HomeMy WebLinkAbout0017 GALLEON WAY - Health 17 GALLEON WAY, MARSTONS MILLS
A=098-042
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS.
c DEPARTMENT OF ENVIRONMENTAL PROTECTION
Sy�
TITLE 5
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Nam
Owner's Address: eta
Date of Inspection:
Name of Inspector: (please rint)
Company Nam
Mailing Address: r �o
k �G
Telephone Number:., . 1171- 9t39 9 /%per ® �O
CERTIFICATION STATEMENT O
I certify that I have personally inspected the sewage disposal system at.this addres�` � atQthe in ation reported
below is true,accurate and.complete as of the time of the.inspection.The inspection as. for d based on my
training and experience in the proper function and maintenance of on site sewage disp al s ems.I am a DEP
approved system inspector pursuant-too Section 15.340 of Title 5(310 CMR.15.000). he system:
V Passes
Conditionally Passes
s Furt er Evaluation by the Local Approving Authority
F s
Inspector's 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 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 6/1.5/2000 page I
Page 2 of 11
4J,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION (continued)
Property Address:
azzzzR Lt-�) a
Owne
Date of Inspection: St// ,/y/
Inspection'Summary: Check A,B,C;D or E 1 ALWAYS complete all of Section D
A. )System Passes:
V I have not found any information.which indicates that any of the failure criteria described in 310 CMR
15 303.or-in 31.0 CMR.15,304 exist.Any•fail. e criteria not evaluated are indicated below.
Comments:
B. System Conditional) Pass yes.
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,vy ll 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'infiltratioh orexfiltration or.tank failure is imminent:System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout 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 than4 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 1.1
OFFICIAL INSPECTION FORM-NOT FOR:;VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /
Owner:
Date of Inspection: ! v�D
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'mannerwliichrwiil proteci public health,�safety and the environment:
Cesspool or privy is within 50 feet of.a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is.functioning in a.manner that protects the.public health;safety and environment:_:.
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 1.00 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
**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
SUBSURFAMSEWAGE DISPOSAL SYSTEM INSPECTION FO'R1VI
PART A
CERTIFICATION(continued)
Property Address:
Owner:k.
Date of Inspection: 1/r / ld/
D. System Failure Criteria applicable to all systems:
You.must indicate"yes"or"no to each of the following for all inspections:
Yes N
— Backup of sewage into facility or system component,due to overloaded or:clogpd.SAS or cesspool
Discharge or ponding of:effluent w the.surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ Static Iiquid 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
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times.pumped
_ V Any portion of the SAS,cesspool or privy is below high groundwater 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 I of a public well.
1 ..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 coliform bacteria and volatile organic compounds
indicates that the well isfree-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 ownershoul'd contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered alarge system:the system must serve a facility with wdesign flow of 10;000-gpd fo.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 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 questibn 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 11
OFFICIAL INSPECTION FORM;-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION:,FORM .
PART B.
CHECKLIST
Property Address: (�
Owner �C.
Date of Inspection: i a Ad
Check if the following have been done.You must indicate"yes"or"no"as to each of the following.
Yes No
,.Pumping mformation.,was,provided by the owner,.occupant,or Board of Health
�Were.any of the system.components pumped out.in the previous two weeks
Has the system received normal flows in the previous two week period?
Have large.volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note.as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break:out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened,and the interior of the tank inspected forthe condition
of the baffle$or tees,material of construction,dimensions,depth of liquid,depth.of sludge and depth.of scum
_7_ 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.
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(3)(b)]
5
Page 6 of 1 I
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OFFICIAL INSPI'CTION'FORM=NOT FOR VOLUNTARY ASSE;SSIVIENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART C
SYSTEMANFORMATION
Property Address:
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(.design):: Number of-bedrooms:(achal):.. :
DESIGN flow based`on 310 CMR 15.203 (for example:110 gpd x 4 of bedrooms):
Number of current residents: _
Does residence have.a garbage grinder(yes or no)Ae— '
Is laundryon a separate sewage system es or no)- �f es se arat
P b y (y no)-
Laundry y p a e inspectiwrequ�red]"
Laundry system inspected(yes or no):
Seasonal use: (yes or no):
lao—
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no)•
Last date of occupancy:
COMMERCIAL/INDUSTRIAL/-)W
Type of establishment: . . ..
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,efc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
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:
Was system pumped as.part of the inspection(yefoir no):.
If yes, volume pumped: gallons--How was qua tity pumped determined?
Reason for pumping:
TYPE F SYSTEM
LeSeptic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
_.Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy'of the DEP approval
—.Other(describe):
A p oximate age of all components,date installed(if known)and sour a of inf ation:
Were.sewage odors detected when arriving atthe site(yes or no):.
6
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: &��.
Owne '
499
Date of Inspection:
BUILDING SEWER(locate.on site plan)
Depth.below grade:
Materials of construction:_cast iron _40 PVC_other(explain):-
Distance from private water.supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,--etc.):
SEPTIC TANK: ocate on site plan)
Depth below grade: (_®
_ g
ber lass
Material of construction:�ncrete metal_fi o __polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) v
Dimensions: S• XC®' k
Sludge depth:
Distance from top of sludge to bottom of outlet zee.-or baffle:
Scum thickness: ° /1
to of scum to to of outlet tee or baffle:
from
Distancep —L.—
P
Distance from bottom:of scum to bottom f outlet tee or baffle:
How were dimensions determined: 0462 A� 1��7�✓
Comments(on pumping recommendat o tnlet and outlet tee or baffle condition,structural integrity, liquid levels
asrelated to outlet invert,evidence of leaka e,etc.):
�.
to
GREASE TRAPtocate on.site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL�`INSPECTION FORM-NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONS FORM
PART C
SYSTEM'I]VFORIVIATION(continued)
Property Address: . '
Owner.
Date of Inspection: �d//r�/[) ✓
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of fasUpumping:
Comments(condition of alarm and,float switches, etc.):
DISTRIBUTION BOX: f/ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 4fwl;.
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
Je4age into or out of box, etc.): s
PUMP CHAM13Ey1 (locate on site plan)
Pumps in working order:(yes or.no):
Alarms nMorking order(yes or..no)
Comments(note condition of pump chamber.,condition of pumps and appurtenances,etc.):
8
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Page 9 of 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ram"G�Uacz
Owner.
.�
Date of Inspection: /e ha 0
SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located explain why:
.type. - .
V 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.
/0d
CESSPO01(SXI,&- (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 or no):
Comments(note condition of soil,signs of hydraulic failure, ie-vel of ponding;cordition•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.):
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:
Owner
Date of Inspection: 9d!
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 wit hin 100 feet.Locate where public water supply enters the building.
3� a
a
10
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Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: /r
Owner:
Date of
SITE EXAM.
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to groundwater feet
i
Please indicate(check).all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked-with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: ��`
t
11
4 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r DEPARTMENT OF ENVIRONMENTAL PROTECTION
A
RECEIVED
APR 1 7 2001
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM NOT FOR.VOLUNTARY:ASSESSME
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Nam
Owner's Address:
Date of Inspection: A/D /
Name of Inspector: (please rint) "L r /D V4
Company Nam —" "�%497i'G
Mailing Address: 7
&A
Telephone Number: , 19
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. I am a DEP
approved system inspector pursuant/Passes
to
Section 15.340 of Title 5(310 CMR 15.000). The system:
Conditionally Passes
Neqds Furt er Evaluation by the Local Approving Authority
F s
Inspector's Signature: i Date: ra i
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 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 6/15/20.00 page 1
Page 2 of 11 _
in
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-- PART A
CERTIFICATION (continued)
E
1 Property Address:
4
Owne
Date of Inspection:'
Inspection`Summary: Check A,B,C,D or E/ALWAYS complete all of Section D.
A. )System Passes:
V I have not found any information which indicates that any of the failure criteria described in 310 CMR
]5.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair; as approved by the Board of Health,Will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial-infiltration or exfiltration or'tank failure is imminent:System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken'or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
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 1'l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
. If7 09-am,
Owner:
".4i-0e.-/ 0dr-it
Date of Inspection: v/O
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b).that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is functioning in a.manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than I00,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 I I
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
.10%�4&9X,
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
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 ''/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
l of times pumped
_ t/ Any portion of the SAS,cesspool or privy is below high groundwater elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
/ water supply.
t/ Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or.privy is less than 100 feet but greater than 50 feet from a private water
supply well-with no acceptable water quality analysis. [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 largesystem the system must serve a facility with a-design flow 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 no.
_ the system i.s.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.
4
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Page 5 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: (-ci
Owner
Date of Inspection: 1 - '
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping.information was provided by the owner,.occupant,or Board of Health_
---,"Were.any of the system.components pumped out.in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large.volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
_ Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site
✓_ 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:
Yes/no
✓ 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(3)(b)]
5
Page 6 of 1.1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
,4
Owner.
Date of Inspection: c�j
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(.design):- Number of bedrooms(actual): 02
DESIGN flow based on 310 CMR 15.203(for example: 11.0 gpd x#of bedrooms): .
Number of current residents:
Does residence have.a garbage grinder(yes or no)
Is laundry on a separate sewage`system(yes or ho);�1d-[if yes separate inspection required]
Laundry system inspected(yes or no):,Z210—
Seasonal use: (yes or no):�Q" .
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: — ?w,
COMMERCIAL/INDUSTRIAL/1,d'—
Type of establishment: . .
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): ." .
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
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:
Was system pumped as part of the inspection(yefor no):�
If yes,volume pumped: gallons--How was qua tittf y pumped determined?
Reason for pumping:
TYPE F SYSTEM
eptic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
_.Privy
_Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_.Other(describe):
A p oximate age of all components,date installed(if known)and source of inf ation:
Were,sewage odors detected when arriving at the site(yes or no): —
6
r
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owne '
Date of Inspection:S/i A lo
BUILDING SEWER(locate on site plan) ✓ '�6—
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):-
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK:_z6ocate on site plan)
Depth below grade: (�
Material of construction:�ncrete_metal_fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is aQe confirmed by a Certificate of Compliance(yes or no): _(attach a copy of
certificate) v
Dimensions: ' •S X�' k
Sludge depth: 3� I/
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 f outlet tee or baffle:
How were dimensions determined: ��i�/ eh�� ,G/T�✓
Comments(on pumping recommendations, Inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leak a e,etc.):
i
GREASE TRAP y
ocate on site plan) " a' '
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
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:
Owner.
Date of Inspection: �// o-�.J� /
TIGHT or HOLDING TANK:6-(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/day
Alarm present(yes or no):
Alarm level: . IAlarm in working order(yes or no):
Date of last pumping.-
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: -I/ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:��1�2�
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
lGakage into or out of box, etc.):
U"
PUMP CHAMBE locate on site plan)
Pumps in working order(yes or no): -
Alarms in working order(yes or no):.
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): '
8
5'+
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART. C
SYSTEM INFORMATION(continued)
Property Address: I fl (�LP,"0'
Owner.
Date of Inspection: lrg�i,3 /0 /
SOIL ABSORPTION SYSTEM (SAS):__jZ(locate on site plan,excavation not required)
If SAS not located explain why:
TYPe
leaching.pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,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.
-/00
f J
I
CESSPOO�(cesspool must be pumped as part of inspect ion)(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 or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: locate.on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
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:
IG14
Owner
Date of Inspection: d/
SKETCROF 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.
3S e
37
10 ,
r
�eh
- Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /r7 L� G
r �
Owner:
Date of Inspection: Q
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water U feet
Please indicate(check)all methods used to'determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: A �fN
I
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l!0_ C,o, 10N SEWAGE PERMIT q0.
_ Lc— S"
d1`LL A GE _;_-4
® � VIp 09p ' OVA
INSTALLER NAME ✓ A ADDRES
N U I L D E R OR OwN ER
DATE PER13IT ISSUED
DAT E COMPLIANCE ISSUED
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.......................
••THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................0F.. N...s.raa ......------.......------.............-----
Appliration for Dispoiial Works Tnnitrnrtion ramit
Application is hereby made for a Permit to Construct (J<) or Repair ( ) an Individual Sewage Disposal
System at:
C'eip LLs
�
7
Location'Address or Lot No.4'P. t- ,�-� °•`- ...................................... ......`....- ��'rc' r a -----•-`•�:
Owner Address
--------------------------------------------- ------•-•-----------------------------
Installer Address
Type of Building Size Lot..a_.�Q¢r z 4..._..Sq. feet
Dwelling—No. of Bedrooms. ___----'�............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons 6.................. Showers
a YP g ---------=----•------------ P ( ) -- Cafeteria ( )
Otherfixtures ..------•---------------------------------------------------------------------------------------------------------- ------
W Design Flow..........,57........................gallons per person per day. Total daily flow___...._._......4? .o................gallons.
r ,r
WSeptic Tank—Liquid capacity./ _.gallons Length_ e__G..__.. 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 ( ),
W Percolation Test Results Performed ........ .................... Date...47...; ...................
Test Pit No. 1.._ ........minutes per inch Depth of Test Pit..le?.._....... Depth to ground water..Ak�p............
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soi1�Ts?� << i15t' i✓ ----•---- Xi/ 3/ /..
V ....................................._...................................................................................................................................................................
W
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
... ---••----------------------------------•-••--------------------•----------------------••--.•-•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee i sued by��e board �heal
Sign d_ ...._... ----
Application Approved By ------ `` -------------
to
Date
Application Disapproved for the following reasons----------------•---------------•- ....................................
......................................
-
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued-.......................................................
Date
N .'� .5� .» .ti : • Fps.... ........._
�*HE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f.1+F�iV 5T /
_ Appliratinn for Disposal Works Tonstrnr#ion rumit
Y' Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
Location.Address or Lot No.
.a.���rl�7i o .............................. it > �.�� �
Owner Address
.......................................... ................................•--•-•---... ..........................................-----....
Installer Address
d Type of Building Size Lot_jo.t�Y.._._..Sq. feet
Dwelling—No. of Bedrooms.................... ..._._.__.Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building A....................... No. of persons...... .................. Showers ( ) — Cafeteria ( )
Otherfixtures -•-•--•-•--•----•-------•-••-•--------------------•-•-'---.......--•--.....---•-•--••-----•--•--•-•---•------------------.....--------........_.------
W Design Flow..........j: .........................gallons per person per day. Total daily flow............... 3 0.................
Septic Tank—Liquid capacityZ ...gallons Length__!q._�_ L. Width.+s...�....... Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.........-........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by..�........�N._..__�� L�=j�?'�� ..................... Date.. '/ !...._...____--------
a
a Test Pit No. 1__ .........minutes per inch Depth of Test Pit..4�........... Depth to ground water./Y..N e
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•---•-•----------------------------------------------•--••---•----. . .... ............................
.----.-------•---•••-.......
---------------
O Description of Soih.1,4--- ....... ,_-
U ----•-••........-••••--•--•------•-•........--••••-------------•---•---------------.............----.....--•---•--------.....--•---.....
W
------------------------------ -•••••••-•----•-----•-••-•---•••-•---••---------•---•••------•----••----•--•--•---------------••------•-•-•-•-----•-----•--•----•••...--•-•--•---...._......•••••.......
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.. ------•--------------•-----------------...•••---•-----.
Agreement: ti
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T'LE 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 by the board of health.
Signed........................................
I------------------------.--------- -----------D-Y-......._....
Application Approved BY ;r,/..... ....-••--•------
Date
Application Disapproved for the following reasons---=------------------------------••-----------------------------------------••------------......------......---
..............•-----•--.....-----•----------•------•-----•-•-•-----------.........--._........------......---
Date
"Permit No......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
./.............................OF... /�!F'/!!.:`!.,f k? .�`.''................................
Trrtifiratr of Tnntplianrr
THIS IS TO, CF`RT!IIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by... .-•-- l._r.( ._.,� ......................................•--•-
/+ Installer
.........a. ............ L ll�,n1.._ri-rc.4,0-•----••----...
has been installed in accordance with the provisions of TI�1 r. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..C9 1._-�;?6................. dated.................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...............................................:-•-----•-----•-•-•-•--.....---•-- Inspector....................................................................................
{
hTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
id g y -c c
No......................... FEE-'}3-_4�.................
Disposal Works TwOn#rnrti.nn anti#
Permission is hereby granted...- P !o.......
r`''h?..!1% ........................--------••.....................•.............•-•-•••-
to Construct or Repair ( } an Individual Sewage Disposal System
at No..... .-----C�-.Z! r ...Ci ter•I t .r_>�.r!_ mil.
. --- ....... .• ....................................................
Street
as shown on the application for Disposal Works Construction P I . No___________________ � ated..___........__._..__....._.____..__......
q J ' Board of Health
DATE---------------•----/.. -
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
w
TOWN OF BARNSTABLE Q
LOCATION 17 G A L L it) e_% SEWAGE # J 7 o
VILLAGE & A R S LQ A1-5 /(sj /LL,j ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. T 114 A C IA 1 el? -/- 5 o N
SEPTIC TANK CAPACITY r O U O 7 9s 33 g
LEAl.tHING FACILITY: (type) �% ' t ^/e(✓ �� (size) _ /-O aD
NO. OF BEDROOMS Z 2
BUILDER OR OWNER
PERMITDATE:_ I -.�a — '_COMPLIANCE DATE:_ /_-Z A - L_
Separation Distance Between the: r
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and LeachingFacility
on site or within 200 feet of leaching facility) any wells exist
Edge of Wetland and Leaching Facility(If any wetlands exist C Feet
within 300 feet of leaching facility)
Feet
Furnished by jp
�h
i
i
TOWN OF BARNSTABLE V
LOCATION 17 G A L 4 P QN lJ Lk-, SEWAGE #
VILLAGE AA A AS rQ N-5 ,�ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. .T° 114 14 C d/14/5e/' f 5 O.N
SEPTIC TANK CAPACITY r O U 7s 3
LEACHING FACILITY: (type) /Je�7f f -r Ale6J )PI r(size) /-O 00
NO.OF BEDROOMS ' �-
BUILDER OR OWNER
PERMUDATE: a X ' -? COMPLIANCE DATE: J--2 ;L y
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Ak Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by y P V e_o n
�� �h oh
� �
� ` ' �� �� �
�£ � �� � �
�,
� � ��
f: �
No. / — -30 ""'"� a Fee $ 50.00
THE COMMONWEALTH OF MASSACHUSETTS;u r Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Migogal *pgtem Con6truction 3permit
Application for a Permit to Construct( )Repair�X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Q1'S'f°h9 rn, S Owner's Name,Address and Tel.No. Palm Florida 32905
17 Galleon Way ' j4e Blanche Karciauskas
` Assessor's Map/Parcel 098-42
268 Prt Malavar BLVD Florida
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
.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass . 02632 Box 66 Centerville,Mass . 02632
Type of Building:
DwellingXXXNo.of Bedrooms 2 Lot Size sq. ft. Garbage Grinder�0 )
Other Type of Building RES No. of Persons 0 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 Z 1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ..1 000 existing Type of S.A.S. 2-1 000 gallonni_ts
Description of Soil one existing
C;na_r,QP ,aa.nd to medium sand
Nature of Repairs or Alterations(Answer when applicable)
Adding a 1000 gallon pit to an existing tank & pit.
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 issu9d by this B and Heal h.
Signed Date 1 /17/97
Application Approved by Date —3'7
Application Disapproved for the following reasons
Permit No. 9 7— _� Date Issued / a- 97
s. 0. 00
No. Fee
y THE COMMONWEALTH OF MASSACHUSETTS " Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0[pprication for 3W50oal *pgtem Construction Permit
Application for a Permit to Construct( )Repair R Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
kCali A ssorLotNo. rnq °HS ► , S Owner's Name;Address and Tel.No. Palm Florida 32905
Ga eon Way Blanche Karciauskas
Assessor'sIvlap/Parcel 098-42, 268 Prt Malavar BLVD Florida
Installer's Name,Address,and Tel.No. 58—7 7 —3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
.P.Macomber & Son Inca J.P.Macomber & Son Inc.
Box 66 Cente-rville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
DwellingXXXNo.of Bedrooms 2 Lot Size sq. ft. Garbage Grinder F0)
Other Type of Building RES No. of Persons 0 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 0 gallons per day. Calculated daily flow 3/110. gallons.
Plan Date Number of sheets Revision Date
Title ,/
Size of Septic Tank 1 000 existing Type of S.A.S. 2-1'0b0 gallonpits
Description of Soil one existing
Coarse sand to medium sand
Nature of Repairs or Alterations(Answer when applicable)
Adding a 1000 gallon pit to an existing tank & pit. ,
Date last inspected:a /7/o 7
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 B 'ard� ea th.
Signe o• Date 1/17/97
Application Approved by � ' Date
Application Disapproved for the following reasons
i. tl
Permit No. 7' `" ' Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired X )Upgraded( )
Abandoned(( )by J.P.Macomber & Son Inc.
at 17 Galleon Way Osterville,Mass• has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 7-3D dated / --" 9
Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & Son Inc.
The issuance of this permit shall not be construed as a guarantee that the suer il�n as,desig ed/ 114
Date l " o�c� 1 -7 Inspector
————q ———————————————————————————————————
No. ( 7 _ 3 e Fee $ 5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
&5po5al *pgtem Con.5truction Permit
Permission is hereby granted to Construct( )Repair((XX)Upgrade( )Abandon( )
Systemlocatedat 17 Galleob Way Osterville,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 thisy-ertnit.
Date: —a� 97 Approved by
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISP6-
WORKS CONSTRUCTION PLIt�,11'I' (1V1'1'11OU'I' DESIGNED PLANS)
I Joseph P.Maeomber Jr. c�rtily that titc application for disposal works
construction pernut signed by ntc 7/97 , concerning the
property located at 17 Galleon Way_0stprm_ 'l 1 P,Mass ineets all of the
following criteria:
There are no wetlands within 300 feet of the proposed septic system
There are no private wells wiIhill 15U feet of the proposed septic system
• The observed groundwater table .s •t feet or greater below the bottom of the leaching facility
There is no increase in flo%v and/or ch;wgc in use proposed ~—
There are no variances requested or needed.
SIGNED : DATE: 1 /17/97
LIC N SEPTIC SYS'ram INS•'ALLER IN'1'1iE TO\YN OF BARNSTABLE NUMBER_
[Attach a sketch plan of the proposed Also if tl:e licensed installer posesses a certified plot plan,
this plan should be submitted].
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Return Receipt Showing to Whom,
Date,&Addressee's Address
0 TOTAL Postage&Fees $ (a .
Postmark or Date
E
LL
�//3/�-
I� Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1.If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at.a post office service m
window or hand it to your rural carrier(no extra charge). m
Q)
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the a)
return address of the article,date,detach,and retain the receipt,and mail the article.
LO
3. If you want a return receipt,write the certified mail number and your name and address rn
on a return receipt card,Forth 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a
RETURN RECEIPT REQUESTED adjacent to the number. Q
4. If you want delivery.restricted to the addressee, or to an authorized agent of the G
addressee,endorse RESTRICTED DELIVERY on the front of the article. M
5. Enter fees for the services requested in the appropriate spaces on the front of this
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. t9
6. Save this receipt and present it if you make an inquiry. d
Town of Barnstable
R� Department of Health, Safety, And Environmental Services
MMK_ "A health Division
367 Main Street,Hyannis MA 02601
Installers "on=A.McKa++
oQice�5 79o-6265 b6ectar d�ntillo tiaMh
Eric. Job-775-3344
TO:
Blanche Karciauskas (Date) January 10, 1997
268 Port Malavar Blvd.
..Palm Bay;' Florida 32905
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 17 Galleon Way Avenue, Circle, Lane,
Road, Street in the village of Marstons Mills was inspected on January 7,97 by
Joseph Macomber Jr. a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following:
Leaching pit is in failure. Septic must be repaired to Title 5 system.
You are directed to hire a licensed Town of Barnstable septic system installer to sketch a
proposed system that will bring the septic system into compliance with 310 CMR 15.00,
The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice.
The septic system must be brought into compliance within thirty (30), sixty (60), ninety
(90) days of your receipt of this letter.
You are also directed to maintain the system by hiring a licensed septage hauler to pump
the septic system to prevent discharge of sewage or effluent into the buildings, onto the
surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BO OF HEALTH
Tho as cKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
title 5(1)
TOWN Olr BARNSTABLE
LOt sATICnt,;,/ 4&CR®e¢� �
PILLAGE � i ASSESSOR'S MAP & LOT
S NAME&PHONE
SEPTIC TANK CAPACITY Ida
LEACHING FACILITY: (type) t-/ (size) ���
NO.OF BEDROOMS -{
BUILDER OR OWNER / COMPLI�'
FORWDA ANCE'DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet ,
_I
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet 2
Edge of Wetland and Leaching Facility(If any wetlands exist 1
within-00 fee of leact'n fa ' ty) Feet
Furnished,by
t 1'
a � p
. r
�TM� ►,, Town of Barnstable
_ Department of Health, Safety, and Environmental Services
t
• `"�" Health Division
�...._ t679• A�
367 Main Street,Hyannis MA 02601
Installer
_Ofr:--5 $790.6265 Thectoonm o McKean
RAJ{: 509-775-3344 llirctor of Public Health
TO:
ram- (Date) / " G s" 7
f-vk
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 1 LgA Avenue, Circle, Lane,
Road, Street in the village of W Rk- was inspected on i --7_ f, by
a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
You are directed to hire a licensed Town of Barnstable septic system installer to sketch a
proposed system that will bring the septic system into compliance with 310 CMR 15.00,
The State Environmental Code, Title 5 within(14) fourteen days of receipt of this notice.
The septic system must be brought into compliance within thirty (30), sixty (60), ninety
(90) days of your receipt of this letter.
You are also directed to maintain the system by hiring a licensed septage hauler to pump
the septic system to prevent discharge of sewage or effluent into the buildings, onto the
surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
title 5(1)
U
Commonwealth of Massachusetts
Executive Office of Environmental Affairs 4
Department of wow�
2nvironmental Protection N`df
L661 Trudy Cox*
,
6a uhs
U.Ga01;,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERTIFICATION
Property Address: 17 Galleon Way Marstons Mills ,MA Address of owner.Blanche Karciauskas
Date of Inapeotiom t /7/97 (If different) 268 Port Malavar BLVD
Name of Inspector.Joseph P.Macomber Jr. Palm Bay Florida
Company Name,Address and Telephone Number. 32905
J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632
CERTIFICATION STATEMENT 508-775-3338
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
mai.nteaance of on-sits sewage disposal systems. The system:
Passes
_ Conditionally Passes
Further Evaluation By the Local Approving Authority
e_ ' Fails
laspector's Signet; Date:
�
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner.wd copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check & B. C, or D:
A) SYSTEM PASSES:
_fL I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) 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 yea,, ,or not determined(Y, N, or ND). Describe basis of determination in all instances. If*not determined', explain why not)
;2 The septic tank is metal, cra:kod, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by tLe Board of Health.
(revised 11/03/95) 1 `
On*Winter Street a Boston, Massachusetts 02108 • FAX(617) $56.1049 a Telephone (617)292.5500
0 Pnnled on Rec W Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Propervmdiesa: 17 Galleon Way Marstons Mills ,Mass .
Owner. Blanche Karciauskas
Date of Inspeotion:1 /7/97
B)SYSTEM CONDITIONALLY PASSES (continued)
d2 Sewage backup or breakout or h0h static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uaevea distribution box. The,system will-pass-inspection-if(with_approval of the_Board� of 0��,
He": (k&4— _�t ± I�7y`k_�i ? '1u;T_1 J r�yAsavtt�i�
broken pipe(s)are replaced
obstruction is removed
distribution boa is levelled or replaced
d& 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:
V Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
&14 Cesspool or privy is within 50 feet of a surface water
.L4 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
_) 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 we11
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 leas than 5 ppm.
3) OTHER
(revised 11/03/95) 2 `
SUBSURFACE
SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
PropertyAddrata: 17 Galleon Way Marstons Mills ,Mass .
Owner. Blanche Karciauskas
Date of Inspectional /7/97
-✓Dl SYSTEM FAILS: "
I have determined that the system violates one or more of the following failure criteria as dsnned in 310 CMA 15.303. The basis for
this determination is identified below. Ths Board of Health should be contactad to determine what will be neoessary to correct the
failure.
,dc�o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
A20 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cerapool.
,d,p Static liquid level in the distribution_bos.above,outlet,inver_t due to an overloaded or,clogged SAS or cesspool.
Liquid depth in oewpo4is Is" than 6"below invert or available volume is less than U2 day flow.
A) Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
A6 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 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
adaptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water aaatyais for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system servw 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:
the system is within 400 feet of a surface drialdng 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(IVJPA)or a mapped Zone 13 of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into frill compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
pr.p.,tyAddr.aa 17 Galleon Way Marstons Mills,Mass.
owner. Blanche Karcivaskas
Data of Inspection: 1 /7/9 7 •
Check if the following have been dons:
,Pumping information was requested of the owner, occupant,and Board of Health.
None of the m components
syste pones} have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not boon introduced into the or u system recently part of this inspection
Zbuilt plans have been obtained and examined. Note if they are not available with N/A.
znl facility or dwelling was inspected for signs of sawage back-up.
system does not receive non-sanitary or industrial waste flow
'he -to was inspected for signs of breakout.
_JZAU.system oompoasab;4,scludiag th±Soil Absorption System, have been located on the site.
n ZThe septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or
material of construction, dimensions, depth of liquid,depth of sludge, depth of scum.
2'sizo and location of the Soi
l Absorption 3 tem on
rp ys the site has been determined based on esisting iafosmation or
ap ted by non-intrusive methods.
The facility owner(and occupants, if 'ty pan different from owner)were provided with information on the proper maiatenaap of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSUIU'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddicba: 17 Galleon Way Marstons Mills ,Mass .
Owner. Blanche Karcivaskas
Datc of lnspeulivt.: 1 /7/9'//fi
FLOW CONDITIONS
RES I D F.NTIA--- I J
Design �
Nu- r of bedrooms:
Number of curnat reeideau:
Carbad� grinder(yea or ao):
Laundry oonnected to ayrum (yes or no):,Z
Seaso:a) cue (yw or no):-d2b
Rnur meat readings, if availnble:_L4 ,
Last data of occupancy:-U"
COMMERCLAL/INDUSTRIAL
Type of ertabLihnteat: J),4-
Derb-a 0ow:A2&jaL0ns/day
Crease crop prweat: (yea or ao)
laduatrial PJaste Holding Tank prearat: (yea or no)_
Non-sanitary wasta discharged to the Title 5 rystam: tyes or no)_
Water meur reading, (l available:
Lan data of oav parry:
OTEER: (Describe) _
Lan data of occupancy:
GENERAL INFORMATION
Pl'MP1NG ORDS
-�8gad spurt of urirauo-: n! _ ��
Sysum pumped u part of inspectwu- (yeas or no)
Lf yes, volume pumped: l asa1' ,ts
Reasoa for pumping i )A �' '�1j1GC s � i 1cy-
TYPE'16 SYSTF
Septic tat.Vdiatribution bo=/sod absorption Y)'Ytem
S;r.,;ie cam.rc l
OvVriaow Ce.:spwl
Privy
Shared eyrum (yea or no) (t(yea, attach previous inspection records, if any)
Other (azplria)
e
TE ACE of all oomponenu, dau u:.+tu11W (if known) and source of information: ��/'
sewace odor. r+.puvriai
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C. •
SYSTEM INFORMATION (continued)
Property Address: 17 Galleon Way Marstons Mills ,Mass .
Owner: Blanche Karcivaskas
Date of Inspection:1 /7/97
SEPTIC TANK: leed P4 -7s e .
(locate on site plan)
n
Depth below grade:
Material of construction: 'concrete _metal _FRP—other(explain)
Dimensions:_ tj L
Sludge depth:
Distance from top of sl e to bottom of outlet tee or baffle:,__
Scum thickness: U
Distance from top of scum to top of outlet tee or baffle: _
Distance from bottom of scum to bottom of outlet tee or baffle— a
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid level in relation to outlet invert, structural
�rity, evidence of leakage, etc.) Pump septic tank every 2=3yearp ;Inlet & o 1411
el-
'tees are in place ;No signs of leakage , � rg�airs needed at
t'hp n,:pepnt. ti ma
GREASE TRAP./04,JQ,
(locate on site plan)
Depth below grade:'N_�_
Material of coNA!rlion, zoncreteNAmetal _FRP _other(explain)
Dimensions
Scum thickness:
Distance from top wf scum to top of outlet tee or bahle:.NA_
Distance from bottom ni srum in bottom of outlet tee or bafle:
Comments:
(recommendation for pumping, condl—ri of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc,L_Grease trap is nbt present.
r
Irevised 6/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
PropertyAddre": 17 Galleon Way Marstons Mills ,Mass.
Owner. Blanche Karcivaskas
Data of In.speotlon: 1 /7 9 7
TIGHT OR HOLDING TANK--&4'P,
(locate on sits plan)
Depth below grads:-64
Material of constiuctlo • concrete_metal_FRP_other(esplain)
AM
Dimensions: JOA
Capacity as
Deep flow: W ona/day
Alarm lsvel:
tea,
(oondition of inlet we,condition of alarm and float switch", eta.)
Tight or holing tank not present
DISTRIBUTION Box,
(locate on site plan)
Depth of liquid level above outlet invert: A Q/ _
Owm ts:
(note if level and distrRyution is equal, evids=of solids carryover,evidsncs of to or out of box,stc.)
Distribution is equal;No signs of solids carry over;No signs
—T—leaT—in or out of the box. No repairs needed at the present
time.
PUMP CHAMBER-AdVIV6�-
(locate on site plan)
Pumps in working order•(y"or uo)NA
Comments
(note condition of pump chambar,condition of pumps and appurtenances,eta.) Pump chamber is not present.
(revised 11/03/95) 7
U
161)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): /6ee, , A. /Prc CrA s T
(locate cn sits plan,if pos ibl ;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain: s
Type. kaebi
leaching chamber,number
leaching ga1lariee,number W O
l achh, trenckes,number,lengw:
Lacking fields,number, ne —
overflow cesspool,number
Comments: (note condition of soil,signs of hydraulic failure, level of pondire Condition of ve etc.)
Medium sand to fine sand;No signs of hydraulic ai�l�ure ; no sTgns
of j)nn8jng; A11 Vegetation is normal. Pit is in ai' u�-Li ucl is with
it must e a e
CESS� h eeisting septic system.��� Rg �7 11v5/_
(locate an site plan)
Number and configuration
Depth-top of liquid to inlet invert:
Depthofsolidslayer.
Depth of scum layer- )9
Dimensions of cesspool
Malarial-of Construction:
Indication of groundwater. _
inflow(cesspool must be pumped as part of inspection)
Comments:(note condition of soil,signs of hydraulic failurs,level of pondin&condition of vegetation,etc.)
r:caapnn1 a Bra not present
PRIVY:
(locate on site plan)
Material-of construction. NA Dimensions: NA '
Depth of solids:,jL
Pt-i�cot sin o t press a kv 'ram mire,level of pondir4 condition of vegetation,itc.)
V,
(revised 11/03/95). g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L:SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
Centerville Osterville Marstons Mills
Water Company
428-6691
Q
DEPTH TO GROUNDWATER,
16�.+ depth to groundwater
r+ptod of determinal or ,approximation:
. .. r .a
r
1 .-f
s ayncY... �...,.«..r... .,_. ......:..:..^'"�'�'�I'-fO#'O-.• abt�s..n.�s. ...,. ,.ti.�.� a,w�npC:4i'^.pt»•W...: ...
•��� o m I d
.24 n
4I r 1, N �l. i
r;
L 4 M
I L•� �•-,.,., l0' .,; . .. Q t •� Gi.3A.-�rrACy V
. 1n
TYPicAL. ','EDIST21ItAuT1ot.i 30X_
UC1Ttc: v«TZ%vkrr#ey.1 saK A.-4D lOoo cv-L. TYPIC.AL %000 GA.'-. SePTtc,
QEI�Fo¢GEti7 sornG Tf+-!1c >Bv AMEOIC. J PMCA%s7r Klorr To SCALE.
OR.EQUAL. L6Tc: TANKS aMLJt^btGEV -T&+eoL4Woy-
WtnA ELjRo_TZv_ w4E\-p6D A.nPe wrTM
2A - ic- mmeaoo&v STEEL eoaS iJ
'�P? 6oTb►�1. CJa.1C. rS �Ooo v5Z T�Sr
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SGALF t- _ 30' BcT'rowt .`Qe+. -c`rr)C�t)`CI) 5D &ef
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THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied
the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ion of Water Pollution Control
i
rTnr.r.—n.r�+•—.err—ern:aerr•rmrrr�mrs�.rrrar:-.•n-s+tnrr�re*+rn�tte'ati++s•�rrv�
I TURN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
`� �:«•Trl�••,••. —T.lif.«.�Tn.7t rnt-rllrt r!tlrlseerfnlT:r'i r'I+T1+7aRRrTARRAf�7nR7 Inn �.-1rrr•r--1• •�..A
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 17 Galleon Way Marstons Mills ,Mass . '
ASSESSORS MAP, BLOCK AND PARCEL # 098-42
OWNER' s NAME Blanche Karciauskas
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME J.P.Macomber & 11'ron Tne,
COMPANY ADDRESS Box 66 Centerville .Mass . 02632
Street Town or Ctty state LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
lIealLh 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.
:XXXXXXXXXSystem FAILED*' \
The inspection wllicll I have con trcted has found that the system .fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature .� Date 1 /7/97
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the DOARD OF HHAL171.
* If the inspection FAILED, the owner or'"o" erator shall u p pgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CFJR 15 . 305 .
partd .doc
�d SENDER:
'a ■Complete items 7 and/or 2 for additional services. i also wish to receive the
I E -Complete items 3,4a,and 4b. , ., following services(for an
w ■Print your name and address on the reverse of this form so that we can return this extra fee):
2 card to you. ai
j ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address
permit.
d ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery CO
■The Return Receipt will show to whom the article was delivered and the date a
delivered. Consult postmaster for fee.
0
v 3.Article Addressed to:/) 4a.Article Number _ p d
�� � qJ� � r 4b.Service Type
a U El Registered :Ji Certified W
to ❑❑ Express Mail Insured
N
o —�"- ❑ Return Receipt for Merchandise ❑ COD
a 3a�p 7.Date of Delivery p�
z � '1 — / 0
5.Received By: (Print Name) 8.Addressee's Addr ss(Only if requested
W- and fee is paid) r
6:Si
O
-= PS Fes_ _ ,'. receipt
UNITED STATES POSTAL SERVICE First-Class MailPostage&Fees Paid
USPS
Permit No.G-10
• Print your name, address, and ZIP Code in this box• j
I
I
I
Putitie AcAnn
Town of Barnstable
P.O.Box 534
Hyannis,Massachusetts 026011
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