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HomeMy WebLinkAbout0055 FIRST AVENUE - Health 55 FIRST AVENUE, OSTERVILLE A = 116 47 1 ° 0 0 �.. _ .a 11b —O�7 No. Fee 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprfcation for M gpogal braem Congtruction 30erri tt Application is hereby made for a Permit to Construct( )or Repair(XX)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 2 8—6$ 4 94 55 First Ave Louise Lahey Osterville Mass . 02655 55 First Ave Osterville 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. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber Jr. J.P.Macomber Jr. Box 66 Centerville,Mass . 02632 Box 66 Centerville,Mass . 02632 Type of Building: Dwelling X No.of Bedrooms 3 Garbage Grinder(NO) Other Type of Building RES No.of Persons 2 Showers(2 ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily flow 3 x 110 gallons. Plan Date 4/18/96 Number of sheets 2 Revision Date NA Title Description of Soil Loamy sand to sand & gravel Nature of Repairs or Alterations(Answer when applicable) Omit cesspools. Install 1—1 5 0 0 gallon tank, 1 -Distribution box. 3-330 rechargtank, 1 -Distribution box. 3-330 rechargers packed in 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 Codg,and not to place the system in operation until a Certifi- cate of Compliance has been issu by this B ar f th. Signe Date 4/18/9 6 Application Approved by Application Disapproved for the following reasons Permit No. .� Date Issued +� /7' / ! & ti -0Z No. Fee 40.00 II! THEE•OMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BikRNSTABLEs MASSACHUSETTS 0(ppYication-for Migotar *proem Cootruction Permit Application is hereby made for a Permit to Construct( )or Repair gX)an On-site Sewage Disposal System at: • d Location Address or Lot No.. . Owner's Name,Address and Tel.No. 428-6894 .. 55 First Ave Louise Lahey, Osterville Mass. 02655 5 First Ave Osterville Mass . Installer's Name,Address,and Tel.No. 508-775s3338 Designer'S Name'Address and Tel.No. 508-775e3338 J.P.Macomber Jr. J.P.Macomber Jr. Box 66 Centerville,Mass. 02632 Dbx 66 Centervill© ,Mass. 02632 Type of Building: Dwelling X No,of Bedrooms 3 Garbage Grinder(N O) Other Type of Building RES No. of Persons 2 Showers(2 ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3x1 1 0 gallons. Plan Date 4/1 8/96 Number of sheets 2 Revision Date IAA F• Title Description of Soil Y Loamy sand to sand & gravel Nature of Repairs or Alterations(Answer when applicable) Omit c e s s po 01 s. Install 1-15 0 0 ; gallon tank 1-�.Distribution box. - 0 rechar ers packed in stone. i 3 33 � p ; 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 Cod&and not to place the system in operation until a Certifi- cate of Compliance has beenAissud by this B and �'f 1'th. Signe Date 4/18/96 li Application Approved by . o Application Disapproved for the following reasons e r Date Issued o.Permmt N + THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS j Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal.System installed( )or repaired/replacedXXX)on by J-P_Mar.nnihAr Jr. for T,ou9 4o La:hey as 55 First. . e Ontnry01A .Mass . h een construed in accordance With the provisions of Title 5 and the for Disposal System Construction Permit No. dated'-'" "- 7_;?j!5` Use-of this system is conditioned on compliance with the provisions set forth below: ------- -- ——— No. Fee THE COMMONWEALTH OF MASSACHUSETTS r PUBLIC HEALTH DIVISION`- BARNSTABLE, MASSACHUSETTS7. igo�aY *potentNongtructtonPermit Permission is hereby granted to J.P.Macomber Jr A, yr f to construct( )repair(XXTan On-site Sewage System located t 4= 55 First Ave Osterville.Mass. 02655 and as described in the above Application for Disposal System)Coristruction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions/or special coq�,�ditions. All construction must be c plet d within two years of the date below': Date: /r I �q Approved by 4/18/96 0 -1500 gallon tank 1-Distribution box 3-33OH2O Rechargers Future exspa.Wsion CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) f s I J.P.Macomber Jr , hereby certify that the application for disposal works construction permit signed by me dated 4/18/96 , concerning the property located at 55 First AvP 0 4 t Prx; 1 i e ,Mass 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 is4 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed - There are no variances requested or needed. SIGNED : . DATE: 4,/1 R/9 LICE 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]. e TOWN OF BARNSTABLE LOCATION .� �5� !f'/iZ��" y SEWAGE # �' 4,� ASSESSOR'S MAP& LOT f'-f-Y INSTALLER'S NAME&PHONE NO. ,l e� k�J�?��' 1/Ja9 /yc— SEPTIC TANK CAPACITY f.5 ,00 �:EACHING FACILITY: (type) . -.Re ck .err (size) :?30 .OF BEDROOMS BUILDER OR OWNER L ' PERMTTDATE: ' COMPLIANCE DATE: �✓' "' '� r Separation Distance Between the: d: 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 / G ,` 1\ � �� � ,� � . a�- � � � .�. � , , ..,� r TOWN OF BARNSTABLE LOCrtTION Irv' f5J'" SEWAGE # VILLAGE ®a e 4 ASSESSOR'S MAP &LOT INSTALLER'S NAME& ,,""/ PHONE NO. - ,i- SEPTIC TANK CAPACITY - �( ®®4'4e— LEACHING FACILITY: (type) (size) _ NO.OF BEDROOMS BUILDER OR OWNER ' 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 206feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 f et of lea ' facility) Feet Furnished by e r.. G.� �: �1. �q� � .. V i, e c� .� \� � � � � i` ' i i � �I ��� � � � ,_� ..� . � x i �� �-- CANd � 77Y DATE:_',3 ,16�96. PROPERTY ADDRESS: 55 first Ave RECEIVED Osterville -• APR ? 5 1996 Mass.4 02655 HEALTH DEPT. TOWN OF BARNSTAELE On the :above date, I inspected the septic system at the above address. This system consists of the following: 1 . 2--6'x8' -block cesspools and, one 61x10l block cesspool. 2:�. Cesspools are in series. One overflows toLthe other. Based bn my Inemnection, I certify the following conditions: 1 . This is-not a title five septi-o ytefa. ' 2, This- is a sewage.. system,. ( 3-block ciWspoo1T-,in series ) .3. Tte', Typtem conditionally .passes. . This means when' the pipefrom the main cesspool to the #2 cesspool-s• -is replaced.-�•*,n)1 the pipe from- #2 - cesspool 'to #. 3 aes4ppools is . replacewdt t)r6f system will be ;LnjprpperVwork3,ng order at -that time and will pass. The #3 ' cesspool is dry, standi.ng water in pipe fron #1 -#2. SIGNATURE: G '( Name:-J.P_M_acomber Jr_,. -,------- -----, _ Company• J_•P.Macoruber_ &_Son- 'Inc . -- A d d re s s:__B44—bb------:1-- -- Centerville LMas_s__0.2.632' ' . • Phone:---548.�.7�...3338___-_-- ., 1 i . J THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. U Tanks-Cesspools-Leaahfields . Pumpad & Installed Town Sewer Connections P.O. Box 56' Centerville, MA 02632-0066 77.5-3338 7754412 r S Commonwealth of Massachusetts too Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Cox* Goamw 8—ouq A�rPaul Celluccl • David B.Struhs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 55 First Ave Osterville,Mass . AddressofOwner. 35 Lodge Street Date of Inspection: 3/12/9 6 (If different) Milton,Mass.0 218 6 Name of Inspector. Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 508-775-3338 CERTIFICATION STATEMENT I certify th4t 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 ov-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails / Inspector's Stgnat G %���` 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 otlice of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: } A) SYSTEM PASSES: dZb_ I have not found any information which indicates that the system violates,any of the failure criteria as derived in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. Bl SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If."not determined",explain.why sot) N 4z The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exflltratio � n,.or tank failure is imminent. Tb*/system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved , by the Board of Health. (revised 11/03/95) 1 Ono Winter Street 9 Boston,Massachusetts 02108 a FAX(617)556-1049 9 Telephone(617)292.5b00 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(ooatinued) Property Addrem 5 5 First Ave Osterville,Mass . Owner. Paul Costello Date of Inspection: 3/1 2/9 6 B)SYSTEM CONDITIONALLY PASSES(coa4ued) �o ,a Sewage backup or breakout or hi static water level observed in the distribution box is due to broken or obstructed pipe(s) tion box. The m will inspection if(with approval of the Board of or due to a broke se ttlad or uneven distribution system pass n, Health: __z 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 Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: , N,�> 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'PFtOTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 60 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well. AV The system has a septic tank and soil absorption system and is-less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for ooliform 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 b ppm. i S) OTHER - -Z Thre block cesspools in series. '2 61x8f and 6,x10, • a (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: 55 First Ave Osterville,Mass . 02655 Owner. Paul Costello Date of Inspection:3/12/9 6 • D] SYSTEM FAIL& • • ,fig a I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. Tb•basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. LD Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. IVOVF.. Static liquid level in the distribution,box above outlet invert due to as overloaded or clogged SAS or cesspool. y¢$ Liquid depth in cesspool 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 pipe(:). Number of times pumped-- �(Q Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Alb Any portion of a cesspool,or privy is within 100 feet of a surface water supply or tributary to a surface water supply. /!l 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 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 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: The following criteria apply to large systems in addition to the criteria above: &0 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: Ay 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 requirements of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for thither information., (revised '11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ProperVAddresa: 55First Ave 08terville,Mass.. 02655 owner. Paul Costello • Date of Inspeotion:3/12/9 6 • t Check-if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. at1}e 4*7 _y(�one of the system components have been pumped for at least two weeks and the system has been receiving normal Clow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. built pleas have been obtained and examined. Note if they are not available with N/A crJ" _L/Tha 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. ` j2A11 system componeati,Auding the Soil Absorption System,have been located.on the site. ypdXThe septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baMes 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 existing information or approximated by non-intrusive methods. , The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 TOWN OF BARNSTABLE SQ b.jff, 1P`r`b SEWAGE M LOCATION ,.. VILLAGE �l�;d� ASSESSOR'S" MAP A LOT INSTALLER'S NAME A PHONE NO. SEPTIC TANK CAPACITY i LEACHING FACILITY:(tlpe) -. (size) OOMS PRIVATE WELL OR PUBLIC WATER_ NO. OF BEDR UILDE R OWNER C DATE`PERMIT ISSUED: DATE..-COMPLIANCE ISSUED: ' r VARIANCE GRANTED: Yes -No ' I , SO 1 ..�'X0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 55 First Ave Osterville,Mass. 02655 Owner. Paul Costello Date of Inspection: 3/12/9 6 ' • FLOW CONDITIONS RESIDENTLAJ-- Design flow: ns • ; Number of bedrooms:, Number of current residents: Garbage grinder(yes or no):� Laundry coi�ected to system(yes or no) Seasonal use(yes or no): ,UD Water meter readings,if available: 9/7�r !�odd J� •I� _ • A /4 Last date of occupancy COMMERCIAL INDUSTRIAL: Type of establishment: Design flow:_&Agallons/day Grease trap present:(yes or no)AA Industrial Waste Holding Tank present:(yes or no)JZLO Non-sanitary waste discharged to the Title 6system: (yes or no)." Water meter readings,if available:' AM Last date of occupancy: , OTHER:(Describe) Last date of occupancy: VA GENERAL INFORMATION PUMPING RECORDS and source of information: A/oN•c 149,4,L.¢ 6110 , System pumped as part of inspection: (yes or no)AI,6 If yes,volume pumped D gallons Reason for pumping: TYPE OF SYSTEM �e Septic tank/distribution box/soil absorption system !/ Single Cesspool .Z Overflow cesspool6 A16 Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPRQYJMATE APE of all components,data installed(if known)and source of information: ae) y DEl/N�r 7--1a7 1 li SSl-Ln'1 e W �i �D�t�c° *r '41 XRy Sewage odors detected when arriving at the site:(yes or no)� / (revised 11/03/95) 6 SUBSURFACE SEWAGE DIF'^!`^'?.SYSTEM INSPECTION FORM SYSTEM INFO. ...,..ION(continued) �I Property Address: 55 First Ave Osterville,Mass . 02655 Paul Costello , owner. ; Date of Inspection:3/1 2 9 6 SEPTIQ TANK:NO (locate on site plea) Depth below gmde:_&� Material-of ooastruetio concrete metal FRP_other(ez `^9�) Dimensions: 4 I Distance from top of sludge to bottom of outlet tee or bal - VJ? - Scum thickness: 04 Distance from top of scum to top of outlet tee or baffle: A)'19 Distance from bottom of scum to bottom of outlet tee or battle: AM i Comments: i (recommendation for pumping,condition of inlet and,outlet tees or bs.Tes, depth of liquid level in relation to outlet invert,stractt:ral i*AVity, evidence of leakage,etc.) We 1411,14,e y T" GREASE TRAP:EP (locate on site plan) l Depth below Veda:� i Material of construction: concrete metal FRP_other(es;^.?,in) Dimension iV Scum thickness: Itllh !,� Distance from top of scum to top of outlet tee or bathe. V If p Distance from bottom of scum to bottom of outlet tee or balne:-" Comments: (recommendation for pumping,condition of inlet and outlet tees or Ic na, depth of liquid level in relation to outlet invert,structural intepitj, evidence of leakage,etc.) /Ua wl (revised 11/03/95) 6 : .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropervAddreas: 55 First Ave Osterville,Mass . 02655 owners Paul Costello i D&U of Inspeotloas 3 12 9 6 TIGHT OR HOLDING TANM O gocats oa site pLw At vial of ooa trv+ a. �etsl�..��other(esplain) • Vit Dimensions: AIA . Capacity: Map flow- allon,/de�Y Alarm level: Comments: (condition of inlet tee;condition of slamand float switches,atc•) DISTRIBUTION BOX:&b (locate on site p1w Depth of liquid level&bow outlet iuvert:!V I Comments: •. • .. (note it level and dWzMution is equal,evidence of solids carryover, evidence of leakage into or out of b0z., etc.) r PUMP CHAMBER::1L6 .' (locate on site plan). . Pumps is worldng orden(yes or no)JA# • Comments: chamber,( condition of pampa and appurtenances, etc.)note co a of pump • (revised.11/03/95) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Pt Tc SYS=.': 1''-"".......:J;:(oontlnuod) PropertyAddrem 55 First Ave Osterville,Mass. 02655 Ownen Paul Costello Date of Inapeotton: 3 12/9 6 , / v�fit'•.. t r,'t r:. i J SOIL ABSORPTION SYSTEM(SAS)s,� e (locate on she plan,if possible;escavatloa not raquh*but may be approximated by non-Intrusive methods) If not determined to be present,explain: Type. : Wching Pita,number'Q leacling chambers,g ram= number .. . . _ . . _•• . ::mot:,< kadinnumber. r leaching trenches,nt zber length: leaching fields,number,dimens ns• overflow cesspool,cumber. Comments:(note condition of soil,signs of hydraulic failure, 1-"' c! condition of vegetation,etc.) Sn31 a; T.nAmg Q nd to medium sand;-NQ..__9 _g.np of hydraulic failure or eve O-P. po2lding All 1rPgzt.at.i._n_n i a nnnmal __ JnA between Overflowcesspool's Ally$ ep e : e. CESSPOOLSt_ pipe. . (locate on site Plan) P - Number and configuration Depth-top of liquid to inletnvert: y� Depth of solids Dyer: i Depth of scum layar. Dimensions of cesspool: a- X '5 L.A'X Materials of const:uctioni 7a Indication of groundwater. l inflow op�o must be pumped as part of • Y�' , f`S irP�r .►trD t.0 LrJJ9 TG� 'Ti¢ ,ice . .' ' . Comments:(note oondition of son,signs of Vdraulio WvrP I��al c'-c• , �, con io of �oo1,etc.) Soils •Loam sand to medium sanc�;no signs o� Mfalau is failure or p_onding. Overflow line rom• -cess o musl be replaced. inver pipe is higher than the outvert pipe. Pipe--must br, lowe•red and replaced wi h_' S =,b4,I PVC pipe. Third cesspool is dry: Qocau on site plan) Materials of construction. Ave Dimensions: , Depth of solids:,Q1[Q_, - -- (note condition of soil,signs of hydraulic Wuta, .on of vegetation.etc.). �. � (revised 11/03195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address 55' First Ave Osterville,Mass . 02655 Owner. Paul Costello . . Date of Inspection:3/12/9 6 ' SKETCH OF SEWAGE DISPOSAL SYSTEM: • include ties to at least two permanent references landmarks or benchmarks locate all walls within 100' Centerville Osterville Manstons MIlls Water Company 428-6691 • DEPTH To GROUNDwATEIi • Depth to girnmdwaterlfeet mfhA of determination r app tion: (revised 11/03/95) 9 1l rnnrr.-nr•rr.•rr-arn:mr•nmrs-++r..rr.•rrr..r.::•r+-r:rnrf�ar.� -srn rrrs�errss+ .. - trs's-r.-nrrarsrrr-r-t-.tr.+rnr.r-••F TOWN OFc*n-n Bar•unstable BOARD OF HEALTH ISUBSURFACE SF.WAOF DISPOSAL SYSTEM INSPECTION FORM - PART U •- CF,IZTIFICATION - h•••art-r••.-:e.-+atr.».a.rn+rtrtn•n:nnrzee:rsTrrrrn'r-ti•f.-urt+st-rn++n•-rr.:rr..+.•rrm=*enz:s•r•�.'a� ismtrmrr.n+s•s�rrrmst�rr'-•rr•�r -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 55 First Ave Osterville,Mass. 02655 ASSESSORS MAP, BLOCK AND �ARCEL # OWNER' s NAME Paul Costtllo PAI?7' D CERTIFICATION r NAME OF 'INSPECTOR Joseph P. Macomber Jr, . COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State LIP COMPANY TELEPHONE t 3338 FAX 508 790 1578 e CERTIFICATION STATEMENT I certify that I havei;personally inspected the sewage disposal, system at this address. and that, the . informat'ion reported is true , accurate, and complete as of the tirfie, df;:.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 . • �i i trr;�it, Check one: bwaSystem PASSED ( conditionally The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR '15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* • I The inspection which I' have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , u Inspector Signature 1. Date 3/15/96 'sue s:rsa•��r=.�� - .—r bne copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF WEALTH. * If the inspection FAILED, th'e owner or""t '* orator shall upgrade ' the eyetem within one vear of the date , of the inspection, unless allowed or' required otherwise as provided in 310 CMR 16 , 306 ,