------------------------------------- --------------------------------------...............................................................................
0 Description of Soil........................................................................................................................................................................
�4 Sand
V .......................................................... -----•-----------------•-------•---•---.......------------•••---------------•-----------------•------•-.........................--------------
W
U Nature of Repairs or Alterations—Answer when applicable.....----Omit Cesspools . Install : 1—0 0 0
...............................................
gallon tank 1—distribution box 1.-.1000____gallon_leach..pit .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has beery issu d by the oar of health.
Signed -- - ....... .. -►----------------------------- ----7J.12/94----:------
Dare
Application Approved By ...............W4,vl�.. ..... ... .vi v ------------------------------------------
--------------- ---7—�-C .
Application Disapproved for the following rea.ron.r: .... ........................ . .......---..........----.........-----.........---...._.......----------------------------
... . . ................................................... ............... .............. ..................-- . ----------------------------------------
Dare
PermitNo. ... ....-..... ��� -------------------- Issued ------._..--------------------------------------------------------
Dare
No.__�.y_n-.:! n t F:ns.... ....30.00
_ ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE J?03 y Oa 1
AVV iration for Divi-Vo!3ttl Works Towitrurfivit lirrutit
Application is hereby made for a Permit to Construct ( ) or Repair 'CXN an Individual Sewage Disposal
System at:
59 Piney Road Cotuit
-•........-•----------------•-•--......-•---•-----•---......-----------.....---......------..----- -•-------------------------------•----•--._...---------•--......------•--•-•-•--------....--•-•---
Location-Address or Lot No.
--••Stan 1.._Bu r...'s-----------•------------------------------------------
Owner Address
W J.P.Macomber Jr.
Installer Address
Type of Building Size Lot............................Sq. feet
UDwellingX No. of Bedrooms_________________2__-----_--.-___---.-..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons 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 ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date...---------------------------------....
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
"'
ODescription of Soil.................................................\.----..............----------------------------------------------.._...-----------------------------------------------
x Sand
U ---------•------•-------•-•----------------------------•----•---------------------•----------------------•------------------------------•---------------•---------------------------...--•--------------
W
UNature of Repairs or Alterations—Answer when applicable......._.Omit Cesspools. Install : ,1-000
gallon tank 1-distribution box 1-1000 gallon leach pit.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has ee issued by the boar of health.
Signed �� -s'�/� I - 7/1.2/94....:.
Dare
Application Approved BY ------------- 1� ----- --------- -J------------------------ ---7-- ----- _
Application Disapproved for the following reasons: . ......................................................... .................-- ...
. ................ ........._`.......................................... .......... _ _............. .... .................. ................... . ......... -------------.....------------ -------
Da
Permit No. ....f .......... Issued
Dare
`------- .—_— .--. -` {'-`---'—r----- ——————————————— -. -------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C11.extifirate of C11omplianve
TH S 1- TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( XXN
v . P.Macomber or.
.
-
59 Piney Road Cotuit "
at .................. ...................... .......... - ..... ....... -------------..........----------------------------------------------------------------------......------__-----------------------
has been installed in accordance with the provisions of TITLE %of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ....- 4-1- ---- .�.3.:......... dated --- ---..........__._----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------- •'4, = �1 �� _._... Inspector ----------- - �_+ ---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE FEE... 3.0....00..
yV�_5 .....................
�, �i��o�tt1 ork� �ost�triuu �rrutit
Permission is hereby granted-__J P.�-Macomber Jr.
to Const5rugcntF. )tor RepaRoak �4Xtdjtndividual Sewage Disposal System
Co -
atNo................................................................... ------------------...-•------------ --------•------------.......------------------------...._...------------...---.......
Street
as shown on the application for Disposal Works Construction Permit No.. &_-_ Dated-----
•................•-----...- --------------------------------...............
p DATE............... �- -------------------------------- Board of Health
7•=--.�.a..'
FORM 36508 HOBBS&WARREN.INC..PUBLISHER$ J�
�i G I�� • '
V
. e�ax.,em.�...n.......+n'v.s:.ew�;x:�,xesre:s.l.�w .,.i.'rot.tiix"da'�re'•.�:
0 TOWN ,OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
MAP NO. 0 3 PARCEL NO:�.
ADDRESS'
OWNER NAME: , ,. f" ,c_^ ,"h am, 4 " ' 1kc I VILLAGE:
.L
INSTALLATION DATE: fn i o L_ BY l i
ADDRESS: 1. l��. CERT. NO.
TANK; I ORMAT I ON _
LOCATION OF' TANK:
CAPACITY TYPE ,AGE) t` ° ` rFUEL`/'CHEM I CAL'%
i
TESTING CERTIFICATION C ] PASS "C' ]'-*Pg-,IL MATE
LEAK DETECTION C ] CHECK IF N/A TYPEI,/B AND
j$ 4
i F
ZONE OF CONTRIBUTION C 7 YES C ] NOS` tDATE TO BE' REM V D ( i tqgq
FIRE DEPT. PERMIT ISSUED -C 7 YES C ] NO DATE
CUNSERVAiION C 7 CHECK IF N/A DA=TE
,BOARD OF HEALTH TAG NO. [ 31 7 E ]C 31 J DAfE
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOC_AQ I ON ON THE BACK OF THIS'..CARD
L
� f , ��I �' =d � �
�,�
NE -
LSON COAL "OIL CO., INC. NELSON COAL $ ® L CO, INC.
-0i1 Burner Sales & Service Uil Burner sales & Service
DISTRIBUTOR OF GULF OIL PRODUCTS
DISTRIBUTOR OF GULF OIL PRODUCTS
180 IYANOUGH ROAD, HYA►NNIS, MA 02601 ; 180 IYALLNOUGH ROAD, HYA NNIS MA 02601
2 F Z�
I NAME, DA
711T ADDRESS
PHONE
IBLE TOWN 6e� PHONE
+RTED TnOUIILE -.
ER BEC•D. BURNER MODEL TIME STARTED TIME FINISHED TOTAL TIME REPORTED
! ORDER REC-D. I BURNER MODEL TIME STARTED TIME FINISRED TOTAL TIME
11
❑Cleaned Boiler ❑ Cleaned Smoke Pipe ❑ Oiled Motors ❑Repaired Oil Leaks
❑ Burner ❑ Chimney Base❑ Oiled Circulator ❑ Checked Draft
i p�W Lf Cleaned Boiler ❑ Cleaned Smoke Pipe ❑ Oiled Motors ❑Repaired Oil Leaks
❑ Controls❑ Nozzle ❑ Oiled Blower ❑Adjusted Flame 00 Eln Burner ❑ M Chimney Base❑ Oiled Circulator ❑ Checked Draft
8 A ❑ Controls El Nozzle ❑ Oiled Blower ❑Adjusted Flame
RTS and MATERIALS. ! PARTS and MATERIALS:
_ Q /G 70
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3
1 - - a641123 s"
7` .
t
�WL s �� ,� �• -2 00
U 5 C O
L11
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PAY THISPAY THIS
p G 3
[US IS YOUR EWOICE AMOUNT -� d i THIS IS YOUR INVOICE AMOUNT --�
fSTOMEWS SERVICE () Q
NATURE X - MAN / { CUSTOMER'S SERVICE
company assumes no responsibility for any damage to person or property caused by operation of heating ! SIGNATURE X MAN '
't Biter serviceman leaves premises except that resulting from its sole negligence. The company assume. no responsibility for any damage to person or property caused by operation of heating
plant after serviceman leaves premises except that resulting from its sole negligence.
a -
Catuit Fire Department
64 High Street, Cotuit
42B-2210
FDID No. 01921 Dates
PERMIT FOR REMOVAL OF RESIDENTIAL UNDERGROUND FUEL TAW
Permission is hereby given to remove and transport an underground
fuel oil tank from the proper y described belowe
Location of property: -5-1�1
J
Owner of records
Person/Contractor removing tank: lve'4�-
Address:--JA'Al Y-26i- Cert. No.
Dig Safe No. Q+ applicable) Start Date
Notices All work shall be performed in accordance with applicable
regulations/restrictions. jheRxcavation and tank must bespected
by a fire department representative Prior to backfill and removal .
(Fire Department Use Only)
TANK INFORMATION
Size E 7- i J 4;50 1 3 500 L 3 1000 Other
Typje Steel (unless otherwise specified) Age Unknown E 0
Board of Health Tag No. Tag No. Unavailable or Not Issued ljj.,,-
INSPECTION/REMOVAL INFORMATION
Contents of tanks E 3 Empty E tY'Disposed of by:__
Inspection a+ tankt E LY-No defects E .3 Evidence of damage found
Inspection of excavationst"N contamination E 3 Contamination found
If contamination found, reporte o: E 3 Board of Health t 3 D.E.O.E.
Tank transported tat
Inspectors Commentst
ZnI6 i
O�— Z
Paul A. Frazier
Head of Fire Department Inspeco'dr-
I =WPI m2ts 4250+ I-t'%*ft -F=r-m wk I I tvm -Fcmjjc3,WAMW
!I Aga
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