The URL can be used to link to this page

Home My WebLink About0050 DEERFIELD ROAD - Health 50 DEERFIELD Ro/(D A=166.071 r C �I Commonwealth of Massachusetts - Title 5 Official Inspection or Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 0ea ' y+7e/7 / e ey Property Address , nD Owner Aoefie_ 1A G L e e is Owners Name information o5 4elvIfB required for every (e Q � ®� •,"; page. City/Town ✓ �::� State Zip Code Date of nspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When Ae General Information filling out forms on the computer, c�` l d 0 use only the tab 1. Inspector: key to move your cursor-do not a�/ O use the return �'1' key. Name of Inspector Company Name O� Company Address ---------------- s A c vV? 141,4 City/Town (>7 ^,n State ! ! ,p Zip Code Telephone Numbe j / j V License Number Bo 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Need Further Evaluation by the Local Approving Authority Inspector' Signature, Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate a 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. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner W C a Owner's Name information is 0s Jeev® � V ®�(.S'J'„ 3 required for every '(' %/� page. City/Town State Zip Code Date of I spe ion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System sses: 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: 13) 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System:DFm - Not for Voluntary Assessments Property Address a(AC, Owner Owner's Name information is ®as �� 1114 3 required for every page. City/Town State Zip Code Date of sp tion Bo Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed -❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y -FIN ❑ ND (Explain below): ❑ obstruction is removed ❑ Y - ❑ N ❑ ND (Explain below): 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments so Owner �j Property Address Owner aw e information is �e Owner's Name required for every ®� 1 v� p� 'z s L .,1�Yo // ®�!� �� •3 ,3 ® ,p page. City/Town State Zip Code Date of nsp tion ®® Bo Certlfsoation (cont.) 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. ❑ 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: F e **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 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 ❑' vll� Backup 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 6" below invert or available volume is less than day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Sol — /I Owner Owner's Name information is ®f-fQ ram,/J required for every '� page. City/Town �— State Zip Code Date oflnspefction Bo Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ L^�1/ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of 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 1 of a public well. ❑ I� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ - Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] ❑ e system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 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 II 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner IQ V c Owner's Name L information is required for every �'G �• ®�,��"� page. City/Town State Zip Code Date of In pec' n Co Checklist Check if the following have been done. You must,indicate-"yes"or"no"as to each of the following: Yes - ❑ ping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ s the system received normal flowstin the previous two week period? ElHave 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 NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of breakout? Were all system components, excluding,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: ❑ 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)] Do 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): 7"® t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner W G�_@ h information is Owner's Name ,�� ® required for every page. City/Town State Zip Code Date of I spe Ion D. System Information Description: �OO C-T /X0mil �tC -.4a� lrS7'�'C brr►�os'D sa�0,}� Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ZNo Laundry system inspected? ❑ Yes LJ' No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? . ❑ Yes No Last date of occupancy: Date Commercial/Industrial 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? k ❑ 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: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachusetts Title 5 OfficialInspectionForm * Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 00 Property Address Owner (A G 4-e y - Owner's Name information is s (�� A ,0.1 CS-5 � ®� required for every page. City/Town State Zip Code Date of 1 spe ion Do System Information (cont.) Last date of occupancy/use: Date Other(describe below): a. General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes �o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S em: , 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of!Massachusetts Title 5 Official Inspection . Foy Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M (2 .De'r 11�, Property Address Owner L4 C 4-e Owner's Name information isl/d Ile- A4 required for every 7� page. City/Town State Zip Code Date of nsp tion D. System Information (coat.) Approximate age of all components, date irlstalled (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet C2 2 kr Material of constructi;'40 ❑ cast iron 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: feet ;Materi f construction: concrete ❑ 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: to Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `M so Property Address I�Q Owner information is Owner's Name � required for every ®s,�`�// page. City/Town State Zip Code Date o In ection D. System Information (cont.) Septic Tank (cont.) ®� Distance from top of sludge to bottom of outlet tee or baffle 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 r ®� How were dimensions determined? --- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): LAot ,�r � ��ela 4 at d s Grease Trap(locate on site plan): 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments SO Property Address Owner At C, e� Owner's Name �4��information isosT� �� 4,4 ^required for every �/ page. City/Town State Zip Code Date of In Wn 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.): } 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 ❑ other(explain): 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts ®Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address � ----- C.4-�e information is r Owner t4 Owner's Name �� required for every F page. City/Town State Zip Code Date of risp ction 0. System Information (cont.) Distribution Box(if present must be opened) (locate on site-plan): Depth of liquid level above outlet invert I've k7 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working'order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms'are not in working order, system is a conditional pass. Soil absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 00 �' 1 Owner Property Address , Owner's Name ®� e ,may information is required for every p-` page. City/Town State Zip Code Date of nsp ction D. System Information (cont.) Type: J Soo 6;r4 1(ov3 C4�oveoa � /�� ✓!� ❑ leaching pits number: — ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, 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.): 01 441 yea C &P-C 8 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 ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Selvage Disposal System �yF/o`r�rm -Not for Voluntary Assessments `M SO iiV P 2�e P �Property Address Owner Owner's Name ` information is 6/ /q-) �+ 3 9 required for every ` 'Q /� �/e�-�®JS _ page. City/Town State Zip Code Date of I spe ion D. System Information (cont.) 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.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 17 Commonwealth of Massachusetts a 'ritle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s as o ® QI / r�ilt� � I Property Address Owner Ci"° e Owner's Name information is required for every �• page. City/Town State Zip Code Date of I specton D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two manent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where is water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately ' d Flo nrr ' Go!!o�/ , S �LIA�MIf'Af� Q G ! I ` 1 `i 6-e. _ ❑ 0 t •n ' w dnc�- " 141- aq 1 - F ct_3- `-¢Go a 3g Am Qtsgr- t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts ®title 5 Official Inspection Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `M -Det2e,' ��!a/ � Property Address Owner AW er Owner's Name information is required for every page. City/Town �St Zip Code Date of In pec on D. System Wormatoon (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells T Estimated depth to high ground water: feet Please indicate all methods used to determine the high groundwater 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) LJ' Checked with local Board of H alth-explain:' ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must de ribe how you est blishe the high ground water elevation: tit �c� q w .BI' 9� �y°? �GI a•�� /0 C do 67 J Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments SO Property Address _ G4-e✓ Owner Owner's Name / ,jA information is 0�,1er�®1/� /e/�- required for every d page. City/Town State Zip Code Date of In ection E. Repo Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed L� S tem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 A No.—� d-- � Fee--$ 50 0,�6 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer; PUBLIC HEALTH DIVISI0N — TOWN OF BARNSTeABLE, MASSACHUSETTS Yes ZIPPficafi®n for i.5p®!gar p.9;tem Congtruction per mit Application for a Permit to Construct( )Repair P ( )Upgrade( )Abandon( j tComplete System ❑Individual Components Fs tion Address or Lot No. 4 2 0—2 4 5 0 Dee r f i e l d Owner's Name,Address and Tel.No. 4 2 0—2 5 0 sor'sMap/Parcel Road Osterville Mass , George® g C, Rucker • 50 Deerfield Road. Osterville Mass. er's Name,Address,and Tel.No.S 0$—7 ]5_3 3 3 8= o Ma comber & Son Inc. Designer's Name,Address and Tel.No. 655 Box 66 Centerville,Masso 02632 BoxJ.P.66cCenterville Inc. 'I�pe of Building: ,Mass , 02632 Dwelling XX No. of Bedrooms 4_- Other Type Lot Size—--_sq. ft. Garbage Grinder yp of Building RES No. of Persons 2 g ( ) Other Fixtures Showers( ) Cafeteria( ) Design Plow Plan Date gallons per day. Calculated daily flow Number of sheets gallons. Title Revision Date Size of Septic Tank Type of S.A.S. Description of Soil Loamy Sand to Medium Sand,and gravel Nature of Repairs or Alterations(Answer when applicable) Omittinq two cesspools Installing 1.01500 gallon tank 1-6istribution box 3-500 gallon chambers Packed in 41 of stone. Date last inspected: Agreements The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this o alth. Signe a Date 1 0/5/9 8 Application Approved b Application Disapprove or the o lowin reasons Date Permit No. " Cj .5- Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgrade&,_WX) Abandoned( )byJ.P.Ma0M & Sm Inc. at 50 Deerfie d Road 09bbrville,Mass, 02655 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - Z dated Installer J.P o Macomber & Son Inc. esigner J e P o Macomber & Son Inc D The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date �. `' Inspector �a� 50.00 TOWN OF BARNSTABLE �f LOCATION ® �e e/Z Ft'eld / e2• SEWAGE # < 0 — N'J VILLAGE O S'�CeC Uo �C ASSESSOR'S MAP & LOT �pi INSTALLER'S NAME&PHONE NO. T 19, AA A C O M IS PIQ I SO Al SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) cf06- NO.OF BEDROOMS BUILDER OR OWNER PERMTr DATE: i G S~'- q`6 COMPLIANCE DATE: r 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 Fiutubued by � a _ e � 6r \ . 9k r _ No. ' 6v� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for rkgont *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 4 2 0—2 4 5 0 Owner's Name,Address and Tel.No. 4 2 0—2 5 0 50 Deerfield Road Osterville Mass. George C. Rucker Assessor'sMap/Parcel /W,"4,0,1 _o 7/ 50 Deerfield Road O*torville Mass. Installer's Name,Address,and Tel.No.5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 02655 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XX No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building RES No. of Persons 2 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 Loamy Sand to Medium Sand.and gravel Nature of Repairs or Alterations(Answer when applicable) Omitting two cesspools. Installing 101500 gallon tank 1 -Distribution box 3-500 gallon chambers Packed in 4 of stone. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this o o alth. SigMthe Date 1 0/5/9 8 Application Approved b Date Application Disapprovelowinj reasons Permit No. ^ 6 ,57 Date Issued No. 7 � 0, Fee $ 5 0 _0 0 4 1„� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Digpoal *pgtem Con,5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System EJ Individual Components Location Address or Lot No. 4 2 0—2 4v 0 Owner's Name,Address and Tel.No. 4 2 0 2 5 0 50 Deerfield Road Osterville Mass. George C. Rucker Assessor'sMap/Parcel " 50 Deerfield Road Os terville Mass. Installer's Name,Address,and Tel.No 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 02655 J.P.Macomber & Son Inc. J.P.Macomber & Son I.nc. Box 66 Centerville,Mass. 02632, Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XX No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building RES No.of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date f Title Size of Septic Tank Type of S.A.S. Description of Soil Loamy Sand to MediumSand:and gravel t Nature of Repairs or Alterations(Answer when applicable) Omitting two cesspools. Installing 101500 gallon tank 1 -Distribution box 3-500-- gallon chambers Packed in 41 of stone. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system � in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has�been iss d by this.Boolb, alth. Signe Date 10 5 98 Application Approved b Date ,U e Application Disapprove or the ollowi reasons : 1 Permit No. — _S + Date Issued AAM —•---- --- --= t — -- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded ) Abandoned( )byJ•P•MXXnbw & Sm Inc. at 50 Deerfield Road 08btrville,Mass. 02655 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. OF- dated J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Installer D 'estgner The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date ,2 Ins pector No. 7 � �/ ---•—•----------------°--------Feed 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS l Diopogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Up radeq X )Abandon( ) System located at 50 Deerfield Road OsterviTle,Mass. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by �� .S r� Y 1019/97 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 ENGINEERED PLANS) 1, Joseph P. .,Macomber J hereby certify that the application for disposal works construction permit signed by me dated 1 0/5/98 , concerning the property located at 50 De i I® wars meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility • 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. If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the than fourteen 14 feet above the maximum adjusted proposed leaching facility will p.pt be located less h ( ) J groundwater table elevation. Please complete the following: A)Top of Ground Elevation (according to the Engineering Division G.I.S. map) S0 B) Observed Groundwater Table Elevation (according to Health Division well map) SIGNED : DATE: 10/5/98 e LIG N D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). q:health folder:Bert 1500 gallon septic tank ° 3=.500 gallon chambers Distribution box a r TOWN OF BARNSTABLE / LOCATION 40 Z?C e ff2 SEWAGE # VILLAGE C�STCIC l/o LL p ASSESSOR'S MAP & LOT Z6k INSTALLER'S NAME&PHONE NO. /. ,Q SEPTIC TANK CAPACITY / U O LEACHING FACILITY: (type) -�L6fuC,�A �eRS' (size) �6 NO.OF BEDROOMS BUILDER OR OWNER r PERMITDATE: _ i C�— - 9 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 Fundshed by