HomeMy WebLinkAbout0061 FOX ISLAND ROAD - Health 61 Pox Island` Road
'Marstons Mills P
A 096 014
C.B.FND. LEGEND:
S3 CB FND. CONCRETE BOUND FOUND
�\ 2
� C.B.FND.
20 PROP. SUNROOM/ C.B.FND.
\ OVER EXISTING
STONE TERRACE
154
EXIST.
TENNIS GARAGE DWELL BOG
couRr H ,6 NIIo POND
POOL �� 1 Co
rI' EXISTIN
,Iry N
12 �ONtOUR \ AA
\ \ 1p0
10
LINE \ OO•
1 / \
DAM POND
\ 04-034
PL 0 T PLAN
FOR THE PURPOSE OF OBTAINING A BUILDING PERMIT
LOCATION 61 FOX ISLAND ROAD
U� PREPARED FOR:
OSTER VILLE R 0 CELL TRUST LL C
SCALE: 1 " = 80' DATE: MARCH 2, 2005 ,s
REFERENCE LCP 5725-46
ASSESS. MAP 96 PCL 14OF Mggsgcy
o ARNE
o� H.
N0.
down cape engineering, inc.
CIVIL ENGINEERS � 19Na3UfZ �O
LAND SURVEYORS ———————————— ------- -------
939 main st. yarmouth, ma 02675 t
DATE REG. URVEYOR
� N
ji
� I I v
�.
�ZVLAA,gp... _
k /s ^�IQ
� Tim-✓I l � , V"/�
A .-
n
.may i
ttt
kA
7
kG Yc.
�pJ�HOF �
DGIR <n
fn
2i47/4
TF/UC TT UHAL
i AL
..........
L4
Adii A t�
= ICHELEAL
�:� ;' �.�.►,�C$-:...�:[fir:_---
t'Y—Ar-
1
? _:7..._. ._..f�!�k'.'rLs4�':"&-2�tE.
AA c
lyll/Z4 �L
Sk-� f Aof 5k'1�
1
'C.•:T�
Zx -
v
U✓FYI CKIST• , I 'i2 P�CICS�(�¢pw0(c ♦ 1 -�C�� i'r'�I
T•G -� y �� `�� MIN, �/-4,1 s
---- ---. 2 !t
a
AA
10 � O E-XTEND PLATE OVER f ULL COLUMN WIDTHri
�, -
ry Z ! 7Sx q, 2-5f.96.L''/�.
. . �� + + +
< x � + + + +
+
00 � �
�. (`1 N y I , INTERIOR
• LALLY
g 3� • I I COLUMN(S) I
t7 b I I TO 'BElE
v REMOVED UN Norio
(� v► S R&� WALL
3 (� FOOTING
p OR
INTERIOR
Q p FOOTING
v (TYP.)
�3 t 5_9 � K-'0,
ELEVATION
o ' N n t� SCALE 1/2'
o n n 0 ►-� (Z�(7SY q.25 l,4EAND
N STEEL PLATE V?" -(j4-'
; cx
\2 ROWS 1/2'
DIA. BOLTS @
r txj. 24' O.C.
_ 1 - 1 STAGGERED
i NOTES'
3 0 (� 1. STRUCTURAL STEEL, ASTM A36J HOP PAINT WITH RUST
m ' m SCALE: 1' = 1'-0' INHIBITED PAINT( COLOR BY ❑WNERl
o 2. THRU-BOLTS ASTM A307 ,1/2' DIAMETER.
o N ?. 0 3. PUNCHED HOLES IN PLATE 9/16' DIAMETER.
�
o OPTIONAL=COUNTERSINK BOLT HOLES-PER OWNER. Tz' /o4�05
o p d 0/, AFCC4/. Ut4 5 gY L�rl�)
0 2115105
Sr 1P
C � � �NOF MASs,9c
o :3. � o�y' NIICCELE A
n> (D : T.0 OR
347 4 ►
w O N� cn ,
F� N v S-TRUCTUPAL s
Q `l
~a (D y 9FCi i s-v j 4
DATE : 8113103
PROPERTY ADDRESS: 61_ 7ox- I.3.2and-Road RECEIVED
------- .
02655 AUG 2 3 Z003
— TOWN OF BARNSTABLE
HEALTH DEPT.
On the above date, I inspected the septic system at the above address.
Tnis system consists of the following: p
(SAP
1. 1- 7000 ga e-eon ze/at.i.c tank. PARCEL
Z. 1-Diztjz.igution Sox.
3. 4-7-eow Dillueaolta ( D2y ) LOT
Baseo on my inspection, I certify the following conditions:
4. 7hia i.s a tit Pe 1.i.ve .6e/2t i.e eyzte'm ( 78 Code )
5. The �3e/2t is zyatem .ins in /12o/2e2 wo2king o2de2
at the /22e•sent time.
6. 42e lout liow di,,,Zu.s.son.s ate pee.6ent ey dzy.
SIGNATUR
Name : .1 . P . Macomber Jr .
orhpany : )gatpt .p�- M_�ISgm��C.d_ Son, Inc .
�oar2ss --�Qx-��------------
_ _ _Ct?.ns�:Yrr1.L�,_ Ja .. _Q.�632- 0066 III
?none : _ _508 775_ 3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks•Cesspools•leachllelds
Pumped b Installed
Town Sewer Connections
P.0 Box 66 Centerville. MA 02632-0066
275.3338 775.6412
I
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:61 Fox Ia2and Road
0,3te1tL),Uf_1e, Nazz.
Owner's Named&e2 Pas au.
Owner's Address:/ o/?e,3 1tay izu6
ne n e2na ion& / ace /3o,6.ton, Na.3.a. 02110-2426
Date of Inspection-8/13/03`
t
Name of Inspector: (please print) ao,3e/2h 1P. Macom&elz a2.
Company Name: 1. 1. I7acom e2 X 3on__7_nC.
Mailing Address: o x 66
en eltv.e e, a.6,3. 02632
Telephone Number: 5 0 R-7 7 5- 3 3 3 R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall mit 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 is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:6 1 Fox Ze Pand /toad
0.ete zv i-01e, 0a.6,3.
Owner: R.2E}ea.t 102att 72uit
Date of Inspection: 8113103
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S st asses:
AI have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
-he ze tiC ZUZteM ih Zn PIZO12elL WOZking oAdeA
rat the DnIpApnl Y imv S S aaezp-Rt eu dliu
B. System Conditionally Passes:
1W) 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
existink 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:
A)6 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
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 61 7ox 1.6 Patzd Road
1A}on ,_
Owner:R2e,e2.t P a.z`t��T2 ' �r�.s.s.
Date of Inspection: 8113103
C. Further Evaluation is Required by the Board of Health:
AJl 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:
,�Jd 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:
%�)e 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.
/U8 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
Alb The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
/UP The system has a septic tank and SAS and the SAS is less than 00 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:61 fox 1.6iand Road
0_,6teILViiPe, 17a,6,6.
Owner: R.P&ezt /Ptah 72uh� s<:.
Date of Inspection: 8113103
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
_ t/ ackup 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
l cesspool , q.4,Ay A i�fiPSJr�rS = (*D;^y
_ l/�iquid depth,in4e"peel is less than 6"below invert or available volume is less than '/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 0 .
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.
arty portion of a cesspool or privy is within a Zone I of a public well.
��\rty portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No)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 now of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes n
i the system is within 400 feet of a surface drinking water supply
_ Zthe system is within 200 feet of a tributary to a surface drinking water supply
Y 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.
4
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 61 Fox Ins nd Road
Owner: Aigeat % 2� " [IUL-6z '
Date of Inspeetion:81 13103
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No/
r/ Pumping information was provided by the owner, occupant,or Board of Health
— v 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 ?
/Were as built plans of the system obtained and examined?or 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?
v Were all system components,.eluding 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 ?
Z— Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no /
_ _ Existing information. For example, a plan at the Board of Health.
kf"_ Determined in the field(if any of the failure criteria related to Part C is at issue a
is unacceptable) (310 CMR 15.302(3)(b)) approximation of distance
5
SEWAGE INSPECTIONS
LOCATION 61 Fox lzi nd Road DATE 8113103
VILLAGE 3 M. , �a,3.3. ASSESSOR'S MAP do LOT0 9 6-014
n.
Ihft- bCTOR jo.aeph P. Ilacomgez aa.
SEPTIC TANK CAPACITY 1000 q iionz 1-Box
LEACHING FACILITY: (typc�_-7iow Di//uzzo2-6 (si7c�'8'X10'X2'
i
NO. OF BEDROOMS 4
BUILDER OR OWNER 4-99e/ t Platt 72u,3t
w
OWNER MAILING ADDRESS
Ropez & G2ay 7/zu,3t
- O e Inteanationai l.dace
Bo.3ton, 1�a.6,6. 02110-2426
106
S
��
i
` I
Po
ol
1�-
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 61 lox I,6iand Road
e/FT7 T T—e—, 77—azz.
Owner: A.`&e/c.t / 2u 2ui
Date or Inspectlon:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN (low based on 310 C &15.203 (for example: 1 10 gpd x Il of bedrooms):
Number of current residents:U f d9jA1 � .`
Does residence have a garbage grinder(yes or no):L '�
Is laundry on a separate sewage system,�(yycs or no): 00' (if yes separate inspection required)
Laundry system inspected es or no): 7;11 d
Seasonal use: (yes or no):.S 200 1-2002=237 000
Water meter readings, if available (last 2 years usage(gpd)): yu�t?orza=6 4 9, 32 C/ C�
Sump pump(yes or no): 4,0 2002=27 5, 000 ga e.Pon.a=7 5 3. 4 3 911 D
Last date of occupancy: zhkz0f11
COMMERCLAVLNDUSTRIAL
,Type of establishment:
Design now(based on 310 CNN 15.263): _gpd
Basis of design now(seats/person's/sgft,etc.):
Grease trap present(yes or no): &G//
Industrial waste holding tank present(yes or,no):Al
Non-sanitary waste discharged to the Title 5 system(yes or no): )
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 46
Was system pumped as pan of the inspection (yes or no):il
If ycs, volume pumped:_ _gallons •• How was quantity pumped determined?
Rcason for pumping:
TYP,Z OF SYSTEM
Scptic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
d Privy
Z�Sharcd system(yes or no)(if yes, attach previous inspection records, if any)
�lnnovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
/Lad Tight tnrtk /tL4AMch a copy of the DEP approval
(►Other(describe): /1JJ
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site(yes or no):,-f,/d
6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 6 1 fox Ih Pand Road
0.6teltL).i.eie, NaT7.
Owner: Aege�zt 11.,zatt 72uet
Date of Inspection: 8173103
BUILDING SEWER(locate on site plan)
�6/I
Depth below grade. .0
Materials of construction: _cast iron "40 PVC 4 other(explain):
Distance from private water supply well or suction line: y 'f
Comments(on condition of joints, venting, evidence of leakage, etc.):
loin,t�s aRRea2 tight. No evidence o, leakage
Sy,6tem -ij vented thzough the hou-6e verzth.
�LLC7 r,•
SEPTIC TANK: Zoocate on site plan)
1
Depth below grade:
Material of construction: concrete 66metaVP fiberglas&�L polyethylene
i( other(explain) ,�
If tank is metal list age:41t is age confirmed by a Certificate of Compliance(yes or no)-/W(attach a copy of
certificate)
Dimensions: i, �.ey y��
Sludge depth%it.t ' ---- ' N
Distance from top�sludgc to bottom of outlet tee or baffle: <2,efz
Scum thickness: J�L,Cldi
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scam to bottom of outlet tee Ior baffle:
How;were dimensions determined: I PA SL4lV
Comments (on pumping recommendations, inlet and outlet tee or battle condition, structural integrity;liquid levels
as related to outlet invert, evidence of-leakage, etc.):
Pump the 6ept to tank annuaiiy. Zniet 9 outiet teea ate
1n n.Przrv, 7hn t ,s-A UcLulza.PiU .6ovnd end Aowe no
ev.tdence o� eeakage. Liquid Peve.P at the out.Pet .invent
..h 51"
GREASE TRAPlocate on site plant,)
Depth below grade:
Material of construction:ilconcrete.&—metal4/4 fiberglass�olyethylene�J.4other
(explain): .4)d
Dimensions: AM
Scum thickness: "1"19
Distance from top of scum to top of outlet tee or baffle: Wig
Distance from bottom of scum to bottom of outlet tee or baffle: z4t—
Date of last pumping: dM
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
C2eahe t2a� to not �Z2eeent
7
Page 8 of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 fox I,6.Pand Road
Owner:
R.P&e2t z1'Lurt
Date of Inspection: 8173103
TIGHT or HOLDING TANXJ,&�f-(tank must be pumped.at time of inspection)(locate on site plan)
Depth below grade: 414
Material of consavction: concrete metal J2&flberglass ALpolyethylene d1h other(explain)'
Dimensions:
Capacity:_ A119 zallons
Design Flow: allons/day
Alarm present(yes or no): A-
Alarm level:_ 1A Alarm-n working order(yes or no):
Date of last pumping:—A2
Comments(condition of alarm and float switches, etc.):
T.i oht na ho2dgin Sri {ank i i v notn�e6en�
DISTRIBUTION BOX: ZICf present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:A
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
[�i�t2i&union Pox f:a,6 one .Patezae. No evidence o� 6otid.6 ca22y
oven. No 'evidence o,,' .Pea aye in o o2 out 6 e ox
PUMP CHAMBERlt7g(locate on site plan)
Pumps in working order(yes or no):_�h
Alarms in working order(yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pum12 cham9p2 .i-6 no /2 won
g .
Page 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 61 7ox I,32and /toad
Ojt ear i.i ee, l7ae,6.
Owner:Ai&ezt Pzatt Trtuet
Date of Inspection: 8113103
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
4-7Qow d-Wuaeo26 in ee2te�.
If SAS not located explain why:
LOCQtRd: Spp AqP 70
Ty e
leaching pits, number: a
leaching chambers, number: �,,0 0*6 sS�rS
leaching galleries,number:
,&P leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool, number:
A-�) innovative/alternative system Type/name of technology: l 7�� t/� C
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
f orimy nrinrl if) myrliiim Pine ArinC1 o 3-ig?z o� hydltuuPit )eaiivae
02 Rond.inrr R22 of the l.Pow d.ilfu,6zo2h �a/te nnezent.iu d�u
So.i z ate drty. Vegetation 1-6 nonma.P. -
CESSP00LS (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 0 _
Depth,-top of liquid to inlet invert:
Depth of solids layer: AM-
Depth
of scum layer: �
Dimensions of cesspool:
Materials of construction: �.
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
e6,612oo 1,3 ate no t naebQnt
PRIVN,9Le(locate on site plan)
Materials of construction: A10
Dimensions:
Depth of solids: )
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C "
SYSTEM INFORMATION(continued)
Property Address:6 I lox I,3iand Road
e/z v zte e, u.6.6.
Owner: Aige2t Matz /auzz
Date of Inspection: 3
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.
t I
106
y
pobc
Fo w
10
Page 11 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropertyAddress: 61 Fox I,3.gand /toad
e"ZV-iiQe, mash.
Owner:A Meet P/zatt 71tu.6t
Date of Inspection: _ 8/13/0 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water, feet
Please indicate (check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked, date of design plan reviewed: NA
q ES Observed site(abutting propery/observation hole within 150 feet of SAS)
NO" Checked with local Board of Health-explain: NA
qE S Checked with local excavators, installers-(attach documentation)
IIES Accessed USGS database-explain: h.tt12:// town. Prian"ta gie. ma. u13.
You must describe how you established the high ground water elevation:
11,6ed: Ca"etjl 4 m; oo1Q_ Mnll g• 72176194 G2ound wate2 eegVa o -6 aPo,)o
_3ea gene e.
'Lied: IZS'S:O9.3"VaLon weii data guno 7992
'L ed: 1LS4S:_7echntu Q � le ui,, 92 000 1 PriPfo �aR�cea—Q,—&UP 01 Oround
gaound wate2 e.gevat.tona. aanua2y 1992
4-7iow 1 il)euhholzz
f� .eet
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frim ter
p p Method
Therefore, the vertical separation distance between the bottorrl j
Of the leaching pit and the adjusted groundwater table is i
feet.
II
•T..1'+�nr•r�"'.TT� r•R�wn•nT.TTRi'enl•R.It•.1.•�Stlflt�nT 1R'r1L 17I�'�11�n1rr1'1
L3 a A 2 b t a g.e a
'I'UNN UP IlOARD OF HEALTH +
0 t .r...•,.*-T"'__SUBSURFACE SFNAGF DISPOSAL SYSTEM INS CTION FORM - PART D •- CERTIFICATION I
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 61 Fox 1.6iand Road Oztezviiie, Mazz.
ASSESSORS MAP , BLOCK AND PARCEL # 096-014
OWNER' s NAME Aigeat P2atU 72urt
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J P Macomber & Sox Inc'.`
COMPANY ADDRESSBox 66 Centerville Mass. 02632
Street Town or City Stat• L(P
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
R
CERTIFICATION STATEMENT
0r as
certify that I have personally inspected the sewage disposJj system at
this address and that the information reported is true , accurate , and
omplete s of the time of .inspection . The inspection was performed and any
ecoinmendatioris 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 Ilritl
Chec one :
System PASSED
The inspection ►+hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
Th.e inspection which I have con toted has found that the system fails to
Protect the public health and the environment in accordance with Title
6 , 3.10 CMR 15 , 303 , and as' speciflcally noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signatur Date
e copy of tl)is certificlZtion must be provided to the OWNER, the BUYER
mov
arn
where applicable ) and the BOARD OF HEAL1'JI.
* If the inspection FAILED, the owner or'" perator ehall u d
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 16 . 305 ,
partd , doc
rRF¢Ai
TOWN OF BARNSTABLE W S?rZs_ LOCATION V A /SEWAGE# E� AO
.VP,LWE S �. I ASSESSOR'S MAP&LOTOY -Cz,
INSTALLER'S NAME&PHONE NO. 01 Um f P U-S oZ d
SEPTIC TANK CAPACITY 1600
;LEACHING FACILITY: (type) 31 aW�� LS£�L-S (size) /e`,Ja' /
NO.OF BEDROOMS
rBUILDER OR OWNER dRATr
PERMTTDATE: COMPLIANCE DATE:of erg "'
Separation Distance Between the:
i
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 Wedand and Leaching Facility(If any wetlands exist
within 300 feet of�Iechinty) Feet
Furnished by
d
- -bo)
30
box w 3
-EO
j �13
M S,SORS MAP
No. `6 � _" "'/ PARCEL NO; Fee CJ
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
0(ppYicatiou for ;Di000al *r5tem Cougtruction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
,57
Wpe of Building:10,
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of R airs or A erations(Answer when a plicable) r� 01
J YJ
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 by this card oLHea
Signed Date
Application Approved by
Application Disapproved for the following reasons
Permit No. " � Date Issued <� �"
No. f TJ'�Gi�/ Q I Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
01pprication for Migpozal ffip!5tem Con..5truction Permit ,Y
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
,Type of Building: ^,
Dwelling No. of Bedrooms /V Z Garbage Grinder( )
Other Type of Building No. of Persons Showers O Cafeteria( )
Other Fixtures �.
Design Flow gallons,per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of R airs or Alterations(Answer when applicable)
G� AAW. 22 e
Date last inspected:
t '
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 by this oard o Health,.
Signed I Date
Application Approved by
Application Disapproved for the following reasons
Permit No. �' �4!:!:�A7 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
Certificate of Compliance
I; THIS IS TO C TIFY that the-Onysite Sewage Disposal System insta e ( )or repair replace n
by for
as has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No —W0'1 dated l-"9?.5
Use of this system is qRdjtioned Qn compl the provisions set forth below:
,W
---- — /-----------------------------
No. � ��/ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLES MASSACHUSETTS
I
Migoar *pg;tem Construction Permit
4
Permission is herebyanted to O-ZO
� CLj
to construct( )repair()()a -site Sewage System located
1
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.
All construction must be completed within two years of the date below.
�" �" Approved b j Date: pp y
. No.�•..3--.V6 Fxs..............................
THE COMMONWEALTH OF MASSACHUSETTS
C BOARD OF HEALTH
0�Co i
t ....................OF...............-...................................................................I......
,� lirtttinn for Mipaiial Worke Tnnitrnr#inn rnmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System t: ,{ �/ ,ff
�j] //
(n.�..... :.k .AW .........'..`..�.�....Y�l lC rvl`�............... ...........
Locat' ddress or Lot No.
..... .. ... .... ....... -----...... ..4..
Own � ddress
W .. ......... ...__.... ...
a Installer Address t/®6
7g S feet
Type of Building Size Lot....:...................... q.
U Dwelling 4-<o. of Bedrooms...3....................................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
44 Other fixtures ............................
Q -----•--•-----------•-----•---... .......
•.... .................
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 ( ) ` 4
~' Percolation Test Results Performed by.......................................................................... Date._:. 43
Z.��.................._..
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
6aO Description of Soil - . ...... - - .....
x
x •---•--------------------------••-•-•-•-••---•••-•••----••----•••-••••------........---...--•----•••-----•••....... ••-• ----- a
U Nature of R� i or A ations—Answer when applicable------• -•-- ------- -
----• • 1 -.-•---•----------------------•-•-•--•-•------•-•-••-•-•-----•---•---------------------•-------•-•---•--------------------.---.------•-
Agreement:
The undersigned agrees to install the aforedescribed, Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the boar health.
I .. ...... ... ------------------------------
D
ApplicationAPpr •••. `.. ................................................................ .. .. .. .............
Date
Application Disapprov or fie following reasons:.................................................................................................................
•.... ..........................• •.........---........_....•-••....................._.....-•---._.......................-•-------•-•..................••.......... ---•--•..... ......•-•-•---
Date
PermitNo......................................................... Issued.._ 3 .....................
Date
_...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
3.
_. ....................OF ...................................................
Appliration for Uiipoiittl Works Tonitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemat: :..................................•--_- ___________.............--.---.-------_-.-
p 7Locat' ddress or Lot No.
................................ ............
&. ddress
W .. _.. ....
Installer Address
y4)d d0____S feet
Type of Building Size Lot________________ q.
U Dwelling zb. of Bedrooms.._.*3.................................... Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons..................._-------- Showers ( ) — Cafeteria ( )
p' Other fixtures _________________________________ _
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
f� Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Dat el?`.+�:��' �„..-•-•--_--•---.....
h h ____. h
Test Pit No. l________________minutes per inc Dept of Test Pit _...___.______ Dept to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
- • -•-•-
O Description of Soil._ ._... .......
x
UNature of i or A ations—Answer when applicable--4a4` ir g ...............
..........4 1 -------------•- -----.....------•--••----.......------------------------------------•---•-----••-•-•-- ..._._......_._.
Agreement:
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued b the b arf health
__, _`. . ...... ............................... s:�p{er....,_
j Dat
Application Appr ue ..... --- ••-............ -•--- ------- . - . f_
Date
Application Disapprov or a following reasons-------------------------------------•----•--------•-•--•------------------------•. •---......._---•--
................................. •--•••-•-•••••---•-••----••--•-------•--•--•••-----•-•----------------••-----------------•-••----•---••--•-------•-•••-•••----•-----•--••••---•••-•-••---.._.._...---
Date
PermitNo......................................................... Issued. "' ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Tatifiratr of Tomplinurr
T I .TO C TIF P°`Xrh the Indiv" ual Sewage Disposal System constructed ( ) or Repaired
x
Installer •.
AfiZ
has been ins led i accordance with the prov sions of TIT 5 of T State Sanitary od as es ed in the
applicatio for Disposal Works Construction Permit No.....
dated..... 'j .................
THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM 1N 6_*jUNCTION SATISFACTORY.
DATE.& ` -K�•........................................................... Inspector -_... ------------•-•---•--•--•----------•--•------•........-----------••--•--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.......................................................................................
No... FE ................
io oo l nr AT notrnrtion rrmit w.
Permission is her y ranted_..••• •---- •••. - •••=- - ----........................••-•-------------
••••-=---••••••• •...................... .•---------
to Construct `fir e it ( ad` ivi 1 rage Disposal System
atNo........... g, fit ..........................
Street
as shown on the a icati or Disposal Works Construction Permit No............... ..........................................
. .................................. . .:. �_... -------...... ......
,, ..
- Board of Health'`'
DATE� �._ .............................................
-----------•-- .
FORM 12$$ A. M. SULKI Ni INC., BOSTON -
r