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Home My WebLink About0116 TROUT BROOK ROAD - Health 116 TROUT BROOij ao�aj' i. No. Z9ZO Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for -Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair 66 Upgrade( ) Abandon( ) ❑Complete System JIndividual Components Location Address or Lot No, 111n -Tr c of bt ool` Rd,. Owner's Name,Address,and Tel.No.Ghc0toP1AQI Owltq Assessor's Map/Parcel LCrtu�t DUV.-,06 I l to 1 ro A Oro oK R d• Installer's Name,Address,and Tel.No. Q 4 g xco o,+o n Designer's Name,Address,and Tel.No. 31•4 900-C V o So ndw,%6-+ boIL•L01•olDS% D-bA 0 rab Type of Building: Dwelling No.of Bedrooms Lot Size' sq.ft. Garbage Grinder(w) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(ruin.required) - gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 1C)OCI ppMOn Type of S.A.S. NIJ Description of Soil Nature of Repairs or Alterations(Answer when applicable) fle0act, Carl S&i n!, CW0,,x '�n SaMG toC,0.*fO(1 Ljk,, new N Zo 033. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boardd ._71 of Health. �l . Signed R<W, gn Date 9�11 2 0 Application Approved by Date Application Disapproved by Date for the following reasons Permit NoAza 300 Date Issued 7 No. V V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes - Rptiratiou for Nsposaf 6pstem Construction 3permit Application for a Permit to Construct( ) Repair(V) Upgrade(j) Abandon,( ) ❑Complete System ,®*Individual Components Location Address or Lot No. Pjc GoY- .P,ct. 'Owner's Name,Address,and Tel.No.r hn {o fb,G! Dc kLI Assessor's Map/Parcel OM 06 Installer's Name,Address,and Tel.No. (j' 4x avo 4�un Designer's Name,Address,and Tel.No. R0J,e, {'�p Scke,ko,0- SU •ti4,i•Ul✓,3 . hXn onl Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(w) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ,, " Design Flow(mina required) /JA` gpd Design flow provided t gpd ram' Plan Date Number of sheets Revision Date Title " Size of Septic Tank 1 bQ C) C�tiO10 ri Type of S A S '>° Description of Soil �W Nature of Repairs or Alterations(Answer when applicable) f1Q_0\0,(c w IcaC?�a. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of r Compliance has been issued by this Boardd of Health. �p Signed 1 Ci7.-�J� _711..fT� Date 9'z, Application.Approved by Date Application Disapproved by Date for the following reasons Permit No. a t} r � Date Issued THE COMMONWEALTH OF MASSACHUSETTS n r _ BARNSTABLE,MASSACHUSETTS f /u Certifirate of �Coru fiance t � THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ✓) Upgraded( ) Abandoned( )by r_x c.avr at {1(v -'T r o j\ (�,c o ok, R 6• has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No.ZEP0--?q)dated f7 �-26 2� Installer 6 cC•XCavU•1, nC, Designer '�Z)-ba, pn1u,. )v #bedrooms lik— Approved design flow gpd The issuance of this/perm/it shall not be construed as a guarantee that the system will function ads designed. J Date ! ''J Ins P --- --- -- ------------- ------ ---- ------ ---------------•----------------------------------- --------------.- . o? No. Zo Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS 30isposaf 6pstem Construction 'ermit Permission is hereby granted to Construct( ) Repair(✓) Upgrade( ) Abandon( ) System located at �1(o 7(o o f and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/hwduty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date Approved by L' DATE.3/9/00----- PROPERTY ADDRESS: 11.6_Trout __ Cotuit_______________ Mass. 02635. On the above date, I Inspected the septic system at the above address. This .system consists of the following: 1 . 1 -1000 gallon septic tank. 2. 1 -Distribution box. 3. 1 -1000 gallon precast leaching pit. 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 0 O at the present time. 6. Pumped septic tank at time of inspection. 7. Leaching pit is presently dry. 8. Raised leaching pit cover. Pit is 6 ' 4" below grade SIGNATURE:,f N a m e:_,L .NssslatgLr_ 1 ------ Company: Jose,2h_P;, Macomber_& Son, Inc. Bo . Address:----x—66--------------- __Centerville , Ma__02632-0066 Phone:---508 775_3338_______ d THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY rJISEPH P. MACOMBER & SON, INC. Tan ks•Cess pool s•Leachf fields Pumped L Installed Town 'sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 E��G�svED AR � 12p00 BARNS?PB`� 'COWNOfd ApEpT. L COMMONWEALTH OF MASSACHUISETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02109 (617) 292-6600 TRUDY C Satr ARGEO PAUL CELLUCCI DAVID B. STR Governor Camm:ss SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART A CERT1fiCATiON Property Addr-,a,: 1 1 6 Trout Brook Road Name of off«George Nesgos Cotuit Mass 026335 Addra,"of Owner: d Date of frtspection: 3/9/0 0 Waban,Mass. 02468 N,rn@ of motor: (Pt.asa Pmo Joseph P.Macomber Jr. I are+a DEP approved system Inspector pursuarrt to Section 15.340 of Title 5(310 Ch4R 15.000) company Name: J.P.Macomber & Son Inc_ MalrvAddrass: Box 66 t^PntA,-xr; lie., mass. 02632 T4opfsone Number: 5 nv88 :;:;S 3338 --- CERTIFICATION STATEMEr1T I certify that I have personally Inspected the &*wage disposal system at this address and that the Information reported below Is true, accurate and complete as of the time of Inspection. The Inspectlon was performed based on my tralNng and experience In the proper function and maintenance of on-sits se age disposal systems. The system: �J Passes _ ConditJonally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fall / Inspectors Sign ; The System Inspectw shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wttNn thirty (30) dsys completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater,the Irupettor and the system owl ' shall submit the report to the appropriate regional office of the Department ofrEnvlronmerms!Protection. The original shoWdUe sent to'" system owner and copies sent to the buyer, It applicable, and the approving authority. . NOTES AND COMMENTS , revised 9/2/98 Page Iorll ��Printd on Rscycld raga SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA PART A CERTIFICATION(oontirwad) ProportyAddress: 116 Trout Brook Road Cotuit,Mass. Owner. George Nesgos Data of kup.ction: 3/9/0 0 INSPECTION SUMMARY: Check A, B, C, " D: A. SYSTEM PASSES: I have not found any Information which Indicates that any of the failure conditions described In 310 CMR 4.303 exist. Any f4wo criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDMONALLY PASSES: ,dM_ One or more system components w described In the'Conditional Peas'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 yes, no,or not determined(Y. N.or NO). Describe basis of determination In all Instances. If'not determined',explain why not. rl 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 inspeotlon; or the septic tank, whether or not metal.Is cracked,structurally unsound, shows substantial Infiltration or exfftration, 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. I�10 Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstucted 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 pipets) are replaced obstruction Is removed distribution box Is levelled or replaced /VD The system squired pumphig-rnon t w1ourdmes v-yeardus to broken or obstructed pipets). The iystim wiltvan—• Inspection If(with approval of the Board of Health): broken pipets)are►eplacid obstruction Is removed revised 9/2/98 Paes2ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cwttirxud) Property Address: 1 1 6 Trout Brook Road Cotuit,Mass.. Owner: George Nesgos Date of inspection: 3/9/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: u ri Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.3MLL.PRa7ECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT- 6 Cesspool or privy is within 60 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. I 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 AND SAFETY AND THE ENVIRONMENT: 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. The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 60 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance N/# (approximation not valid). 3) OTHER revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION(continued) Property Address: 1 1 6 Trout Brook Road Cotuit,Mass. owner: Gegrge Nesgos Date of Inspection:3/9/0 0 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: _l 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 of-sewage irrMfeciRty"er•aTaten+component due tto an overloaded orvbggsdSiAS-or-cesspoot. 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 i�sty�bution box above outlet invert due to an overloaded or clogged SAS or cesspool. �� Liquid depth in eessprfot'Is less than 6" below invert or available volume Is less than 1l2 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped I . - 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 lose-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for »coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen. - 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 i 1/ the system is within 400 feet of a surface drinking water supply _ -0000� the system-is-within 200€e9tof04fR utary4e ssudaoe4Wnkiag-waW-supply '• - • -- the system)s located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infor,(nation. revised 9/2/98 Page 4ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:1 1 6 Trout Brook Road Cotuit,Mass. Owner: George Nesgos Date of Inspection: 3/9/0 0 Check if the following have been done: You must Indicate either"Yes" or "No" as to each of the following: Yea N Pumping information was provided by the owner,occupant, or Board of Health. None of the system composents wawaimen pusnped&6watJeast two w*Ww and-thovystsm hasJSaeovaceiviwy mead flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with /A. Al" _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The she was Inspected for signs of breakout. _ All system components,a=ludiny the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orr the 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) I15.302(3)(b)) _ The facility owner(and.ocrupsuts,lf diNaraW from owner),war&prauldadawith lnteuaatlon on thA propp°<=srsan-M�^f SubSurface Disposal Systems. revised 9/2/98 Page.sofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION P„peftyAd,eu: 116 Trout Brook Road Cotuit,Mass. owns.: George Nesgos Date Of knPectic": 3/9/0 0 FLOW CONDMONS RESIDENTIAL: Design flow:__JZ g.p.d./bedro M. Number of bedrooms esi n Number of bedrooms(actual):. Total DESIGN flow Number of current residents. Garbage grinder(yes or no): Laundry(separate system) ( es or If If yes, separate Impaction,required Laundry system inspected, or no) Seasonal use(yes or no): n� Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): Ab Last date of occupancy: COMMERCIAL/W DUSTRIAL: Type of establishment: Design flow: d ( Based on 16.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present:(yes or no)_AA hA Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: 14 Last date of occupancy:&_ I OTHER:(Describe) AM Last date of occupancy: AW1 GENERAL INFORMATION PUMPING RECORDS and so rce m n: �� O S�/ �r, c (� Z --LL System pumped as part of inspection: (yes or no) if yes, volume pumped: Il Rona j ,r Reason for pumping: , TYPE OF YSTEM Septic tank/distribution box/soil absorption system AD Single cesspool Overflow cesspool- Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank a Copy of DEP Approval Other 4� APPROXIMATE AGE of all components, date installediif known)-and source of4nforrnation: Sewsge odors detected when arriving at the site: (yes or no) 10 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPkCTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 Trout Brook Road Cotuit,Mass. owner: George Nesgos Date of Inspection: 3/9/0 0 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:_cast iron/0 PVC4h other(explain) Distance from privatewater supply well or suction line ' Diameter_I Comments: (condition of joints, venting, evidence of leakage,-etc.) - 17ni_nt g appear i•i nhf- No cvi dennc of leakage - - S K: (locate on site plan) 1! Depth below grade: Material of construction: concrete etal�tl�Fiberglass 4Polyethylene#hther(explain) l If tank is (petal,list age a Is.age.confwmed by Certificate of Compliance�(Yes/No) Dimensions: i" Sludge depth: Distance from top of sludge to bottom of outlet tea ortsaffle Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottgr of outi t tee or baffle: How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or.baffles, depth of liquid level in relation to outlet invert, structuroHntegrity, evidence of leakage,etc.) Pump the septic tank ever 2-3 years. Inlet & outlet tees are in place. The tank is structurally sound and chnwc no euiAance of 1aakagav GREASE TRAP: e, (locate on site plan) Depth below grade:-,V/4 Material of construction✓,f concretwi/4 metab✓4Fiberglass4�iP Polyethylena&other(explain) Dimensions: Scum thickness:—A& Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:�f�I 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.) r'r^a^^ Trap i G nni prpqpnf - revised 9/2/98 Page 7orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: 1 1 6 Trout Brook Road Cotuit,Mass. owner: George Nesgos Daft of Inspector: 3/9/0 0 TIGHT OR HOLDING TANK:_AIL&ank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade:A Material of construction:/JAd concretekll metal 4QFiberglass,{RPolyethylene/,Y_other(explain) Dimensions: AM Copeciry: gallons Design flow: gallons/day Alarm present Alarm level: LWA Alarm in working order:Yes Nw& Date of previous pumping: Aj�4 Comments: (condition of inlet tea, condition of alarm and float switches,etc.) Tight or hol di nq tanks am nni—races.nt DISTRIBUTIONI BOX:Z (locate on site plan) Depth of liquid level above outlet invert:__ Comments: (note if level and distribution is equal, evidenoe of solids carryover, evidence of leakage into or out of box, etc.) - - Di cagy QUer- o evi ence o ea age in o or out of e ox. PUMP CHAMBERAhA (locate on site plan) Pumps in working order:(Yes or No)AA Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Plimin t-hamher i ,c not nrosowt revised 9/2/98 Page 9ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PmpwtyAddresa: 116 Trout Brook Road Cotuit,Mass. own«: George Nesgos Dais of Inspection: 3/9/0 0 SOU.ABSORrWN SYSTEM(SAS) (locate on site plan.If possible;excavation not required,location may be approximated by non-Intrusive methods) If not located, explain: Type: leaching pits,number: leaching chambers,number: leaching galleries,numbsr: leaching trenches,number,length: leaching fields, number, dime Ions: overflow cesspool,number:;� Alternative system:_ Name of Technology: Comments: Inote condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, *to.) nr failbrennr3i ng, a arc rT. VGTtS��Aii 6 iiQrraajj CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to Inlet Invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: AM inflow(cesspool must be pumped as part of Inspection) �Cessspool s are not c recant Comments: (note condition of soil, signs of hydrauUc failura,.Isvel of ponding,condition of.vegetation, etc.) Cesspools are note rpaPnt PRIVY:Q)&VP— . (locate on site plan) I/ Materjals of constru on: /U1l Dim�nslons: /Ui� Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy is nnt prPqPnt- revised 9/2/98 Pses9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C I SYSTEM INFORMATION(condnued) Prop-%y Ad&—: 1 1 6 Trout Brook Road Cotuit,Mass. Ownw: George Nesgos Dau of 4u4mcdon: 3/9/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: � Include ties to at least two permanent reference landmarks or benchmarks locate all walls within 100' (locate where publlo water supply comes Into house) j i W. a revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C " SYSTEM INFORMATION(continued) Property Address: 1 1 6 Trout Brook Road Cotuit,Mass. Owrw: George Nesgos. Date of Inspection: 3/9/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater �Foot Plea se indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record bserved Sits(Abutting propert , observation hole, basement sump etc.) determined from local conditions _ZChecked with local Board of health Checked FEMA Maps Checked pumping records _ZChecked local excavators, Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map. Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11of11 rrn rs.-n:nr*-�r- ++r:mr•nsenr�-+� r�nre*sr::r-rwsr►r+r�*n�rm*te'n•v*+�-s��rwt+ TOWN OF Barnstable BOARD OF HEALTH 0 SUIISURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I •••T••1•T•••••1-T.IIT.••.�TTITT.'T•n.'flITTiQTTf7f'�1T'f�t1r•ItRR�1�.R1�rTllRlAf/1�TtlR�rt tnfl •.T!•T•R•1. �..A -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRES$ 116 Trout Brook Road Cotuit Mass. ' ASSESSORS MAP, DLOCK AND PARCEL # OWNER' s NAME George Nesgos PART .D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son 166: COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 790 _ 1 578 A 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 . Chec 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 public 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 . Inspector Signature D ate 0 ._ r�zrasr�rs� _ . ne copy of this rtification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. If the inspection FAILED, thb owner or operator shall upgrade ' the system within one ;,year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 Ch1R 15 . 305 . B partd .doc TOWN OF BARNSTABLE LOCATION Ame Ami SEWAGE # VILLACtE Merl ASSESSOR'S MAP& LOT ALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��Dfl ✓ � LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 11 BUILDER OR OWNER eG* PERMITDATE: 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 wetlands exist within 300 feet of t ac g facility) Feet Furnished by G" o c