HomeMy WebLinkAbout0060 BRIDGE STREET - Health 6� ride Street
Osterville P
A = 116 003 - —
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DATE :8/14/03
----- RECEIVE®
PROPERTY ADORESS:60 Dzidge Staeet
_OAte2zpii-2eL(7aee._-______ AUG 2 3 2003
02655______ _____------ TOWN OFBARNSTABLE
HEALTH DEPT.
On the above date, I inspected the septic system-`at the above address,
Tnis system consists of the lollowing:
1. 1- 1500 ga-tion he/1t.ic .tank,
1-Pump chamge2. On. o,,�,P, Fight 9 a-ea2m. ;".Voats MAP � F
3.. 5-.in�i-et2atozz .in 6eaie.6. PARCEL _ ��.3r..s....eased on my inspection, I certify the lollowing condlllons:
4. 7h.ia .i..a a tit-Pe /.ive .6e/2t.ie 3y,6t,4-m. (95 Code) LOT
5. The Je/2t.ic Zyztem .i.s .in /2ao/2ea woak.ing oadea
at the /2ne,3ent time.
6. The 3egt.ic tank zhouid ge pum/2ed annua.PPy.
SIGNATUR
N 2 m e J__ P . _Macomber_Jr . _
Corhpany : , q�Qph -per_ 0.�Sgmt2pr b_ Son, Inc .
Dares S : @Qx ............
CenS2.YLUP-- �ja - -Q.2-632- 0066
?^one _ _508 . 775_ ) 3 )8- - - ---- ----
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
a
JOSEPH P. MACOMBER 8' SON, INC.
Tanks-Cesspools-Leachllelds
Pumped & Installed
Town Sewer Connections
P 0 Box 66 Centerville. MA 02632.0066
' 775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLES
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM
PART A
CERTIFICATION
Property Address: 60 l32 idge St2eei
e2v-L e,
Owner's Name:Pau.Q 13oizni t e in
Owner's Address: 8174103
Date of Inspection: ,Srrma ,
Name of Inspector: (please print) ao,6el2h P. Nacom&en a2.
Company Name:1. P, Nacom jen R ,S.nn Inc.
Mailing Address:130 x 66
Centeltv-ieie. ft.6,6. 02632
Telephone Number: 5 n R_7 7 5_ 3 33 g
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
t// asses
y Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: eF9-!� d.;�
The system inspector sha ubmit a copy of this inspection report t 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 different
conditions of use.
Title.5 Inspection Form 6/15/2000 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 60 /3.,zidge St2eet
Owner: Paul 13o2rz,6 e-c/z
Date of Inspection: 8114103
Inspectio ummary. Check A,B,C,D or E/ALWAYS-complete all of Section D
Systetn'Passes.
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The Beat is eurtem i.6 in R2o2e2 wo2king o2cfe2 at the
/?2P_bP_2f- - — •-- _
B. System Conditionally Passes:
Q One or more system components as described in the "Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, 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:
1/t)UJClbservation 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):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
I A ,
m / �C(�'J LI
DATA
�Y
AAL .. E ..:: "" X ASSESSMEN` S
•?v
..
�r q Ad&r-+.. 6 Ba-id, e. St2eet
'' F!+rthgr Evaluation is t2e ulrrd b
!V� colsailic oxim which ra"ito
WOW ��i aatlo ;' 'the rl:nw;!.4 P44M in order to determine if the system
is,faint to protect.)tuck rintt�h,_ ty dt the opvironwni._
i, yiiem will paver Q ergk) s 4�r'ir � A.�+ ice�vi�a�§�Cl IS.
+� 10*1)(b)1th4o Ike
�Ya36'�1 Ya Ik(K ttau'+stic�ttdng i�• gi aQor Wa'j� ti" * ��: �Pta c:Moak*94*q r ►d the onviropmeat;
Nd "Ss p(JI c{ pr.l:.�,. within So felt of Cs►r ` `water
. t Bs;r.Ate! Y s*iE In SQ feet of s iif�idur±�ig.va :tai d wfjt u,!.sr'4«r. t mush
c
ate40 r:d.oi"Uialtt rtY�.t�{. water Slt fixr <f it rietpreinitee�r,�=: :ti.::c
+)'Y��t1Y .1 At�CkjSJrt�'ita J ,r;Rnner.:S#t�b.';R�t�sYS t�tia.sa'q�itt����iyiC'kig sa1��,y,u�d:an�iraq�ment:
The c+ r 1: .:septic ta;tk and av�l eh+x� S'tC7T i!t�#.�}r^^.'i --'the y/' S L4itliin itl0�F.".:;
T�Itti a ,:lt`1 ..JY.i% °':!C�d{t�:lti7�; :1 `i x`..`'ill?1!s `.+. �. p�'�" � w •�S4FF
�Q. 7.a u•sr;rci. ant ,i;is�w�tn►it<:it Teat aY ptivt •,� @ter,�4AR1Ys.wctl'.
Til$6 v ii:.(Y{i<, +s;•ic5s r:h^-n 1CIO tm tJldt+Sf? 6i'rQ('Ur;JY1!tEi
PEP ae'rtifiod wj�.i:
• :�� � �a:,. ,� ,� .� :��af the�>>Vti'ia it�'.fr6�rtptNil.e;' , ,.� ,(h}t�,fQ4..�-?:�i"•.C,!i.
MUST 414
- . ,.i,t?'lYe� .t:..= :r-'�a `-�rf)��•n.�&'�q�i;:+�;..u,¢r„5,,;&4,i�,Y :ri.:�. 1
I�
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 60 B,z-idge Stlzeet
e zvi e, 0 a.a.6.
Owner:Paui 23o2n� e.-n
Date of Inspection: 8114103
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No I
_ ✓�ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
t/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
4�Wt'o Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool -.,��,,�Tr.9T�;^S
Liquid depth in cesspool is less than 6"below invert or available volume is less than '/-.day flow
a/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped a .
_ 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
4/water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
1,my 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.]
,,t)6 (Yes/No)The system fails. 1 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.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
i�the system is within 400 feet of a surface drinking water supply
tithe system is within 200 feet of a tributary,to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
M 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
Page 5 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B '
CHECKLIST
Property Address: 60 BAidge Staee.t
Owner:Pau.P /3o�crz,3.t e in
Date of Inspection: 8114103
Check if the following have been done. You must indicate 'fes"or"no"as to each of the following:
Yes No / '
_ 7were
ing information was provided by the owner, occupant,or Boardof Health
any of the system um components p pumped out to the previous two weeks
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?
Was the site inspected for signs of break out ?
v Were all system components,4x2cluding 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 o
Existing information. For example, a plan at the Board of Health.
v — Determined in the field (if any of the failure criteria related to Part C is at issue approximation
is unacceptable)(310 CMR I5,302(3)(b)) Pp matron of distance
1
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address. /32�cl ye Sheet
Owner: Paul crUIC11'61c-e4_11
Date of Inspection: 8114103
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): llJJ
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x M of bedrooms):
Number of current residents:2iL y
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no): _ (if yes separate inspection required)
Laundry system inspected (yes or no): `�
Seasonal use: (yes or no):_VV
Water meter readings, if available (last 2 years usage (gpd)): 2001=20 3, 000 ya e Qonz=5 5 6. 17 Ggl)D
Sump pump(yes or no): ZOU2= 7 /6—,—= yaPPon.3=482. 20 91)D
Last date of occupancy:� S/22 ink eel h yzt em /22ezent
COMMERCIALQNDUSTRIAL
Type of establishment.
Design now(based on 310 CMR 15.203): gpd
Basis of design now(seats/persons/s ft,etc.):
Grease trap present(YV orXq):,
Industrial waste holdiKg-tbr& present(yes or no):a�4-
Non-sanitary waste discharged to the Title 5 system (yes or no):'11?
Water meter readings, if available.
Last date of occupancy/use:_ 4
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no)A�'1
If yes, volume pumped:_gallons -- How was quantity pumped determined? i¢
Reason for pumping:
yOF SYSTEM
ptic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
Ianovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained fiom system owner)
Tight tank 4� Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date ' stalled(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):/L,2)
6
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:60 Bit.idge Stzeet
Ownerl'auQ Bo zn.6te.'r
Date of Inspection: 8174103
BUILDING SEWER(locate on site plan)
Depth below grade: /K^�o
Materials of construction t iron ✓ 40 PVC other(explain): Al;f
Distance from private water supply well or suction line: le 7`
Comments(on condition ofjoints, venting, evidence of leakage, etc.):
aocrt� a/2/2eaz t.iyh.t. No eU.ideree o,,P ieakarae.
SEPTIC TANK: t/(locate on site plan)
Depth below grade: �
Material of construction: ✓concrete,4/Nrrt eta IWJ fiberglass 4lpolyethylene
&)other(explain) .e)h
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no).,�?4_(attach a copy of
certificate) � ,
Dimensions: 117` Z '' �Cj '�/�
Sludge depth.zf=
Distance from top offssllu a to bottom of outlet tee or baffle:
Scum thickness: Ad
Distance from top of scum to top of outlet tee or baffle: �1
Distance from bonom of scum to bottom of outlet teg or baffle:
How.were dimensions determined: M.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.leakage, etc.):
llumr the beat-in tank onnijo.PYI - TnPof R nul0of iooA -a 2 6n—,n-PcA 2e.
The tank .c,6 etuctuaai—eu AouLY onr/ an o>»rJonro n'e
leakage.
GREASE TRAP "locate on site plan)
Depth below grade:
Material of construction:. concrete metal fiberglasstolyethylenC,t/ other
(explain): it
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or battle: X/Q
Distance from bottom of scu 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.):
�nonAo 7anIn 6nny a6IgQ�.
7
Page 8 of l l
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISP OSA.L SYSTEM INSPECTION
NS ECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60 Ba-id ye S.t 2 ee t
b Z e2y.G e, ah-s.
Owner: P0121 3o2n�te�n
Date of Inspection: 74/UJ
TIGHT or HOLDING TANK l',(tank must be pumped at time of inspection)(locate on site plan)
Depth below glade:
Material of construction: concrete metal V&flberglass t' Dolyethylcne 4,14 other(explain):
Dimensions: R
Capacity: g allons
Dcsign Flow: , allons/day
Alarm present(yes or no):
Alum level: _ Alarm in working order(yes or no):
Date of last pumping:_A
Commenu (condition of alarm and float switches, etc.):
Tight o2 ho—Pd .ng ;tank-6 ate not /22e.6ent
DISTRIBUTION BOXA&&(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: A)A
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.):
17j'.tifni0ui!an Oax ii nc.- 2RP ipnf
PUMP CHAMBER: .e,.S (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump c amber, condition of pumps and appurtenances, etc.):
Pum2 ehamge2 i htauetuaaM .sound and 3how.6 no ev-.dence
Ponknc�v_
i •
8
i
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60 13a-idge S.t2eet
e�u.c e, a.a'�.
Owner:Paui $oTT3 e in
Date of Inspection:8114103
SOIL ABSORPTION SYSTEM (SAS): / (locate on site plan,excavation not required)
5-H.i.gh caRacitu .inJietzato2.6
If SAS not located explain why:
fornior/ .Soo pogo IQ R 104
Ty e
leaching pits,number: _
leaching chambers, number:f�- i�7%CftT7r$
4t leaching galleries,number:_CL_
leaching trenches,number, length: C
,00 leaching fields, number, dimensions: 0
All0 overflow cesspool,number: C)
innovative/alternative system Type/name of technology:�r��
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
L a-- - --ad f 0 gcl beem� �tne hand. No � i ynh o� h ycL2au P.ie ea i Pu2e
oa Inn_ r/��oiiA ate cL2y. Vege.tai-ion .i.e' no2fflu.e.
CESSPQQLM&ticesspool must be pumped as part of inspection)(locate on site plan)
Numbet and configuration: (')
Depth-top of liquid to inlet invert: N4
Depth of solids layer:
Depth of scum layer: jJ
Dimensions of cesspool: -
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.):
Ce,6,6 ociz ate not 2ezent.
PRIVW,(t . (locate on site plan)
Materials of construction:
Dimensions: IL14
Depth of solids: y�
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
a 904_100.eAl2nf
9
Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60 131Lidge St2ee.t
e2v c e,7 a .6.
Owner:'Paul Bo zn.6 e cn
Date of Inspection: 8174103 ,...,
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
1
10
TOWN OF BARNSTABLE
I. LOCATION Q SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
I 3G4
j SEPTIC TANK CAPACITY /�C pm �Qif
i
LEACHING FACILITY:(type) -` ' (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATE
BUILDER OR OWNER
i DATE PERMIT ISSUED: �Q
DATE COMPLIANCE ISSUED: "
VARIANCE GRANTED: Yes No
t�G 144 Po F c k
Z 59
• &Z6� I
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 60 Baidge Staeet
0,6 e2v.c e, aee.
Owner: 11auP Bo.,znetein
Date of Inspection: 8114103
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
1 _
Estimated depth to ground water feet .
•
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed: gF�y�/�
serve�sile utttng prop bservation hole within 150 feet of SAS)Checkedcal Boarr o Health-explain: '49 ha)ZI
Checked with local excavators, installers-(attach doc entati )
S Accessed USGS database-explain: ' �¢�► � � Ind //SJ
You must describe how you established the higgh gground water elevation:
heed: Gahzety � (7.i.P.Pe2 Plode.P 12/1F 4 Ga.ound watelz e.Pevati.oae o6ove eea Peve ,
U-6ed:1ZSGS: 09eeavat.ion we.P.P data ,tune 1992
11eed:1ZSGS • 7echnica.P gu.P.Pet.in 92-000- 1 PPate e2 Rnnua.P aangee o� gaound
wnip2 Q 4a4, nn._s. 2an.ia2u 1992
round
5 H. gh capacity
�:n�.i.Pt eat o2e
J/
��eet
Groundwater: Feet Below Bottom.of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the botto,✓m
Of the leaching pit and the adjusted groundwater table is DjJ'
feet. ,
11
I _
+•T.nT.-..1•f7r••TT�\\lf:J..f•rl/RTTR1Tt.1TtR•.IrIS�.TITRT'1f.n.1R.1L TlRI�11R\ .�r+r.Tr -• �
TOWN OF Ba/zn,3•ta&Pe BOARD OF HEALTH
SUI)SU11FACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CEIITIFICATION 1
•••Ti'f•r••••.:.-T.111.�..:1T1t\►\II'f1.'1TITT1lT\11A1T'��t'I\"IiRR't 1.Rlr•rTR�A�T�.�f7R� '
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 60 B2id9e Staeet Obtezv-iiie, Mazz. '
ASSESSORS MAP, BLOCK AND PARCEL # 116-90:3
OWNER' s NAME Pa" [3o?2eoteia
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J P Macomber & Soa Inc''.`
COMPANY ADDRESSBox 66 Centerville Mass. 02632
Street Town or Clty State IIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT '
I certify that I have personally 'inspected the sewage disposal system nt
this address and that the information reported is true , accurate , and
omplete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
--i-1/ System PASSED ;
The inspection lrhich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*.
The inspection which I hRve con Octed 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 ,
I
Inspector Signature
Date
nd copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEAL1'll.
* If the inspection FAILED, the owner or" perator shall upgrade
he ayste
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provid�d in 3.10 CMR 16 , 306 .
partd .doc
~t
ASSESSORS MAP NO- -
�� PARCEL NO: 11'a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF
,��.�ltrtt�i�it fnr �i��n�ttl nxk,� C���t��ixr#inn �.exmi�
Application is hereby made for a Permit to Construct ( ) or Repair ()oo) an Individual Sewage Disposal
System at:
................................................... !_. . ........................................................................
Location•Address or Lot No.
G✓�_�lr i--....•.••----•/-A................................................... .................................. ..............
Owner / Address
W ..........°�✓ i �l r�� !......._ ..:.... ._A i
Installer Address
Type of Building Size Lot................:...........Sq. feet
U Dwelling—No. of Bedrooms.....��-..............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............ No. of persons............................ Showers — Cafeteria
G4 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.
3 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •---------•••--•••-•--•-•----•-••••••..............••--------••-------...........................-•-•...-•---•-•••------...............................•••••.
0 Description of Soil....................................•--.........----•-••---•-•--------••--•---.._..............................•---.....................................................
x
W ---=----------------------------------------------------------------------------------
x Nature of Repairs jor Alterations—Answer when applicable.. ...!.TY......t7..fff......Zj.......
'�� .............-S 7> �3-•� . ....... .............................................
Agreement:
The undersigned agrees to install the aforedescribed Tndividtial Sewage Disposal System in accordance with
the provisions,of:IT,i 5 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 lie ,th.
Signed .`..... 9-51—
a
Application Approved BY---•-=... --••-•--- - ----•---- ------ --•-•--•-- .....r.......... ......................ate
Application Disapproved for the following reasons:................................................................................................._............
-•...........................•-----...---....-----------------...---------•-•---••--•---........_........•---•--•...........----•-------••-•.......••-•---••-•--••••.....-•-•••.......--•--.......•-•-•-
�� Dat,�,�
Permit No....... Issued..... .....`. ..Iti.......... .......
Date
t
T' ''_ALTH OF MASSACHUSETTS
z
No................_....._ FEx................
_...._
THE COMMONV%Q0.a t OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF -H �6C
, lirttt utt fur �9iu uuttlY1EVirks Tunutrurtiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair (>o� an Individual Sewage Disposal
System at:
Location•Address or Lot No.
-------------•-- .......:__ �:�;.t. ., ::.._...................................---•--................._...............
Uwner ...... C�._ •`-dr..!: .1._...._.,e,� :.. ✓._..__
Installer Address
�q Type of Building �..- Size Lot............................Sq. feet
.t Dwelling—No. of Bedrooms.__....................................:Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons........................ Showers
a g -•------._..-•--•-----...--- P ---- ( ) — Cafeteria ( )
dOther 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.
3 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li, Test Pit No. 2.....__.........minutes per inch Depth of Test. Pit.................... Depth to ground water........................
a -----------------------------------•---........_......._..-•---......_.......__.....--•••-•••.....••.........................................................
0 Description of Soil..........................................................................................................................................................................
W
U Nature of Repairs or Alterations—Answer when applicable.&????,e....._ .._.....t_e�t......
P
CdX.....__ ....... .....................
Agreement:
The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with
the provisions of TITiE 5 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.
Signed.l>.0-•--S,.. ....................................... �Z�s . .. '. .
Application Approved By.'` ........... ..... - '....... <�`.....:...a_:.........
�
P t
Date
Application Disapproved for the following reasons:....................................................................................... ._.....___...
.....................•----••-•-----•---•-----••-•--•----.._.......----...-------............------....-----•-••---.........._.................-•--•----------.....___....-----......._•----__-•••-•••••-
7 j Da
s
Permit No.....•....... .......... �� ._.._.:.... Issued...... •-........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
.'„ BOARD OF HEALTH
TOWN of YARMOUTH
Tatif irtttr of Tnmplittnrie
T IS IS CERT/jj-Y��t,,the Individual Sewage Disposal System constructed ( ) or Repaired.O
by
t"j.0 Z�✓L ;- ..y/, J/C aver
at............ ._..-•-•.......................................•-• ___._._._.......----•--•------•------••--•-----•---•-------•----...............................
has been installed in accordance with the provisions of TI I-LE ,of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._./`.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN TI N TISEACTORY.
6 !.../
DATE.....:................. ...!_`'-_ -•---.._...._...... ........_......:L��2y ................
THE COMMONWEALTH OF MASSACHUSETTS .
BOARD OF HEALTH
TOWN of YARMOUTH
No.:1. :. � Y FEE...�../�'��--G?�-�
�is�ru�tt1 urk� �urt��r,
Permission is hereby granted -�_!
._ ............................................. ....
to Construct ( or Repair ) an Individual Sea age Dis o System
'
atNo....&a.......... -S2 N-. ---------=s-`•---•-. .....-•------------•-• ------------------•--•-----_.._.._..--•-•--•--•-------•-•-•-••--••--•--....._.........
Street Q�� (�K / ��--'
as shown on the application for Disposal Works Construction Permit Nc ._.�._..'..U__:__ ted.......................�`. .
....................�-` �� .��. ._
lloanl of health
DATE `` '' ...
TOWN OF BARNSTABLE
LOCATION Q SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT,
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ' (size) ,
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATE
.BUILDER OR OWNER
�QZ
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED;
VARIANCE GRANTED: Yes No
__-, ---- ,
u� us
ASSESSORS MAP NO:—,
PMCMNO'
PROPERTY ADDRESS:_60 Bride Street_
Osterville
------------------------
Mass. 02655
------------------------
On the above date, I inspected the septic system at the above address.
This system consists of the following:
A. Three block Ceespools.
B. Main pool changed to react as a septic tank.
Based on my inspection, I certify the following conditions:
A. This not a title five septic sytem. '
B. Third cess pool in water table.
C. The sewage system system is in failure.Because of high water table.
D. Should be upgraded to a title five septic system.
` E. The sewage sytem is in proper working order at the present time.
SIGNATURE:
Name: J.P.Macomber Jr
Company:_J_P_Macomber_&-Eo.A-Inc.
Address:- Box 66 ----------- NMM
__ Centg�y J,a,Mass—Z2632 '066T Q add
Phone:_ 508_775_3338 __------ Q2JI/11Uz1Nl��
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTry
i
F0
CP. MACOMBER & SON, INC.anks-Cesspools-LeachfieldsPumped & Installed
Town Sewer Connections
66 Centerville, MA 02632-0066
775-3338 775-6412
04/04/1995 12:46 508-426-3508 C'.-.O.MM. WATER DEPT PAGE 03
KEY NUMBER <655 >
NAME <CALLAHAN, WILLIAM, F > B-C 1 B-C 2
C/O J CALL B-C 3 B-C 4
STREET 167 PORTLAND STREET
CITY ST JOHNSBURY ST VT ZIP 05819-2033 REF 1 REF 2
PHONE ( ) - REF 3 REF 4
METER NO.< 548> DATE READING CONS
STREET <BRIDGE ST NO. 60> 12/31/94 667 �43 )
CITY OST S ST LOC 06/30/94 624
PHONE ( ) - 12/31/93 622 284
06/30/93 338 . 5
ROUTE NUMBER 12 12/31/92 333 333
SERVICE DATE 07/18/41 06/30/92 0 0
METER DATE 05/13/92 05/13/92 0 0
CAPACITY 7 05/13/92 1128 0
STYLE T10
SIZE 1 RATE SCHEDULE
KEY PIT PLASTIC
NOTE RR LEFT SIDE RENTAL! ADDITIONAL CONS 0
ALTERNATE MIN 0
. g
draft 1113195
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property Go
Owner's name (and/or resident) 1, Pr j (P hA-n
Date of Inspection Iq(q5
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Healt
None of the system components have been pumped for.at least 30 days and the
system has been receiving normal flow rates during that period. Large volumes
of water have not been introduced into the system recently or as part of this
inspection.
�[ As built plans have been obtained.
✓ The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding the SAS, 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 SAS on the site has been determined based on
existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with
information on the proper maintenance of SSDS.
draft 1113195 9
_ SUBSURFACE SELVAGE DISPOSAL SYSTEAT INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
& number of bedrooms c N t �,,�{
ry c3,wJ G� S`fa-t:-s
b number of current residents
garbage grinder, yes or no S rvv
Y0t/ laundry connected to system, yes or no
YE✓ seasonal use, yes or no
If nonresidential, calculated flow:
_.� �13019 -3 �voo 644
Water meter readings, if available: 8 ,)4DL) 64-1
i Z
b �3°�y t 2i you JG.�
— Last date of occupancy 4 3' o o 644
LA $t SVy v- � ✓t�- z13i1gf
GENERAL INFORMATION
`. ..Inping records and source of information:
/00
Vo System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
Septic tank/distribution box/soil absorption system
_ Single cesspool
Overflow cesspools
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
Approximate age of all components. Date installed, if.known. Source of information: OLD Buse 11 20 - 19 ¢o
Sewaee odors detected when arrivinn at the 6te vec nr G)
r
draft 1113195
SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: - y�S I sf CL i SS o o
(locate on site plan) "� 4 cl '`� • � S o I►
ve sS Q — b i'tz w, b' 6.L�
depth below grade:
G u^fir-fa y r 4,d-e-_ ✓ r .
,r—
material of constructi n: oncrete _metal _FRP _other(explain)
dimensions: 3.7' 6'' D C eT H
sludge depth
1' distance from top of sludge to bottom of outlet tee or baffle
scum thickness
/A- distance from top of scum to top of outlet tee or baffle
distance from reom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for I umping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to
outlet invert, structura integrity, evidence of leakage, recommendations for repairs, etc.)
do oy l(
/mac w J 14%
DISTRIBUTION BOX: lU o
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distributi is equal, evidence of solids carryover, evidence of leakage into or out of box,
recommendation for repairs etc.)
drop 1113195 11
PUMP CHAMBER: Or-
ate on site plan)
pumps in worki g order, yes or no
Comments:
(note condition of purr, chamber, condition of pumps and appurtenances, recommendations for maintenance or
repairs,etc.)
SOIL ABSORPTION SYSTEM (SAS): W 5
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number leaching trenches,
number, length
leaching fields, number, dimensions
overflow cesspool, number 2 vvPr-�f�:,� cesfeoa is
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for
maintenance or repairs,etc.)
_ Y'C��R•re_ — /L�r S� JTF�, - �F}S 1-�c� �, (�rowoc�w'��
draft 1113195 x l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
i
CESSPOOLS:
(locate on site plan)
number and configuration 3
depth-top of liquid to inlet invert yE BHr.C. /�"
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater io5 Leve/ i&wo;NGs i ,u�o c qf'
inflow (cesspool must be pumped as pan of S �'`"'`� t''1 '- '"'' Fool 3
inspection)
Comments: - U,o S_Az;
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for
maintenance or repairs,etc.)
6:e4j /,Q��,n , s ' 6e%w �.,� a� 3�� ���j— rvti,� .41 /64//cA�-"6
(�r0 ✓NCP w11
ay— gt.�al�rnR„sLj
PRIVY: N//1'
(locate on site plan)
materials of constiuction
dimensions
depth of solids
Comments:
(note condition of soil, s ns of hydraulic failure, level of ponding, condition of vegetation, recommendations.
maintenance or repairs,et .)
drop 1113195 13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B _
SYSTEM MOR IATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Bn
13,0
��iU �"�� Nzo 5 6elvw
DEPTH TO GROUNDWATER
J,r' depth to groundwater r
method of determination or approximation:
v,#•4( yry [G� be d uj �vSe n l, , X�
i- .54t"rM1,9 A j q( 4 13egEwis 7b 136 6r6u,"a&jA- f—
I
r
i
�y
draft 1113195
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA4
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not
determined", explain why not)
Alb Backup of sewage into facility?
tiv Discharge or ponding of effluent to the surface of the ground or surface waters?
Static liquid level in the distribution box above.outlet invert?
M5 Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow?
00 Pumped 4•times or more in the last year? number of times pumped Aa�-+L.
NO . Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank
failure imminent?
Is any portion of the SAS, cesspool or privy:
� S below the high groundwater elevation?
�(b within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface water supply?
Ao within a Zone I of a public well?
No within SO feet of a bordering vegetated wetland or salt marsh?
within SO feet of a private water supply well?
less than 100 feet but greater than SO 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.
draft 1113195 15
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector
Inspector Number I191s , ) b a
Company Name
Company Address ox ZS B 1N yA-v ni +
Certification Statement
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported is true, accurate and complete as of the time of inspection.
Check one:
I have 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.
I have determined that the system fails to protect public health and the
environment as defined in 310 CMR 15.303. The basis for this determination is
provided in the FAILURE CRITERIA section of this form.
Inspector's Signature
Date
Original to system owner IN ILL I rh,-, C A-
P
Co ies to:
Buyer (if applicable)
proving authority
C>
I
1 .
rat �4;�';•t-t- .
• ( is ' - .;• -i\ .
AL-L f
� 3
IT
�. ' TOWN OF BARNSTABLE
0-3
LOCATION LOCATION Q SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT�L•�
INSTALLER'S NAME PHONE NO.
$. AA049 t
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATE
BUILDER OR OWNER
DATE PERMIT ISSUED: �- s--
DATE COMPLIANCE ISSUED: '"
VARIANCE GRANTED: Yes No �/'
•' N ` +t .y;Yam. •'N(..
c r � Po c k