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Home My WebLink About0019 CROSBY CIRCLE - Health y 19 Crosby Circle Osterville - A=116-015 e o r e r' Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address i t� c7lM 1 ` Oft 2�sG_ Owner Owner's Nome Information required is n5�\)\ \� required for every page. CihflTown state Zip Code i5ate of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered In any way. Ir"p°fl"t When filling out A. General Information forms on the �C(! computer,use 1. Inspector: only the tab key ® to move your cursor- not N me of Inspector L keey the retet urn n (� Q p y ompany ame Company Address M0&a,pe Cif �ZZIo 4 G Cityrrown — state Zip Code -- .'50c, —aral--50o?i Telephone Number License Number B. Certification 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: -- Passes ❑ Conditionally Passes ❑ Falls 1 Si. ❑ Needs Further Evaluation by the Local Approving Authority C to 16 (0 1 pector's signature Date ram` The system inspector shall submit a copy of this inspection report to the Approving Aut ority(BWrd of Health or DEP)within 30 days of completing this inspection. If the system is a shar 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. """"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. tblrap.doc•080 Tide 6 Olrklel Irrspe¢tba Form:Subsurface Sewage Disposal System•Page 1 of 16 Commonwealth of Wesachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments tA P pe Address Owner Owner's Name1 d iequire tion Is (v) required for every page. chyfr� 16 State Zip Code f Inspeetion B. Certification (cunt.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) S y toPasses: 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as 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: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health), ❑ broken pipe(s)are replaced ❑ obstruction is removed Wrtsp.doc•08M Title 5 Orticlal Inspedbn Form:Subsurface Savage Disposal System•Page 2 of 16 Commonwealth of Massachti6etts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ---j Owner er's Nam ma Infortion is , g e t t A- 16[1 required for e V l \ every page. &to Zip Code Deta of inspe ion B. Certification (cons.) B) System Conditionally Passes(cont.): ❑ 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: 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 public health,safety or the environment. 1. System will pass unless Board of Health determines In accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ 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 SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 151nap doc•011D5 Title 6 Official Inspection Form:Subsurface SaMpe Dlepoeal System•Page 3 of 15 CommonweaM of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments gyAddress Owner ame information Is required for � ��`j - _ � Aw 0 every page. CitylTawn Ste Zip Code Date`olrinspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health(cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El clogged of sewage into facility or system component due to 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 ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than B" below invert or available volume is less El than'/day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ %gl Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5lnsp.doc•08M Title 5 Official Inspeclbn Form:Subsunace Sewage DNposai System•Page 4 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property ddres Owner Owner's NameInforn Q required atbn is v �y� f1 required For every page. Cf y[rown state Zip Code Date of Ins eation B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ Any portion of a cesspool or privy is within a Zone 1 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. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria Indicates absent 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 and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ k� The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the . system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5IMp doc•08M 'rite 5 omdal irmpectlon Form:subsurtace smoo Dl wsi ep%m•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;Z��(v 14UQ.,T` Azl$c _ _ oPe rty Address Owner is Name E Information is required for 6SI—C e I/t I(( ', -- — %J #-z every page. Ci ylI own S to Zip Code Da of In pecd C. Checklist Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant,or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? °� ❑ Has the system received normal flows in the previous two week period? ✓❑` Have large volumes of water been introduced to the system recently or as part of this inspection? ig ❑ Were as built plans of the system obtained and examined?(if they were not available note as NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components,excluding the SAS, located on site? V] ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ❑ b--Jp Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] Wrtsp.doc•08M TWO 6 O IMI In$M tbn Farm:Subeurfaee SM04P Disposal System•Page 6 of IS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -L We _ Property.�Address Owner war ee s Name Information Is required for every page, dy C' /To 5tete Zip Code Date of In pectin D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes No Laundry system inspected? $U Yes ❑ No Seasonal use? Yes [] No Water meter readings, if available(last 2 years usage(gpd)): " Sump pump? ❑ Yes [ No Last date of occupancy: �csh�dl� �•-- Date CommercialAndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd), Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): — t51nsp.doc•08M Title 5 Olfldal Inspedbn Poem;SubWftc6 Sewage DlePosal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1.11-1tatl— P party,Address Owner ees Name Information Is required for _ — every page. City own tote Zip Code Da*a1lbnipecdon D. System Information (cunt.) General Information Pumping Records: oft Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: fGti Were sewage odors detected when arriving at the site? ❑ Yes No t5lnsp doe OW6 TMe 5 ORkial I repedbn Form:Subsurhae Sewage Dloposal System•Page a of 15 Commonweaakh of Massachusetts _ Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ddres�s — Vi OwnerInfo Owrlar s Name redfo is required required for every page. Cityfrown to Zip Code D of specti n D. System Information (cunt.) Building Sewer(locate on site plan): j Depth below grade: et Material of construction: ❑cast iron g4o PVC ❑other(explain): Distance from private water supply well or suction line: feet' Comments(on condition of joints,venting, evidence of leakage,etc.), Septic Tank(locate on site plan): Depth below grade: teat Material of construction: XConcrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 1 vL Scum thickness � G! Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle }low were dimensions determined? �a t6Urep.40t:•080 Title 5 oftlat trrepeftn Form:Stlb Arse Sewage Dlepm]Syet m•Page 9 o116 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Ma-6 Disposal System Form -Not for Voluntary Assessments �P operty p Address Owner Owner Owner's Neine Information is K �1,11i required for ��'� Q _' ��— tA lin every page. City/Town SfElfe Zip Code Da of nape on D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Traplocate on site plan): ( P ) Depth below grade: feet --_ Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene y El other(explain): t51nsp doc•OBM Title 5 dial rnpedlon Porn:Suftrtgce SeMage Disposal System•Page 10 of 16 , Commonwealth of Massachusett$ Title 5 Official Inspection Fort Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro rty caress Owner owner's Warns Ile required /�� ,a )L n �' required for l �Ylr`W Y Cle every page. City/Town to Zip Code Date of I spectlon D. System Information (cunt.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). is copy attached? Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert � QCQ e.j ®�� U�`�� 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.): a Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t6hap doc•MM Tdle 5 olB W Irgn tbn ram:Suuaurace sempe DjWm=l System•Pape 11 or 16 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name Informrequired tion is (CST _��y U� In fa required for y�1� U —__ every page. CityCity/Town state Zip Code We of in sPctio D. System Information cunt. y (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number: leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length leaching fields num ber, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): 5MA Ab 5-45i�0 '& dif--6J8966a"e Dtk" tstnap•doc oafOB TIN 5 Offklal lnveatbn Form:Subsurface Sewage Mpasaf System•Page 12 ar 16 Commonwealth of Massachusetts 1WTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 pe Address Owner er's Name InforrrotIon Is required for every page. Cky/Town State Zip Code f Inspect ort D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow El Yes No Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): tsImp dw•08/06 TO 5 tJRkNI Irppedbn Form:8ubeurhee Bsnip 01spoul8yeMm•PaOe 73 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ag 6 WMT- -Prqpenypodress Owner owner's Name required is /pj�o��t if(1„ required for CJ� �[.1s UL/ — I A lat,3 every page. City/Town state Zip Code Date of inspe6ftn D. System Information (cont.) 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. lu �Z Ell it � 3 I 4 + _ tS C4-32 33 -a7 63 30 P Mnsp doc•080 Tdfe 5 Official In*eftn Form;Suf= toe SWA95 Dlaposal Sysbm•Page 14 or 15. o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments kddret 6T— O ss Owner � -- wner's Name Information Is (p110 ®c required for Zip Data Ins action every page. City/Tovrn P Code P D. System Information (cont.) Site Exam: heck Slope W11's-urface water �h k cellar Shallow wells Estimated depth to ground water: feet _ Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Q Nrk l,(x �Il, t5lnsp.doc•ow Titles of ial Inspeftn Form:subsuftes sompe Disposal sodem•Page 16 o116 �OP /a, D AT E: 7/1,,/98N , J PROPERTY ADDRESS: 296 West Bay Road . Osterville,Mass. cra �f,' 7 Igo TOWN OF BARNST 02655 , HFATLH"pEpr. LE t On the above date, I Inspected the septic system at the above add=ra;g: This system consists of the following: 1 . 1 -1500 gallon septic tank. 2 . 1 -Distribution box, 3 . 8-infiltrators. Based bn my Insoactlon, I certify the following conditlons: 4 . This is a title five septic system. ( "95 Code ) 5 . The septic system is 'in proper working order at the present time. 6.. - The system was installed in June of 1995 . Permit # 9571559 7 . Installed by J.P.Macomber & Son `Inc. SIGNATURE': Name J_P M_acomber Jr_, i .Company:_J• P_Macomber & Son_Inc , Address• __Cente_rvilLeLMass__0.2.632 ` Phone• ' •---50.8...Z7�..-3338------- ' 1 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tank&-Ceupool&-Leachflelds . Pump#d & Installe•d Town Sewor Connectlons P.O. Box 66' Centerville, MA 02632.0066 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292.5500 W1LL1ANI F.VELD TRUDY CO Govcmor Sccrct ARGEO PAUL CELLUCCI DAVID B.STRU Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissio PART A CERTIFICATION Property Address: 296 West Bay Road Osterville Address of Owner: Date of Inspection:6/3 0/9 8 Mass. (If different) Name of Inspector: JoseAh P.Macomber Jr. I 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: 508-775-3338 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: asses -_ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails w . Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system own< 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: B) SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass' section need to be replaced or repaired. The system, upo completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yeses no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. /l 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; c a= the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tans 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. (revised 04/25/97) Peg* 1 o1 10 DEP on the World Wide Web: http://www.magnet.state.ma.us/dep Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 296 West Bay Road Osterville,Mass . Owner: Estate Of Virginia Fuller. ATTN: Melissa Tavilla Date of Inspection: 6/3 0/9 8 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced ,Z 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: &A 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: Cesspool or privy is within SO feet of a surface water Cesspool or privy is within SO 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: 416 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. 06 The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. tO The system has a septic tank and soil absorption system and the SAS is within SO 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 SO 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 S ppm. Method used to determine distance •fJ (approximation not valid). 3) OTHER VIff (zovl.aed 04/25/91) Yaq• 2 of 10 . 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 296 West Bay Road Osterville,Mass. Owner: Estate Of Virginia Fuller ATTN: Melissa Tavilla Date of Inspection: 6/3 0/9 8 D) SYSTEM FAILS: You must indicate ei;r,er "Yes" or "No" as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CN1R 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 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. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth inees9peel is less than low invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El 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: 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 Np ��dd the system is within 400 feet of a surface drinking water supply Ir the system is within 200 feet of a tributary to a surface drinking water supply A-97 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 requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 296 West Bay Road Osterville,Mass. Owner: Estate Of Virginia Fuller Attn; Melissa Tavilla Date of Inspection: 6/3 0/9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No , Pumping information was provided by the owner, occupant, or Board of Health. (� None of the 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,akcluding 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 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)) (seviaed 04/25/97) P&qo 4 of 10 t SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTIO-N FORM PART C SYSTEM INFORMATION Propen, Address: 296 West Bay Road Osterville,Mass. oNner:Estate Of Virginia Fuller. ATTN: Melissa Tavilla Date of Inspection: 6/30/98 FLOW CONDITIONS RESID_ ENTlay ti Design tlo�. �. dibedroom for S.A.S. lumber of bedrooms:cJ -Number of current residents: Caroage gander (yes or no) Laundry connected to system (yes or no)." Seasonal use Ices or nol.h& � = 1,70 't'✓`�� .� Water meter readings. if available (last two (2) year usage tgpdt: a " ,U� r Sump Pump lyes or no):&, / <G� g044W r5 /'Z F6 Last date of occupancy COMMERCIAUINOUSTRIAL: Type of establishment:_ Design flow:/_gallons/day Crease trap present: (yes or no)" industrial waste Holding Tank present: (yes or no)AO Non-sanitary waste discharged to the Title S system: (yes or no)/ Water meter readings, if available._ .(O Last date of occupancy: y OTHER: :Describet � Last date of occupancy, CE-NERAL INFORMATION Pu."PINC RECORDS and source of i f rmatfon. , Od� *1 A 0 System pumped as pan of rnspeclfon: (yes or no)-Ap If Yes. volume pumped: gallons Reason for pumping rypi OF Septic tank distribution box./soil absorption system Single cesspool —4/0 Overflow cesspool Privy NO Shared system (yes or no) (if yes, anach previous inspection records, if any) _44VIL UA Technology etc. Copy of up to date contractif Otheroll APP OXIMATE ACE of all com nee�niss_d�ate f stalled (if known) and source of information: o S,e-jge odors detected when arriving at the site: (yes or no)" tr•�3••d O�/1S/f)1 ��y• 5 of 10 • � 1 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 296 West Bay Road Osterville,Mass. Owner:Estate Of Virginia Fuller ATTN: Melissa... Tavilla Date of Inspection: 6/3 0/9 8 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron 4 40 PVC_other (explain) Distance from private water supply well or suction line *0 _ Diameter !� Comments: (condition of joints, venting, evidence of leakage, etc.) Joints agpear System is vented tnrougn tne nouse vent. _ SEPTIC Q TANK:L 6DO hljo 9; (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list ag e Is age confirmed by Certificate of Compliance.t/•y(Yes/No) Dimensions: r`pl �8u�i V,7iil7 Sludge depth: r�tl�i Distance from toe_2f sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle:ZAGs Distance from bottom of scum to boAm of outlets)tee or baffle:ldeL- How dimensions were determined:.lwSIA(i�.�d, 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.) pump tank every 2-3 yParc; _ Tnl Pt R rritl et tees are in place, mhP tank i g qf-rnr�iir�l 1 y%Qilnd an shows no signs of leakage. GREASE TRAP.�!/ lP— (locate-on site plan) Depth below grade:40 Material of construction-ANconcreta?lmetabf) iberglasSllPolyethylene2other(explain) AW Dimensions: AN Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sc to bottom of outlet tee or baffle: Date of last pumping: i Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,-etc.) Grease trap is not present. (revioed 04/25/97) P&90 6 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 296 West Bay Road Osterville,Mass. Owner: Estate Of Virginia Fuller ATTN; Melissa Tavilla Date of Inspection: 6/3 0/98 TIGHT OR HOLDING TANK:�aank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:AM Material of con struction:A/Rconcrete V/6etalNRFiberglassdPolyethylene f they(explain) Nft t Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order'U�Yes;0 No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) !lV r®r uUq 7W -0 " Ar Z Ir-19 di - DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: AO Comments: ( ote 'f Lev I and d�ibution is equal, evidenFe of solid .car over, evidence of leakage in or�out of ox, etc.) e r^ tPY� PUMP CHAMBER:-&av . (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) J�rA i (revised 04/25/97) P.g. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 296 West Bay Road Osterville,Mass . Owner: Estate Of Virginia Fuller. ATTN; Melissa Tavilla Date of Inspection: 6/3 0/9 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, num ?A ber: Jt)A11'AT Dr7 leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: 12 overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to medium fine sand:No signs of hydraulic failure or ponding: Vegetation is normal; ThP system is nrPsently dry - CESSPOOLS: (locate on site plan) Number and configuration: b Depth-top of liquid to inlet invert: AM Depth of solids layer: Depth of scum layer: If 114 Dimensions of cesspool: WAI Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Cesst,00ls are not present. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not present, PRIVY: Qi (locate on site plan) Materials of construction:_ Dimensions:_ /W Depth of solids:,&& Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not present. (revised 01/2S/97) ?&go 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propeny Address: 296 West Bay Road Osterville,Mass. O nor: Estate Of Virginia Fuller. ATTN: Melissa Tavilla Date of Inspection: 6/30/98 SKEZCH 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) - — ----- �30 Rj� ) �3 111d � I i C . (s•vi�•d 0 /�f/f7) P•y• 9 of 10 l SUBSURFACE SEWAGE DISPc_;S:;L SYSTEM INSPECTION FORM Pr•.i:7 C. SYSTEM INFOR:,i .PION (continued) Property Address:296 West Bay Road Osterville,Mass. Owner: Estate Of Virginia Fuller ATTN; Melissa. Tavilla Date of Inspection: 6/3 0/9 8 t Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elwation: Obtained from Design Plans on record Observation of Site Abuning pro e , bservation hole, basernert sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps _zcheck pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Gfoun&'rerElevation. Must be completed) Installed system in June of 1995 Used water contours Map Gahrety & Miller Model 12/16/94 (revised 04/25/97) Pag« 160f 10 ]•wnrlTlrnt•ITr.T-\'i►�mf'n1iRRT.1.Ti.IT.RrilrrTrRlIT.R.*RT\TTT.L I�Y'�]1iP1IiT �s�-m:n•:cnaro.r•n-n:-�•-.�r,:rr-:..�..r... TOWN OF Barnstable WARD OF HEALTH SUI)SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION `� F^•TT•1�T•:-::\-T.IIT.�.�TT4Tt T.R1•.I.N.T+t]r.4T\IT]�T1:.�t•Ir.V]\rY�l'lrmr-1'TTCOv�Ri�.f!'.w'RTf Innn7+srr++r[ip�Trnnrrr.•.rrrr•rr-1 �...! -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS _ 296 West Bay Road Osterville,Mass _ ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Estate Of Virginia Fuller Attn; Melissa Tavilla PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber JR. COMPANY NAME J.P.Macomber� & Soft Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 . Street Town or City State LIP COMPANY TELEPHONE (508 1 775 - 3338 FAX ( 508 790 - 1578 w CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system 'at 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 : System 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 con icted has found that the system fails to protect the jiublic 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 Date 60- One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF 11RAL1'1I. If the inspection FAILED, the owner or• 'o' erator shall upgrado ' tho system * i p within o'ne year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 . partd .doc r •S/ w - 1 7 - r1, ti b THE COMMONWEALTH OF MASSA.CHUSETTS DEPARTMENT OF ENVIRONMENTAL 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 CERTIFIED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. Acting Dircctt>r of Elie l)' -iur, uI Water Pollution Control ram.; IO"SFBARNSTABLE LGCATI014 SEWAGE # VILLAGE C`TL LIt a ASSESSOR'S MAP &LOT ` " . e INSTALLER'S NAME&PHONE NO. �i �I �'Y1 jqPDIM&✓' St711 'T-n SEPTIC TANK CAPACITY t5Z0O LEACHING FACILITY: (type) 551- 7,r7 WF r iklZa4OR5 (size) NO. OF BEDROOMS BUILDER OR OWNER Va ,,, r t�SC�-e.✓ PERMITDATE: f 5 :J OMPLIANCE DATE: S— 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 facility) Feet Furnished by ' � I o� n� f TOWN OF B TABLE 0 ,3v,/5 7' �' fr_GC.�TION SEWAGE # VII,LAGE ASSESSOR'S MAP & LOT, C� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type`L)), (size) NO.OF BEDROOMS BUILDER OR OWNERI� 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 d aching Facility(If any wetlands exist within 300 fe o e fig fa ' ' Feet Furnished ( 30 n J s�i a jb 16P �� w P,s ;r Ig A y �J 30.0 THE COMMONWEALTH OF MASSACHUSETTS J — G 5 BOAR® OF HEALTH TOWN OF BARNSTABLE Apphrattutt for Di-tivu!3ttl Worbi Tomitrurttutt ramit Application is hereby made for a Permit to Construct ( ) or Repair ( Xk an Individual Sewage Disposal System at: .29.6....Wes.t._ ay-b...ROad...0stterville............... ------------------------------------------------------------------------------------------•------- Location-Address or Lot No. uigj rij-a..Fu1.1.ex------------------------------------------------------- Owner Address a J_P Macomber...-Jr-_------------------------------•-----------•----_----y ---------------.......--------.-....----------•-------•-----------•------------••----•--.......... Installer Address Type of Building Size Lot............................Sq. feet DwellingX—No. of Bedrooms.........3---------------------------- ---Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - --------------------------------------------------------- W Design Flow---------------------------------------------gallons per person per day. Total daily flow..-.-......-.--..-----..-.-_-__----------...gallons. WSeptic Tank—Liquid capacity-----------gallons Length...------ Width--------------_ Diameter..-------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet-------------------- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit_................. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.--.....---.....--.. Depth to ground water...........---.----..... --------------------------------------------------------------------------------••---•-••--•------------------ -... ------_-----------•... -••--•--......-...-.. ODescription of Soil-------------------------------•----------------------------:-----------------------------------.... ---------------------------------------------------.....----••----- xSand &...Gravel........................................................................................................................................................... v W ---------------------- -------------------------------------------------------- -------- ----------- ----------------------------------------- .................................................... UNature of Repairs or Alterations—Answer when applicable----Re1_a-cer t.--Q-f..-Cave-d....],n...Ce.:z.5p.w.] ......... 1-1 500...gpjlon...tank....1--A stribut on.--box-_-8---inflltrator_s---pac-keel---ia...a oae...-_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Cer ' 'cate of Complia ce has b e ssu d by the po,;pd of health. igned .... - -d--- - ------------ ------------------------------- 6./.1---19t�......... ---/-- Alication Approved B ---- ..... . . ............. .. .. - ��.? �( PP PP Y to Application Disapproved for the following reasons. ............................... ......._..........................._........................... . --------------- ..._---------------------... ..... - ...:_.. ......�Dare.................. 7 Permit No. ✓ Issued .........../// . �------ .................. G ate $ 30.0 No.7-----•---..._.... � FE$............................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH s TOWN OF BARNSTABLE Appliration for Diispwml Work.6 Trim fr�>ltrtion runtit ` I Application is hereby made for a Permit to Construct ( ) or Repair ( X= an Individual Sewage Disposal System at: f .Z �1. Gle ..R yk�.•Rn ...C2 4 €? y a ........ •-----------------•--•---•••••-----•----•---------•-......... Location-Address or Lot No. ...........................---•----•----------------- _--------------------------•-------•-------•-----•----------------...................... Owner Address aP Mar tnhar .Trm.................................................... -••••-•••••--------•••-••-•-•--•--•••----•-----------------•-•--••---........-•--•-•.............. Install-r Address d Type of Building Size Lot............................Sq. feet U Dwelling)No. of Bedrooms._._.-_--3--------------------------------Expansion Attic ( ) Garbage Grinder"`("" ) f a Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow...........................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width--_-.._------ Diameter----.----------- Depth-_--.-_----..... x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter..------.-.-..------ Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water...................--... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-..----. --._:..--_--. �+ ---•---------------------------------------------------------------•----•-----------------...................---------•--•------------....--•••••----.---•-- 0 Description of Soil........................................................................................................................................................................ --•••-•.Sand--& Gravel ....................................................... UNature of Repairs or Alterations—Answer when applicable...RP14pgnt__Of___caved__in_-_cesspool________. 1-1500 cla.....on_. tank._ 1---di.st.d.buta._on-_.box.8___in f iltratflrs___pac3 ed___in...s ong--___. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has Zb/en�`ssued by the boar of health. Signed f.1.1.��.l - Application,A roved B ... ��('. ----- -- ------ ------- --------------� __!. ... ._....PP PP Y � ._... - v - Application Disapproved for the following reasons: ------.-- / .......-----------. .. -- .. Da --------------- Permit N . / - ..� re------ --.r a=e.----------.emu-sae—�a.�.r a��e--.e.—o— --`.— -----u-e�c...._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�Ertifira#e of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XX ) �� J P Macomber.-.Jr:. by ... .................. . ....... - .. ......-- ---------------------------------------------------------------------- ........................ at .....296...West Bay Road---Ostervi.11e----------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE of hep tate„ mwronmental Code as described in the application for Disposal Works Construction Permit No.�� /.. ... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------- -- -i.r:....:,._. :....... ........................................Inspector __._... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /� 9 TOWN OF BARNSTABLE No.-- •_J FEE . ..... �i��r�aonl ork� �rrnn�rttr#ion �erntit Permission is hereby granted.-.J-. ._Macomber_-J'r......................................................................... .................... to Construct ( ) or Repair (XX) an Individual Sewage Disposal System / at No--------West -AaY---�tcaad--®stervilla------------------------------- ---------.........t 1 .. ..! as shown on the application or Disposal Works Construction ermit �q �_=; 1� !! -• ------------ - --- --�-----.------ ram,- ✓� Board of-Hearth/ DATE................. J = ---------------------------- r r FORM 36508 H0883 6 WARREN,INC..PUBLISHERS CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, J.P.Macomber Jr. , hereby certify that the application for disposal works construction permit signed by me dated 6/1 /9 5 , concerning the property located at 296 west Bay Road Osterville meets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility 6) There is no increase in flow and/or change in use proposed There are no variances requested or needed. 1` SIGNED : c DATE: l- LICENSE?SEPTIC SYSTEM INSTALLER•IN TIlE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certificu plot plan, this plan should be submitted]. iw s7N (2 AV Ito i'V Cl"55��dk p al iz7r6�9 S