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HomeMy WebLinkAbout0050 CHARDON LANE - Health 50 Chardon Lane, Osterville A= 166 - 107 r i 0 a F 4 i p� y f ` �I TOWN OF BARNSTABLE ✓ I:OCATION.��,ySQCN\, � • SEWAGE # " �?YLLAGEL2 aQ-01 U-2 < ASSESSOR'S MBA`P & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY�'��S� ®C)C LEACHING FACILITY: (type) v 2 2 kk-k-k (size) [�1TC ")((0y/ NO. OF BEDROOMS BUILDER O. WNER PERMIT DATE: �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 leaching facility) Feet Furnished by I3 0 -Jk,4, I u w iv u r LiA1c1v J I Ati L1:, `LOCA rION 6D C �WN� L#_4ZC- SEAEW��� VILLAGE ASSESSOR'S MAP & LOT rINSTALLER'S NAME& PHONE NO. SEPTIC TANK.CAPACITY g-_'714W 71*116 LEACHING FACILITY: (type) '�� i��7 (size) NO. OF BEDROOMS �5 BUILDER OR OWNER 76__r z '4�)xyn PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 leaching acili ) Feet.-* ; Furnished by i A o , C4 No. Fee _ THE COMMONWEALTH OF MA SACHUSETTS Entered in computer: CAY' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipphration for Zi Y stern Construction Permit Application for a Permit to Construct( " )Repair( Upgrade( )Abandon( ) ❑Complete System 0 Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. iao- �PL�- D� R WNP�� t ow Assessor's Map/Parcel � 02 e s Names s and Tel.No. Designer's Name,Address and Tel.No. WM 1k J Type of Building: X Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Natureof Repairs r Alterations(Answer when applicable) — CI S - i 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 provision e 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ue t-' Boar ealt Signed Date Application Approved by Date _ Application Disapproved for the olio g reasons Permit No. 3>3 Date Issued THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I A-- , I- M 7-�-C(LJL DA TA 1, ,..Y,,, :F_"-+a.. in.. �-.•� ,,,.•.s}.:.ram �� !'w.-.-^ r"� . .�..v'„--=w— "r- •.:{1 a'.... r -,.:..+.� ` _ h."tr-�yr ^+aF�,�.�L.r+•`vw, No. / �"' `� [(0 Fee Entered in computer: " �� THE COMMONWEALTH OF MASSACHUSETTS P ;.' . Lit{u` ��PUBLIC HEALTH'DIVISION —TOWN OF BARNSTABLE, MASSACHUSETTS Yes y Xh 21p,ptication for -Mi_qpo al *potem Conotruction Permit Application for a f erinit to Construct-(-'-J Repair( __. Upgrade( )Abandon{ ,J 11 Complete System ❑Individual Components Y± Location Address or Lot Owner's Name,Address and Tel.No. r Assessor's Map/Parcel- �st e1ri's Name Addr Map Tel.No Designer's Name,.Address and Tel.{No. !Y✓`� , AJ Type of Building: fit, J w Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) 'Other Type of Building No.of Persons Showers yp g ( Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ` - Size of Septic Tank Type of S.A.S. Description of Soil J � _ Nature.of Repairs Alterations(Answer when applicable) ...fy � U. 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 provision &e�5 f the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ue #yoard;(f)THealtSigned Date C4 Application Approved by 7" Date 4 9 r, Application Disapproved for the olio •ng reasons Permit No., 33! Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance ' THIS IS TO TIFY =h th�On-site Sewag Disposal System Constructed( )Repaired( `Upgraded Abandoned )by It �nld'�4 at ( .._ �1�� has been constructed ft accordance with the Rrovisions of Taff-5 d the for Disposal.System Construction Permit No. ��t° dated Installer ,;- tE�� � ��`���t ,.� Designer The issuance of this permit shall n,t be construed as a guarantee that the system wiilllfunction as designed.`J�' V Date 11� �.� W `' Inspector /� ———— -3 f' ---------------- 7 ------------=�— NO. Fee THE COMMONWEALTH OF MASSACHUSETTS 64 UBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSIETFS � l `!1)0 1-6petem Con5truction Permit ",ism uc t eRepair(A-')Upgrade )Abandon( ) tion for Disposal System Construction Permit. The applicant recognizes his/her duty to al provisions or special conditions. �mpleted within three years of the date of this permit. Approved by 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I' by certify that the application for disposal works construction permit signed by me dated concerning the property located at 5 + meets all of the following criteria: • The failed system is connected to a'residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) ` B) G.W.Elevation +the MAX. High G.W. Adjustment. D CE BETWEEN A and B J ., SIGNE DATE: [Sketch proposed plan of system on back]. q:health folder:cert 1 � s l 0 a o � Kzxc�' DATE : _1 /12/98 PROPERTY ADDRESS : 50 Chardon Lane Qgt-izrv; > > o,Mass . 02655- On the above date, I Inspected the s-eptic system at the above aCCress. This system consists of the following: 1 . This is a title five septic system. ( 78 Code ) 2 . 'The septic system is in proper working order' at the present time. 3 . Pump gray water tank annually. Garbage disposal is present. Sasad on my InPnactlon, I cerllfy the following coriditlons: 4 . 2-1000 gallon septic tanks. 2-1000 gallon precast leaching pits. SIGNATURE Nama : J . P . Macomber Jr .. Company: J . P_Macomber &_ Son-_Inc , �. N1 �. CenCervi1Le `Mas9__02632 '- T `S 1998 � HFg1rHp�jrAB(F �� Phone :_--SJS—_3338------- I C> THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY LRH P, MAGOMBER & SON, INC, T,nk C•upool►-1 hlleld� Pump+d L Inat.11lyd Town Sower ConnoctIon{ x 60 ' Centerville, MA 02632.0066 115-3 3 38 115-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617.292.5500 u ILLl.4N1 F WELD TRLD1'CO\E Go%cmor Sccrctan ARGEO PAUL CELLUCCI DAVID B STRUFLS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr PART A CERTIFICATION Property Address: 50 Chardon Lane Osterville MA Address of Owner:333 Oakharbor Drive Date of Inspection:1 /1 2/98 (If different) Juneo beach Florida Name of Inspector: ,TOGcPDh P_Macomber Jr. 33408 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: BOX 66 Centerville,Mass . 02632 Telephone Number: r;08_7.75_*j-j-jft 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails / p Inspector's Signature: Date: The System Inspect all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this ins oion If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspect w or and the system owner shall submit Pe Y Y g the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the sys7em owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: - I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303 Any failure criteria not evaluated are indicated below. COMMENTS: 81 SYSTEM CONDITIONALLY PASSES: fC,�} One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (raviaad 04/25/97) Page 1 of 10 DEP on the World Woe Web: http:1twww.magnet.state.ma usrdep {j Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Chardon Lane Osterville,Mass . Owner: Frederick Lapham Date of Inspection: 1 /12/98 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the Oisuibuti� �is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ,&20 Cesspool or privy is within 50 feet of a surface water D 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ,D The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. Q�D 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 50 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 Ali - (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 '1\ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Chardon Lane Osterville,Mass . Owner: Frederick Lapham Date of Inspection: 1 /1 2/98 DI SYSTEM FAILS: You must indicate ei;•.er "Yes" or "No" as to each of the following: _j2d I have determined that the system violates one or more of the following failure criteria as defined 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 L� Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. L[/A,()tL-- Static liquid level in the Aistribution box above outlet invert due to an overloaded or clogged SAS or cesspool 4644A r5 Liquid depth in cesspeal is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets). Number of times pumped 411. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the 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" as to each of the following: The following criteria apply to large systems in addition to the criteria above: _Z.42 The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 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 II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program i f requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office o the Department for further information. 7 (revised 04/25/97) Pegs 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 Chardon Lane Osterville,Mass . Owner: Frederick Lapham Date of Inspection: 1 /12/98 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes N Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks 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 and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tankS manholeswere 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 on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. 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) (15.302(3)(b)) (revised 04/25/97) Pay• 4 of 10 Cl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 Chardon Lane Osterville,Mass . Owner: Frederick Lapham Date of Inspection: 1 /12/98 FLOW CONDITIONS RESIDENTIAL: Design flow: TWO Q.p.d./bedroom for S.A.S. N'umber of bedrooms: 07 plumber of current residents: 0 Garbage grinder (yes or no):_&S Laundry connected to system (yes or no):� Seasonal use (yes or no):"-kCi Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):_Q Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: ti14 Design flow: AJA gallons/day Grease trap present: (yes or no),,J& Industrial Waste Holding Tank present: (yes or no),Aio Non-sanitary waste discharged to the Title 5 system: (yes or no1� Water meter readings, if available.d/�9 Last date of occupancy:�� OTHER: (Describe) ti/ft Last date of occupancy: j GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)�.�l If yes, volume pumped: gallons Reason for pumping: - 41* TYPE OF SYSTEM � Septic tank/d444NAiaw x/soil absorption system ,e/c7 Single cesspool '41,21 Overflow cesspool �Q Privy �/ Shared system (yes or no) (if yes, attach previous inspection records, if any) Vd I/A Technology etc. Copy of up to date contract? Other _ 't-'4 APPROXIMATE.AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Chardon Lane Osterville,Mass . Owner: Frederick Lapham Date of Inspection: 1 /1 2/98 BUILDING SEWER: (Locate on site plan) IJ Depth below, grader Material of construction: cast iron 40 PVC _ other (explain) Distance from Ovate water supply well or suction line Diameter 4` Comments: (condition of joints, v nting, evidence of leakage, etc.) +, 'J c � T 1 Y� � SEPTIC TANK:,/ax--J7Ado,,J M4)�r (locate on site plan) K! Depth below grader Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance I (Yes/No) Dimensions r//v" - 1 �!� GU •� ✓� L Sludge depth:' Distance from top of sludge to bonom of outlet tee or barfleTA, Scum thickness:T� Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bono of outlet tee or baffle: �� How dimensions were determined: Comments: (recommendation for pumping, condo n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 74 > e AET ;Z— 124T �e 1 �' / 2 C C� `i � GREASE TRAP: (locate on site plan) Depth below grade: Material of construction;t 14concrete4!,&r,etal JL4Fibergl ass AAPoI yet hylene4))other(explain) Dimensions: IV Scum AJ14 Distance from top of scum to top of outlet tee or baffle: A[, Distance from bottom of scum to bottom of outlet tee or baffle:.A),o Date of last pumping: 43114 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.) rc� 8 n_k 32 (revised 04/25/97) page 6 of 10 , /TT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Chardon Lane Osterville,Mass . owner: Frederick Lapham Date of Inspection: 1 /1 2/98 TIGHT OR HOLDING TANK: B�fTank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grader Material of con struaion:,v4concrete 1V4meta1,L/,4FiberglassA_4PolyethyleneV, other(explain) A Dimensions. A)h Capaciry: AAA gallons Design ilow: 6)gallons/day Alarm level._N,Alarm in working orderer Yes, Vl Nu Date of previous pumping: NIf Comments. (condition of inlet tee, condition of alarm and float switches, etc.) �'B T DISTRIBUTION BOX:/Z12t' (locate on site plan) Depth c' IiQjid level above outlet invert: 4�,4 Comments. (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No)A4 Alarms n working order (Yes or No)-V—/-9- Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r.vis.d 04/25/97) P.g. 7 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Chardon Lane Osterville,Mass. Owner: Frederick Lapham Date of Inspections /1 2/9 8 SOIL ABSORPTION SYSTEM (SAS):' ;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, number. leaching chambers, number: 0 leaching galleries, number:= leaching trenches, number,length: leaching fields, number, dimensions: L' overflow cesspool, number: Alternative system: ) Name of Technology: 7 zr.& Comments: tnote condition of soil, signs of h draulic failure,Plevel o ponding, condition of vegetation, etc.) ) .>i4 !i St Le- /c /rt late— 4 CESSPOOLS: (locate on site plan) Number and configuration: �✓9 r Depth-top of liquid to inlet inven: A Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: JiL Indication of groundwater: N' inflow (cesspool must be pumped as part of inspenion) Comments: tncte condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) S stO�c s e VM7- P RI VY:/l�c✓L� (locate on site plan) Materials of construction: Dimensions: lkt�11_'A Depth of solids: Comments: (note condition of soil, signs pf hydraulic failure, level of ponding, condition of vegetation, etc.) 27>r-27- Ore id-de77 (r•vls•d 04/25/97) Yag• 6 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Pfopen. Acdress: 50 Chardon Lane Osterville,Mass . 0. ner: Frederick Lapham Dite of tnspect�on:1 /1 2/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 (locate where public water supply comes into house) �1 Q � r � I � r \ 1 / I � I gyp,\ L-F t SUBSURFACE SE%VAGE DISP1 SYSTEM INSPECTION FORM t C SYSTEM INFOI. ;ON (continued) Property Address: 50 Chardon Lane Osterville,Mass . Owner: Frederick Lapham Date of Inspection:1 /1 2/98 Depth to Groundwater /t7 feet ?lease indicate all the methods used to determine High Groundwater Ell;:ation: Obtained from Design Plans on record _�/Observation of Site (Abuning paoperty, observation hole, basement s imp etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps heck pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High GrouncloaurElevation. Must be completed) Used Ground waters contours Map Based on Gahrety & Miller model 12/16/94 (r.vis.d 04/25/97) Pic. u! 10 y+•ran r+�nirv—�^r-ieir:err.•nmrr�+.-ren.rrr.:•.�+•+e+o.r:•rr.-srnm mitt na-srrer.rn� .. .re.-r.�- .r-.T--..-.._. . I1 TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION fI �„ �'•.•-•^-r••.-•. --..r.^.-.-r1':-:n•n.�nirsrrrrrrr•r.�•.��+.:•n+-�.rmer`.'rt+r•rs+ra�rerorrmre.-cr•� .�mn•mrrr��ty-rrr.rr+r.—.r r.- r•�. -. ^ -TYPE OR PRINT CU ARLY- PROPERTY INSPECTED STREET ADDRESS _ 50 Chardon Lane Osterville,MaSs _ ASSESSORS MAP , BLOCK AND PARCEL # 166-107 OWNERRIs NAME Frederick Isapham PARV D - CEIRTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Serfi 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City Stat• i►P COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1578 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 complete 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 : _2/1sYsteui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe 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 \\40cted has found that the system fails to Protect the 'public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature d. Date 1 /12/98 sue....--p:�-..T��T�.-. ..�. One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF 112AL1'll. * It the inspection FAILED , the owner or " perator shall upgrade • the aystem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CDJR 16 . 305 . partd . doc l , 9 :v ti kv THE CONMONWVEA.LTH OF MASSACHUSETTS DEPARTMENT OF ENY MONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CER + i D TITLE S SYSTEM INSPECTOR as provided in 310 CMR 1 S_340 and Section 13 of Chapter 21 A of the General Laws . Issued by The Department of Environmental Protection. )unc 8 1 S --- AcunH Uiccctor of (tic O�, cSuon U( Witct Pollutic)n Control j t��! TOWN OF BARNSTABLE LOCATION, O 5.�A �f�`J��Yl� . SEWAGE # -3 VILLAGE_ !C ���I( t ASSESSOR'S MAP & LOT — !,� INSTALLER'S NAME&PHONE NO. C Q 711 C—a6q SEPTIC TANK CAPACITY ' LEACHING FACILITY: (type) � (size) X, r3(y NO. OF BEDROOMS 3 I BUILDER O WNER I PERMITDATE: COMPLIANCE DATE: i Separation Distance Between the: I Maximum Adjusted Groundwater Table to the Bottom of Leaching Y Facilit 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 leaching facility) Feet Furnished by f 6 b = "A ,' LX 4-01 6 - LOC&TION 5EW&(:,E PERMIT UO. - IWSTQLLER5 IJ&ME ADDRESS j BUILDERS Q &VAE �. ADDRESS DATE PERWT ISSUED =-V-7� -I - - - DATE CONMPLI L1,t`10E ISSUF-D :. ��/�Z { ►'� � ��' � � t r �� of j , ?