HomeMy WebLinkAbout0224 OLD MILL ROAD - Health F224 OLD MILL R4� MARSTONS MILLS
- ---- -- - -- -- -- A= 046 100
tjtlLQi �-
No. "' � Fee d
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
01pplitation for Misposal 6pstem Construction Pffmit
Application for a Permit to Construct( ) Repair(Y) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 2 Z IjP o-b M I i i AD. ALM Owner's Name,Address,and Tel.No.
i
Assessor's Map/Parcel O y 6//o D J o s epiq Si m w+co s
Installer's Name,Address,and Tel.No. So16 -4-1l- V8-11 Designer's Name,Address,and Tel.No.
�n�e.RT Ci o�R Co -
3(�3 toti, Pot Tif S yAam,x,T-I Oz(_Ly-
Type of Building:
Dwelling No.of Bedrooms KJJA Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A I I gpd Design flow provided AIV gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
RC'FLdkc.2. MPHN Livie Fmpu /-kv.so 7b T,-t-lK jgjs All SA-rl,Y-1R7 ,c ANb
r16c4,' aj Acej)et
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance o e afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental de and n lace the system in operation until a Certificate of
Compliance has been issued by this Board of Health. ?
Signed Date J _
Application Approved by tAaDate
Application Disapproved by Date
for the following reasons
Permit No. fl��'�C Date Issued
No. V �. .. f' ; Fee, %/«
THE COMMONWEALTH,OF MASSACHUSETTS Entered in computer: t
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 1'eS
4plitation for Mispbsal 6psfirAn Construction Permit �
Application for a Permit to Construct( ) Repair Upgrade( Abandon( ) ❑Complete System ❑Individual Components 0
Location Address or Lot No. 2 Z' , -b M r t f /k�I Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel Q�1(O//O n Q S` M 11 S
— , • ��
Installer's Name,Address,and Tel.T4. S � `t l i - Va I I Designer's Name,Address,and Teel:No. ��
C Cvt'� CQ .
Type of Building:
Dwelling No.of Bedrooms 104 Lot Size sq ft Garbage Grinder( )
a
Other Type of Building No.of Persons - Showers( Cafeteria( )
Other Fixtures- -
Design Flow(min.required) "MA gpd Design flow provided ��(� gpd
Plan Date 1 y Number of sheets Revision Date
r _
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
i
i k Nature of Repairs or Alterations(Answer when applicable)
jATc k Vti+A i N L i vi t 616r1a �-Jav se 7 c, l'�M!< !�t_S �� P r it rn tz.1 T c A-i .
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 Certificate of
Compliance has been issued by this Board of Health.
Signed l F f Date 1 7
Application Approved by �\Ci(�AVA, L95_; Date
Application Disapproved by d Date
for the following reasons
Permit No �- � I Date Issued tntl�,�,,..��,�j
i.
THE COMMONWEALTH OF MASSACHUSETTS d
BARNSTABLE,MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded,(' )
Abandoned( )by
x- - at �, �"( ` /� - rl tt - has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No_,. v�C,�}"(j�( dated ( � J
P
Installer Designer
#bedrooms �'�( — Approved design flow t1.r - gpd
The issuance of this permit shall not be construed as a guarantee that the system� will f netion as designed. '1 i, !! � (
Date � �-�• Inspector `i ,i�( :'�U'1•; � `'
- - - - _-- -- - - -�j - - - -- - - - * ----------------------
,. No —i�� Fee ,
-` THE COMMONWEALTH OF MASSACHUSETTS' ry
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at E—( { ( A,(j (2A 1 �! n
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date ( p �`� Approved by A ., ,, P 41/ Ae r1l 1/2 r^
DATE: •.'L25_/_U----
I
PROPERTY ADORESS:2224; Q] C1 NU 11.._Raad-__---
- Marstons Mills
On the aboye date, I Inapeoled the septlo systeM at the aboye address.
ThIJ ayi(em Con51313 of the following; FAUG
VED
1 . 1 -1000 gal.lon septic tank.
2- 1 -1000 gallon precast leaching pit. 2001
ee3ed on my In3pecllon, I cortlly the Iollowln9 oondltNSTABLE
3 . This is a title five septic system. ( 78 Code ) DEPT.
4 . The septic- system is in hydraulic failure.
5. The waste and waste water is above all of the
invert pipes.
6. A new leaching area needs to be installed.
510NATUREt„/ _ JG
Name :_ ..P.,.jijssat«_�U--______
Company: )oo .2h_P _ N•comborvb Son , Inc ,
Addre55 ; Box 66
_-C#n t v r r 1 1 1 e � N a__o z 6 2-o oP�ILED INSPECTION
Phone , --- 508_775_ 3338____---
THIS C✓`ATIFICATION ODES NOT CONSTITVTti A OVARANTY OR WARRANTY
J6SEPH P. MACOMBER & SON, INC,
Tanks-0111pooh-Lo achllslds
PVmpsd 4 Installed
Town Sswsr Connsvtlons
P,O, 6ox 66 CsnlorYllls, MA 02632-0060
775JJJ8 775641z
tied ,�o
r
,-.ram
�-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL. PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:224 Old Mill Rc)arl
Marstons Mills
Owner's Name�7ietnam Vei'Pranc
Owner's Address:
Date of Inspection:
Name of Inspector: (please print) J.P. Macomber i
Company Name:Joseph P. macomber & Son Inc
Mailing Address: Box 66
cent ryilla MA 02632
Telephone Number: 508-775_1338
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 to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
_ Conditionally Passes
/N eeds Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall s 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 I
Nee 3 of I I
OFFICIAL INSPECTION FOR
M— NOT FOR VOLU
NTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 224 Old Mill Road
Mars tons Miiis
Owner:Vietnam Veterans
Date of Inspection: r/25/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: Ve
l5 1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or m 310 Mr 5.304 exist. An failure criteria Y not evaluated are indicated below.
Comments:
The Dresent se tic system is in hydraulic failure.
A naw 1 r=,arhi nq Area needs to be instalied.
B. System Conditionally Passes:
Xld 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.
100 The septic tank is metal and over 20 years old' or the septic tartk(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing taak is replaced with a complying septic tank as approved by the Board of Health.
'A metal sepric 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, senled 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 I
OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 224 Old mill Road
Marstons Mills
Owner: Vietnam Veterans
Date of lospectioo: _7/25/01
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.
I. S,N•stem 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
t�0 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:
,'L/O 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 I of a public water supple.
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
orivate water supple 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
tie 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. O:her:
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: 224 Old Mill Road
Marstons Mills
Owner:Vietnam Veterans
Date of inspection:`M� /n1_
D. System Failure Criteria applicable to all systems:
You must indicate 'yes" or"no" to each of the following for all inspections:
Ye No
_/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
__j,1e4Le Static liquid level in th distribution boxDabove outlet invert due to an overloaded or clogged SAS or
cesspool 1—),dk aD
�squid depth in4o"geeri is less than 6"below invert or available volume is less than fi day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
— � of times pumped �.
arty 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.
— ,A�r,y portion of a cesspool or privy is within a Zone I of a public well.
�_Z y portion of a cesspool or privy is within 50 feet of a private water supply well.
y 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. iTbis system passes if the well water analysis,
performed at a DEP certified laboratory, for collform 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 forma
J—eL (Yes/No) h�system have determined that one or more of the above failure criteria exist as
descri ed 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 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
Zf—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: 224 Old Mill Road
Marstons Mills
Owner:Vietnam vptprans
Date of Inspection: J'/2 5/01
Check if the following have been done. You must indicate`yes"or"no"as to each of the following:
Yes No
_ 1/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
Z_ Has the system received normal flows in the previous two week period?
_ _ZHave large volumes of water been introduced to the system recently or as part of this inspection?
—V—/— 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 ?
ZWere all system components, Xluding the SAS, located on site ?
-lam 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:
YXno ,
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)j
5
Page 6 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Add ress224 Old Mill Road
Marstons Mills
Owner:Vietnam Veterans Asso
Date of Inspection:]!/25/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): X/i =
Number of current residents: •Z
Does residence have a garbage grinder(yes or no):�Q
Is laundry on a separate sewage system (yes or no): (if yes separate inspection required]
Laundry system inspedted (yes or no):
Seasonal use: (yes or no):y 9 =74; 00 ( l) >as
Water meter readings, if available (last 2 years usage (gpd)): 7, �la�s G t�1), —aX-M,
Sump pump(yes orno): �
Last date of occupaa ncy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): yA rind
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no): w 4
Industrial waste holding tank present(yes or no): .VA
Non-sanitary waste discharged to the Title 5 system (yes or no): .G
Water mete:-readings, if available: /JA
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as pan of the inspection (yes or no): _
If yes, volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping:
TYP,B'OF SYSTEM
Septic tank, t�e;hex, soil absorption system
,VL 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)
NO Tight tank 41_Attach a copy of the DEP approval
,k16 Other(describe): 'e)
�roximat age of all components,date in ed(if known) and source of information:
57
Were sewage odors detected when arriving at the site(yes or no): 10
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:224 Old Mill Road
Marstons Mills
OwnerVietnam Veterans Assoc
Date of Inspection: 25 01
BUILDING SEWER(locate on site plan)
Depth below grade:5T�l
Materials of construction:,a/ ast iron Z0 PVC&Anther(explain): yA
Distance from private eater supply well or suction line: &4
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
Joints appear tight No ev; dt-n(-P c)f leakage System is v nted
/"9 5 through the house vent.
SEPTIC TANK: (locate on site plan)
Depth below grade: czs7
Material of construction:Ai,
&/metal.dfiberglass,&polyethylene
4�&other(explain) 410
If tank is metal list age:" Is age confirmed by a Certificate of Compliance(yes or no)A.,&, (attach a copy of
certificate)
Dimensions:
"J y 1
p' /
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Ay-& -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage, etc.):
Pump thp spDtin tank 4zVt=cry 2-3 '"Gars Inlet & let J--ees are
sown an an
evi ence o ea age.Tan s waste is above the invert & outlet
� // invert pipes.
GREASE TRAPr�/kLOlocate on site plan)
Depth below grade:—j
Material of construction:&-�)concrete metal V,�fiberglass4/Qpolyethylene v other
(explain): ,yA
Dimensions: .6114
Scum thickness: 41,14
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: .4)4
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
(,raaca trap is net—present
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 Add ress:224 Old Mill Road
Marstons Mills
Owner:yetnam veterans Assoc
Date of Inspection: $/25/01
TIGHT or HOLDING TANK k&(tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: —4zL4
Material of construction: concrete 41A metal dZ,�q fiberglass polyethylene el—other(explain):
d14
Dimensions: AAA
Capacity: ft gallons
Design Flow: AZA gallons/day
Alarm present (yes or no): '-
Alarm level: —4Z�L Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
Tight or holding tanks are not present
DISTRIBUTION BOX: 2(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:4e,
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.):
Distribution box not present
PUMP CHAMBEFj,(&Le4locate on site plan.)
Pumps in working order(yes or no): �ilJp
Alarms in working order(yes or no):C
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Dime chamber—AC- t pr'Osent
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 224 Old Mill Road
Marstons Mills
Owner:Vietnam veterans Assoc
Date of Inspection:_ 25 01 /
SOIL ABSORPTION SYSTEM (SAS): t/ (locate on site plan, excavation not required)
If SAS not located explain why:
Located
Type
leaching pits, number:
�d leaching chambers,number: d
�11 leaching galleries,number:
d1,0 leaching trenches,number, length:
i(/b leaching fields, number, dimensions: (�
overflow cesspool, number: Q
innovative/alternative system Type/name of technology: 7T)- 7F
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy boney sand to fine sand. The leaching pit is in
y rau is tailure.A new eac ing area nee s o e ins-tailed.
Waste water is above the invert pipe.Vege a ion iush.
CESSPOOLS ,(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
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.):
Cesspool not present
PRIVY(locate on site plan)
Materials of construction: �/y1
Dimensions: 4
Depth of solids: 419
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy not present
9
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Page 10 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:224 Old Mill Road
Marstons Mills
Owner:Vietnam veterans Assoc
Date of inspection: 25 01
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.
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10
06/23/2001 09:30 15087781094 NAM VETS ASSOCIATIN PAGE 01
LOCATION AAGE A
/J ACE ERMiT MQ,.
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VILLAGE
472,
I N S T A LLER'S NAME i ADDRESS
G c
I UIL0ER OR owNEp I
DATE PERMIT ISSUED
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CO.MPLIA:MCE ISSUED 3-137 � f
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Page 1 1 of I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 224 Old Mill Road
Marstons Mills
Owner: Vietnam veterans Assoc
Date of lospection:1/2 5/01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
�y/
Estimated depth to ground water l� feet
Please indicate (check) all methods used to determine the high ground water elevation:
r;he
�btained from system de lans on record - If checked,date of design plan reviewed:
served site(abutting grope bservation hole within 150 feet f SA )
cked with loca oar o Health-explain:Q1b 1,414;,l_!
±//Checked with local excavators, installers- (attach documentation)
_Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used water contours Maw;
Gahrety & Miller Model
12/16/94
11
`>•nrnr�.—n•r�r.'n�trtrr Jnr•r.tr.rTn.r r9rrrer.rR7r+1►nrllfnTTln tn•rs1Y 101"�I��IwT T7-''rr-�'--:..-.,,�...'
TOWN OF BARNSTABLE BOARD OF HEALTH
SUIISURFACF SFWAOF DISNSAL ,SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I r•1•T••. •.' -T,Il.^.�TTI,T TIII',1.7T1TRlR1fT,1,}T:rt'I r'lIRT7ifR�f-"r�AAfiR1�At�1t�7 TII .r rrT'1r•�. �..A
-TYPE OR PRINT CLEARLY-
PI?OPERTY INSPECTED
STREET ADDRESS 224 Old Mill Road Marstons Mills
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Vietnam Veterans Association.
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr..
COMPANY NAME Joseph P. Macomber &°"ion Inc
COMPANY ADDRESS Box 66 Centerville Ma 02632
Street Town or City State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 .1 790 - 1 578
R
A
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
omplete 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
health or, Lhe environment as defined in 310 CMR 150303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
his form ,
U System FAILED
The inspection which I have con tcted 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 specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
r -
Inspector Signature Date
ecopy of this rt.ification must be provided to the OWNER, the BUYER
D.n
here applicable ) and the I30ARD OF HEALTII,
* If the inspection FAILED, the owner or ',operator shall u
within one ,year of the date of the inspection , unless allowed dort required
he m
otherwise as provided in 3.10 CMR 16 . 306 .
partd .doc
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property ,�a �f� /V,
Owner's name P ��fo r Yar-tA Wes f
Date of Inspection y0� S, iM f, f'th fit.
9-$-95 Qes /�1o:nPS 1'A 50 30 y
PART A
CHECKLIST
Check if. the following have been done:
✓ Pumping information was requested of the owner, occupant, and Board of
Health.
-None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
✓ As built plans have been obtained and examined. Note if they are not
available with N/A.
N,9 The facility or dwelling was inspected for signs of sewage back-up.
V The site was inspected for signs of breakout.-
All system components, excluding the SAS, have been located on the
site.
✓ The septic tank manholes were uncovered, opened, and ,the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions,- depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
_ The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
S A P 5 1995 N
l
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
__0 number of current residents {�.,.,� 10.lxwrsf ^rpve
H4 garbage grinder, yes or no
yrs laundry connected to system, yes or no
we seasonal use, yes or no
If nonresidential , calculated flow:
jy9'3
Water meter readings, if available: /yyy 77, y,r/.
95 ,q9s 3so�Jy9/
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
Ale System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
1 S-i,s?rw� �vi S�.f/� �r1�lo �lctor�^5 Td ti?s .6✓�' U�'<i�rN.•�5
f
=,Alo Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B .
.SYSTEM INFORMATION continued
SEPTIC TANK: ✓
(locate on site plan)
depth below grade:
a /ta 3 frin¢ Over bro✓'%1 t7 ?1 ,F i✓ac%
yr ,rJr,nJc Yf 1A / O �>1 10 e
nfCGL� to lr bra Qr 4.pee,- •"
material of construction: ✓concrete metal FRP other(explain)
e
dimensions:-_ y�io ,prPGkff /o0ay r." A
sludge depth
_,2y� distance from top of sludge to bottom of outlet tee or 'baffle
-q scum thickness
distance from top of scum to top of ,outlet tee or baffle
- 3 � distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. ) ,/
CC P" a -to.'7 {/ ' ,(f'fq� dG"C �D ` e-w✓�2 huo'I'I -yO Of ,SGc/cs/J.
�T
.k b!lg,_, ?/C D ti't/f t :n✓ee T 7 's :s ova�dN 6/e give To
u r✓�.H o r L tk/, :., 7tif -'y k ei tAler' ?A a tov s'P7 or 7"(e wex Arlie ,'n ,b,.f
Brc.rit✓Se /iO;. se his 6ee.o (�oe�.ti't 7�c L.'�.•:ef LP✓.--/ /ivs dr�r�c/ 6�T jSr 74�, �
Sao..// f� '+� Pia�vsry -+�TeN , t recPr✓es .r+orlYru/ f/o"i,s•
DISTRIBUTION BOX:. A9
(locate on site plan) v
D depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
P- /fo-( "IMP^ 6� �� If Llr</ a,Me f N'de bye Or^
�GLk -mod �O�/c'/^ y� `Q/J✓. !4✓jg1t gee ✓CP—
?o A.',, oT grusl-e .
P CHAMBER:
(loca on site plan)
pumps working order, yes or no
Comments:
,;note condition of pump cha dition of _pumps and appurtenances,
recommendations for mainten 0 airs,etc. )
J 1®
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) 1 00 /�;v.
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of nvegetation, recommendations for maintenance or repairs,etc. )
q'v.'cY Le ve l i1 •i'' .ie : .!/o v '�:d/ s:y✓i� o'�
-Ile
ESSPOOLS (locate on site plan) :
number configuration
depth-top o id to inlet invert
depth of solids r
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must umped as
part of inspectio
Comments:
not ondition of soil, signs of hydraulic failure, level o ding,
c ition of vegetation, recommendations for maintenance or repair c. )
IVY:
(lo on site plan)
materials of con tion
dimensions
depth of solids
Comments:
(note co ion Of soil , signs of hydraulic failure, - 1 of ponding,
co ion of vegetation, recommendations for maintenance or airs etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
�9 .
—L-17
L--j
o<< t
L10
-
cy 30' 37'
DEPTH TO GROUNDWATER
0 / depth to groundwater
method of determination or approximation:
f le V-I o f Tact L.t cv=/4r<<J Tv 7.4 c
sirrovv�� .�S crrk
I - `
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
_..AW Backup of sewage into facility? A. �{�y TO 4et ;47'v- AV-15 C
Qnc� 1"'/41 n07 'Trr/A( G✓:f� �QY�i/iovl OCc'✓�v*,73:
-2-1 Discharge or ponding of effluent to the surface of the ground or
surface waters?
/y - Static liquid level in the distribution box above outlet invert?
Al Liquid . depth in cesspool <6" below invert or available volume< 1/2 day
flow?
/1 Required pumping 4 times or more in the last year?
number of times pumped
1 Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
_ within 50 feet of a surface water?
within II. 100 feet of a surface water supply or tributary to a surface
water supply?
. Itl within a Zone I of a public well?
Al within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?,
within 50 feet of a private water supply well?
_A less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analys'
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
TOWN OF Arn S futile BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D -.CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED 1e /
STREET ADDRESS oZoZ `� O/G� / �� � a?GY,*
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Dl-wre/
PART D - CERTIFICATION
NAME OF INSPECTOR lox,
COMPANY NAME ToA n R. 44 /to A,,k/i oc
COMPANY ADDRESS r VAp
Street Town or City State Z-
COMPANY TELEPHONE (5-08 FAX (So: ) WO
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system
this address and that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and an;
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience_ in the proper function and maintenance of c
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
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section c
this form.
System FAILED*
The inspection which I have conducted has found that the system fails -
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 QC Date
One copy of this certification must be provided to the OWNER, the BUYER
(where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED-, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.d
f
LO CAT ION
`' ^ ��
S I AGE PERMIT . No.
VILLACE
,.::I:NSTA LLER'S NAME A ADDRESS
B U I L D E R OR -OWNER
A:ATE PERMIT ISSUED
`DATE COMPLIANCE ISSUED
G �n
S ,S
ATLANTIC ENVIRONMENTAL
P.O. BOX 2384
MASBPEE,MA 02649
Attn: Commonwealth of Massachusetts Date:.�06/19/96
Town of Barnstable "
Board of Health
367 Main Street
Barnstable, MA 02630
49,
From : Mr Michael DeDecko
Po Box 2384
Mashpee MA 02630
Dear Board of Health Official;.
I certify that I have personnally inspected the sewage disposal systems at the following
address : 224 Old Mill Road. Marstons Mills, Ma.
The informations reported are true, accurate and complete as of the time of the
inspection.
If you have any questions regarding this inspection, please contact me at this number:
(508)477-14-20. Thank you.
Sincerely,
Michael DeDecko
phone 508 477-1420
Commonwealth of Massachusetts
Executive of Environmental Affairs
DEP.
Department of
Environmental Protection
��
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A •
CERTIFICATION
2
Property Address: 224 OId Mill Rd. Marston Mills, Ma. i0q,
Address of Owner: NAM Vets Assoc. of Cape Cod
(if different) 565 Main Street. Hyannis, Ma
Date of Inspection: 06/18/96
Name of Inspector: Michael D eD ecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o B ox 2384 - M ashpee M a 02649. Tel : (508) 4771420
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system at this address and
that the information reported below is true, accurate and complete as of the time of
inspection . The inspection was performed based on my training and experience in the
proper function and maintenance of on site sewage disposal systems. The system
K. Passes
-- Conditionally Passes
---- Needs further evaluation by the local Approving Authority
---- Fails
Inspector' s Signature: x�., �-,-� Date: 06/19/96
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 or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer,if applicable
and the approving authority.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 224 O Id M ill R oad. M arston M ills, M a.
Owners : Nam bets Assoc. of Cape Cod
Date of Inspection : 06/18/96
INSPECTION SUMMARY:
Check A, B, C, or D
A) SYSTEM PASSES:
11 have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CM 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 yes, no, or not determinate CYR or ND). Describe basis of determination in all
instances. If "not determinated", explain why not.
---- The septic tank is metal, cracked, 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 conforming septic tank as approved by the Board of
Health.
---- Sewage backup or breakout or high static water level observed in the distribution
box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven
distribution box. The system will pass inspection if (with approval of the Board of
Health).
----- broken pipe(s) are replaced
---- obstruction is removed
---- distribution box is levelled or replaced
---- The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if (with approval of the Board of Health):
----- broken pipe(s) are replaced
----- obstruction is removed
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address : 224 O Id M ill R oad. M arston M ills,M a.
Owner : Nam bets Assoc. of Cape Cod.
Date of Inspection: 06118/96
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health ,safety and the environ-
ment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
---- Cesspool or privy is within 50 feet of a surface of water
---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING INAMANNER 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 50 feet
of a private water supply well.
---- 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 analy-
sis 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 notrogen is equal to or less than 5 ppm.
D) SYSTEM FAILS:
-- I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM 15.303. The basis for this determination is identified below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
--- Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 224 O Id M ill R oad. M arston M ills,M a
Owner: Nam Vets Assoc. of Cape Cod
Date of Inspection : 06118/96
D) SYSTEM FAILS (continued)
-- 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 over-
loaded or clogged SAS or cesspool.
--- Liquid depth in cesspool is less than 6" below invert or available volume is
less than 1/2 day flow.
--- Required pumping more than 4 times in the last year NO T due to clogged
or obstructed pipe(s).
number of times pumped
--- Any portion of the Soil Absorption System, cesspool or privy is below the high
groundwater elevation.
--- Any portion of cesspool or privy is within 100 feet of a surface water supply
ortributary to a surface water supply.
---Any portion of a cesspool or privy is within a Zone I of a public well.
--- Any portion of a cesspool or privy is within 50 feet of.a private water supply
well
--- Any portion of a cesspool or privy is less than 100 feet but greater than 50
feet from a private water supply well with no acceptable water quality ana-
lysis. If the well has been analyzed to be acceptable, attach copy of well
water analysis for coliform bacteria, volatile organic compounds, ammonia
nitrogen and nitrate nitrogen.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 224 Old Mill Road. Marston Mills Ma.
Owner: Nam Vets Assoc. of Cape Cod
Date of Inspection : 06/18/96
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above :
The design flow of system is 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 fallowing conditions exist :
--- the system is within 400 feet of a surface drinking water supply
--- the system is within 200 feet of a tributary to a surface drinking water supply
--- the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area - IWPA) or a mapped Zone II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compli-
ance 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
Property Address: 224 O Id M ill R oad. M arston M ills M a.
Owner: Nam filets Assoc. of Cape Cod.
Date of Inspection: 06/18/96
Check if the following have been done :
-x Pumping information was requested of the owner ,occupant and Board of
Health.
--x None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during the period. Large
volumes of water have not been introduced into the system recently or as part
of this inspection.
--x As built plans have been obtained and examined. Note if they are not available
with N/A.
--x The facility or dwelling was inspected for signs of sewage back-up.
--x The system does not receive non-sanitary or industrial waste flow.
--x The site was inspected for signs of breakout.
--x All system components, excluding the Soil Absorption System, have been
located on the site.
--x The septic tank manholes were uncovered, opened and the interior of the sep-
tic tank was inspected for conditions of baffles or tees, material of construc-
tion, dimensions, depth of liquid,depth of sludge, depth of scum.
---x The size and location of the Soil Absorption System on the site has been deter-
mined based on existing information or approximated by non-intrusive methods
---x The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 224 Old Mill Road. Marston Mills Ma.
Owner: Nam Lets Assoc. of Cape Cod
Date of Inspection: 06/18/96
RESIDENTIAL: ,
Design flow : �0 gallons
Number of bedrooms : '5
Number of current residents: o
Garbage grinder(yes or no) : fJv
Laundry connected to system (yes or no): vie S
Seasonal use(yes or no) : No
Water meter readings, if available: ��!y
Last date of occupancy : �6�sti� ti
COMMERCIALIINDUSTRIAL :
Type of establishment:
Design flow : gallons/day
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 :
Other: (Describe) ............................................................................................................
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information :
System pumped as part of inspection (yes or no) :.... cam........
if yes, volume pomped : .................... gallons
Reasonfor pumping :............................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 224 0Id M ill R oad. M arston M ills, M a.
Owner: Nam Vets Assoc. of Cape Cod.
Date of inspection: 06/18/96
TYPE OF SYSTEM
S Septic tank/distribution box/soil absorption system
--- Single cesspool
--- Overflow cesspool
--- Privy
--- Shared system(yes or no) (if yes, attach previous inspection records, if any)
--- Other (explain)...........................................................................................
APPROXIMATE AGE of all components, date installed (if known) and source of information
ktY ..... ............................................................................................
................................................................................................................................................
................................
Sewage odors detected when arriving at the site: (yes or no)....
SEPTIC TANK : ...
(locate on site plan)
Depth below grade: . 0 ��� � ?- `C• ,1
Material of construction: ..'A.,. concrete ......... metal ........ FRP ........ other (explain)
.................................. ... .........................................................................................................
D imensions:
Sludge depth :....3:'......
Distance from top of sludge to bottom of outlet tee or baffle:.....S.\....................
Scum thickness :....(9::............
Distance from top of scum to top of outlet tee or baffle: ...........!.Q..'.�....................
Distance from bottom of scum to bottom of outlet tee or baffle :....k.G`.'...............
Comments :
(recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage,etc.)......................
T�C,"�iAN'C_r�c.,c, , =,fsG; \ •;!��''1:t; - -�' d; R� ;.^", � ;?' <o .. _�.. ; 'S �t,'�lctZ.,�
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 224 O Id M ill R oad. M arston M ills, M a.
Owner: Nam Vets Assoc. of Cape Cod.
Date of inspection: 06/18/96
GREASE TRAP :
(locate on site plan)
Depth below grade: ...............
Material of construction: ........concrete.........metal........FRP........other(explain)....
..........................................................................................................................................
Dimensions:...............................
Scum thickness:........................
Distance from top of scum to top of outlet tee or baffle:.......................................
Distance from bottom scum to bottom of outlet tee or baffle:...............................
Comments:
(Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................
................................................................................................................................................
TIGHT OR HOLDING TANKS:.....ODt`.......
(locate on site plan)
Depth below grade:.:....*........
Material of construction:........concrete........metal.........FR P..........other (explain)..........
................................................................................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallons/day
Alarm level:.........................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 224 Old Mill Road. Marston Mills Ma.
Owner: Nam Vets Assoc of Cape Cod
Date of inspection: 06/18/96
DISTRIBUTION BOX.s.�.tS
(locate on site plan)
Depth of liquid level above outlet
Comment:
(note if level and distribution equal evidence of solids carryover, evidence of leakage into
or out of box, etc.)....... . Q ucs.�l..r.y�s
F.UO? ?. % x.....R ..T:\W—
..............................
PUMP CHAMBER:.....
(locate on the site)
Pumps in working order: (des or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)....................
................................................................................................................................................
................................................................................................................................................
SOIL ABSORPTION SYSTEM (SAS):.... 5.......
(locate on site plan, if possible; excavation not required, but may be approximated by non-
intrusive methods)
if not determined to be present, explain:
................................................................................................................................................
................................................................................................................................................
Type:
leaching pits, number: ...v.`.l-xt..?
leaching chambers,number:........
leaching galleries, number:...........
leaching trenches,number , length:.....................
leaching fields,number, dimensions:...................
overflow cesspool, number:..........
Comments:
1966 condition of soil , signs of;h draw' failur level of ponding, condition of vegetation,
.�1,4_�,._Ap,��.�-S v g �WoT �c.V�a.aev��` �-��w�•..-�.: <� , `��c�-\�''�t
'36 c�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: 224 Old Mill Road. Marston Mills Ma.
Owner: Nam Vets Assoc. of Cape Cod
Date of inspection: 06/1 SI96
CESSPOOLS:....N�..
(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: .....................
Indicator of ground water: ....................
inflow (cesspool must be pumped as part of inspection)
.................................................................................................
.................................................................................................
Comments: l
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,.
etc.)
................................................................................................................................................
................................................................................................................................................
PRIVY : ....
(locate on the site)
Material of construction: ...................................
Dimensions: ......................
Depth of solids: ................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.) .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address : 224 O Id M ill R oad. M arston M ills, M a.
Owner: Nam pets Assoc. of Cape Cod.
Date of inspection: 06/18/96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'
°-I 2
LA
� y
DEPTH TO GROUNDWATER:
Depth to groundwater: A0...feet
Method of deterrAination or approximative: ,
.. ....s.s_....�:ea�ST.
� ......ar.. .y........................................................... ......................................................
TOWN OF BARNSTABLE �
T. 00ATION � ®C �\ SEWAGE # ��
VILLAGE �'��1`> ASSESSOR'S MAP & LOT U
INSTALLER'S NAME&PHONE
SEPTIC TANK CAPACITY leap
LEACHING FACILITY: (type) S (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: TCOMPLIANCE DATE: A
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
f_
' '
No. � i i .: Fee 50.0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Mfigpooal bpotem Construction Permit
Application for a Permit to Construct(X )Repair(C,)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
224 Old Mill Road Marstons Mills Nam vets Assoc.
Assessor's Map/Parcel 0
/ ,1or, 569 Main Street Hyannis 778-1590
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
nc Joseph P. Macomber & Son Inc
Box 66 Centerville 775-3338
Type of B 'ding:
Dwelling No.of Bedrooms. r Lot Size sq.ft. 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 S
Size of Septic Tank ' Type of S.A.S. ^L
Description of Soil 1iaarn)L i n math i iim fins c�nri 12q�x. \C.
Nature of Repairs or Alterations(Answer when applicable) St'a 1 IngQ gailo
chambers.
�® i
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of he aforedescnli'e 6k%'gilalw—Mg"ldtspo9al1 system-.
in accordance with the provisions of Title 5 of th Environmental Code_and t toaplac�et ti��Cerfifi
"t S INSTAMLLEti IN ,rT,.,�"
cate of Compliance has been is ed by t ' Bo d o ealth. I 1 -� O ,
Signed U Date / ���
Application Approved b Date
Application Disapprove for the following reasons
Permit No. u%y�l�'f�- Date Issued
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
Date Issuedcormc
r
�:OMMONWEALTH FAASSACHUSETTS
BARNSTABLE, MASS�CHUSETTS dre
Jam/
Certificate of C=4ri f ance upgraded( )
THIS IS TO RTIFY that the On-site Sewage Disposal System'Constructed(X)Repaired( )
� g P
Abandoned( )by le n.e PUx r f 5
at a j oa i +S has been constructed i accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No, UU
-7 dated 2`1 a Op/ 11
Installer p p y Designer H C 12 Sd.� ��
The issua,ice of this permit shall not be construed as a guarantee that the system i11 unction as designed.
IAA
Date_I/�� �or� ! Inspector y '� 1!l/
y t Cy *N.. A L/A
Fee 5 0.0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
.. >_ Yes
PUBLIC HEALTH.DIVISION -'TOWN OF BARNSTABLE, MASSACHUSETTS
ZipoYication for Zigogar bpgtem �Conotruction Permit
X
,Application for a Permit to Construct(K )Repair(X)Upgrade( )Abandon( ) El Complete System O Individual Components
Location Address or Lot No.4 Owner's Name,Address and Tel.No.
224 Old Mill Road Marstons Mills Nam vets Assoc. "
Assessor'sMap/Parcel 569 Maim Street Hyannis 7;78�-,1_590
Installer's Name,Address,and Tel.No. t Designer's Name,Address and Tel.No. ; a
nc Joseph Pr Macomber & Son•Inc
Box r�6,;. hterville 775-3338
,
t WIC
J c6
Type of Bud ding: i
Dweliwng No of Bedrooms / Lot Size sq.ft. Garbage Grinder( )
Other Type of Building a No.of Persons Showers( ) Cafeteria( ) i
Other Fixtures
Design Flow s gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
,,K,Title:' ' T VF (C AAd.S
Size~of Septic Tank- , 'f'(`L� s Type of S.A.S. �'� � ?[�C� WN
Description of Soil Loamy t-o marl ii i rnf jre SFAMS
Nature of Repair's or Alterations(Answer when applicable) I
chambers. {
DSO yjl
Date last inspected:
Agreement: +
The undersigned agrees to ensure the construction and maintenance of theafore described on-site sewage disposal system
in accordance with the provisions of Title 5 of thp Environmental Code and the system in operation until a Certifi-
cate of Compliance has been is�ed by Bo d of ealth.
rib- -�Signed t Dates - J
Application Approved b / Date�� t
Application Disapprove for the following reasons E
{x
k .
Permit No. 'a4'.�f�-+ .- Date Issued "
r 3
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance? " 17.
+ THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(x )Repaired;( x )Upgraded( )
Abandoned( )by oSe h P (( � y-4
at 2240 old Mill Road Marstons Mills has been constructed in accordance
with the provisions of Title 5 and the for Disposal Sys m C ns cti3n P l �.1� dated �•- �-� �'�� r
Installer-J-P*—� Designer J.P. Macomber & Son Inc
The issuance o this permit shall not be construed as a guarantee-that the system will function as d si ned.
Date 0 ( u Inspector � A
v
--------------------------- —————— - --
IN
No. ���'` _ / Fee 56,00
THE COMMONWEALTH OF MASSACHUSETTS -
i R4fi�"fa FNGINEERiNWI ICE c^
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACH,I,.ISf ' M Cer=)W',
- • `iHE SYSTEFJI WAS IN iTA l_+L-:) 1,4
�Digogal *pgtem Congtruction effff ,'ICE TO PLAN.
Permission is hereby granted to Construct()()Repair( X)Upgrade( )Abandon( )
System located at 224 Olds Dill Road Marstons Mills
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 t ' e t�
Date: ApproveddSew,
116199
NOTICE; This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
ASSESSORS MAP.NO•Q
PWQNO:- /
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPO
SAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
Joseph P.Macomber Jr. hereby certify that the application for disposal,.-works '
construction permit signed by me dated 6/28/01 concerning the
property located at 224 Old Mill Road, Marstons Mills.Masmeets all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• " There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when appbcablel
• if the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will m be located less than fourteen(14) fect above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation ''d-O + the MAX, High G.W. Adjustment .79
. DIFFERENCE BETWEEN UB � .
SIGNED : DATE: 6/28/01
(Sketch pro ed plan of system on back).
Q:hcatth folder.cen
Existing 1000 gallon
Leaching pit.
New; 2-500 gallon
leaching chambers packed ;-. Existing Distribution box
in 4 ' of 12" stone.
25 'X13 'X2 '
® Existing 1000 gallon septic
tank.
rin
..r
r:
y Y
I
- L f
y..cs:y' �b x_Y.d .::: 'cte:s: 's st -� 'Naa-.�i?.ssszwt�_':ai-'r<5 ''x^^si't,ct..+- -�:7"'^ •- a.+ qz - r c ^* _. - 'y 4` -
�'4`^'
r ���:d��r .� °T ldt1•+�+' x `�'+r^a y. � f.P� �-v. �:5� ,r.^'u y. -"rw4.+}•`/S(�.z�.�^•.-:t« '�,'((.�d2.? �_"�4'_^cde.: ��I,��� A 3
'.'��;SAY`
'�st' .v"`` t' �,.F' _* r f:v.•'3, - r - n- Ark .,,, .
�" y'7Kw. �''` < 7�''.•"ar"-t.f,,;.0 '�ti1o'.'�.:�.,
LOCATION
VII,LAG -ASSESSOR'S''MAP;&LOT �)— luy_
INSTALLER'S NAME&'PHONE N0 1' i 1V eV6 P—
S.E.P'ITC'TANK CAPACITY
LEACHING.FACII.ITY: (type • (si zP)
. .:. . .. .. . . .
NO.OF BEDROOMS
BUILDER OR OWNER
p
COMPLIANCE DATE Separation Distance Between the
-. • . I : Feetr
Maximum-'Adjusted Groundwater Table and Bottom of Leaching FactLty
Private Water Supply Well and Leactung Facility (If any wells east
on site of within 200:feet of.leacling facthty) Feet•
4 Edge of Wetland and Leaching Facility(If any wetlands exist
- Wit)iin'300 feet of leaching facility)
Feett
Furnished'by
.. `� N
5--[ 5` t WE
14..i r
l z i. i � •
.1 u
•
+
fsr
-
a r y: v '° y.Yt�j 4f r°.�t� t � t:='S. ��t[� t t•`}s�"��'&s -�9.i� '
y 1 w t f ♦ t '' v u �i F>~ a.,. �•.. �, to „{r.-.. ..: t .zt'`„•r.:' n. .xx
. }t
� r
S ru.
,
30
-
60�
iL►AN1L -
_ r i 4
November 23, 2001
224 Old Mill Lane
Marstons Mills,AL4
Mr. Thomas McKean
Director,Barnstable Health Department
Barnstable, MA
Mr. McKean,
This letter is to certify that the septic system at the above noted property was installed in
substantial compliance with the State of Massachusetts Title V regulations and Town of
Barnstable bylaws.
Sincerely,
Tho arcello, E.
OF
THOMAS y
MARCEi.L�
Oft
Na.244211
FSS/OHAL E��
E-WAGE
PERMIT NO.
h0CAT10N S G
ad
PILLAGE ln
I N S T A LLER'S NAME ADDRESS
B U I L D E R OR OWN ER
I
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 3-13 � C
-
I �4
N
ON V
-^ c
a. a,
N31.... F�s....�t.S..-_.........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
ALTH
.-----...To.wr....................OF........►�rr.SACII AT..--------------------_-.:_.........------------
Appliration for Ui£pnaal Works Tnnitrnrtion runfit
Application is hereby made for a Permit-to Construct ( ) or Repair ,(*) an Individual Sewage Disposal
System at:
Location-Address o Lot No.
Owner L �Address
W __-•-f----•--------...el�Qwlqb.......................................................... ...-- _.n.------....._...--- ..... Gu��[ -q!f!o
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_________________ ....................Expansion Attic ( ) Garbage Grinder (0)
PL4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
C4Other fixtures -----------------------------------------••---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ Depth................
} x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter................_--- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground 'water........................
M •---•-•---••-----------------•-•••••---•-•••-•---•-•----•--•-•••••••-•-••-•-----•----........-------.......
_•----------------------------------------------
•--
0 Description of Soil........................................................................................................................................................................
•---------•---------- -----•-------.._..------------•--•-----.._._..-----------------•--•-•---•--••------.-.----------------••-•----• =
Nature of Repairs or Al rations—Answer when applicable___:1:QAo_ ._' i �= t�_ _._l_oS2A_.gCd_.._._____.
gcc t -S_.._ YID 5 r utr ..............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITh11 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.
rigned-- '' �i' -•-- ---- ilk -------------------------•---•......... ................................
Date
Date
Application Approved By-•••••• = 2''s- C
.....•• ----....._..
Date
Application Disapproved for the following reasons_______________________--•-•------•------••--------••---•---••---•-••••---••_______________ ._......_...__
...........................................................------••--•-......----•----......-•-•--•••••...
--------------------------------------------------------------------------------
Date
Permit No.--------- .- ................. Issued.----••--------•--• -
' Date--•--••---•------------•---•---
k
r
No: :.�...... n.t.... FEB.....L�................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 n.cvn. ..---......--OF.......!'`-�Aare.r
AVVfirafton for Bhgpos al Workii Tonstrnrtion rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal
System at://�� f )n�l ►ply
-••••-....�. V_........�t-�GC3�.... J....e�n._•!! .......•...... ..................................................................................................
.__--
1 ^—r-�� Location-Address orr Lot�J INo, n) _
EJy : tn(shtrr C3jr._ l�_�. �td(a Y,...1.:t.C.f. njn �'S
nn Owner
w r! J� AAddress
43 0(_i)C`r-1 WGIh ........ (L�e,
...................•..--........................................-•----............................ _............................... .......... ?.._.�/.!,.._r_l_M1_n.n...t.a�..FI
.6...............
p� Installer Address
d, Type of Building Size Lot............................Sq. fegt
Dwelling—No. of Bedrooms.................. ....................Expansion Attic ( ) Garbage Grinder
Other—Type of Building ............................ No. of persons.....................--.---. Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------•--••......-•---•-•--------•----
Design Flow............................................gallons.per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------------_---- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 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........................
•----------------------------•-----•----------------•--••--•---•--••-----••-•-•-----•--••••.................................................................
0 Description of Soil............................................................................--------------------------•----------------•--------------••----•--•-•••-•-•••......------.
x
U ----------------
•------------------------------------------------------------------------------------------------------------
•---•---------------------------•-----------------------•-----------
W ------------------------•-----------•-------••---•----------------•-----•--•--••------•••----••--••--•----...-•-•-••------•--•----t --------------•-------------------------------...
VNature of Repai s or Alterations—Answer when applicable.-...Lobes__�i�.A•..-4&., �•_-•-J../�hc_ -_.�. can_-•c�Q__________.
......................n ..t•... (.. ............I.........................
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-ssued by the board of health.
Signed.. -�t�a� ...•.........---•----------------•--•-- .... f?2?-6G:......-•--
�._.__� g t f:.
Application Approved By �- , ate'
/ 1 � tD �.
....... •..... .. ^ C I = _`............................... ......... .... •----c..._....
Date
Application Disapproved for the following reasons------------------------•--------------------------•-------------•--•-•-----------------------...-------•---•--
....•-•--••••--•••--•----•-........••....•-•---......--•---....--•----••----••----------------••••----•-----•••••--•-•-•--------.....----•••-------•---•-------•------------•-----••-•--••--•-••-------.
Date
Permit No.........:E.......6---•'--- _ - Issued.......................................................
----- -- ---C-r--1----•--------•---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF 'HEALTH,
......................O F. `3G .......................................................l....... ..
Trrtifirttte of Tompfiattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (. )
`, Installer ,
......
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...--�__7-_-..rt:._ .-..___.. dated_._............................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN SATISFACTORY.
DATE...........................7�?P----------•----------•-----. Inspector.-•-•-- ----------•------------------.......................
�I 15 THE COMMONWEALTH OF MASSACHUSETTS
BOARD
� OF� iHEALTH
Ot��Y1.......................,OF...t`,,•��Q! t�r1012
No .................... FEE...�S_..........
Disposal Workii Toniirnrtion firrmit
Permission is hereby granted- D' 1:-1 ----�;` ^-------------------------------------••-..............------------•••.................
to Construct ( ) or Repair ( ) an -Individual Sewage Disposal System
at No.......- �� ��.
Street C"" �'I �, lam`
as shown on the application for Disposal Works Construction Permit No.......:............ Dated.._.._._!/:-.. .....................
r� ....................... Board of Health
DATE. �......... .........------•-= -
a FORM 1255 HOH,BS\&\WARREN, INC., PUBLISHERS
'�ti
BOARD OF WATER COMMISSIONERS
CENTERVILLE-OSTERVILLE FIRE DISTRICT
OSTERVILLE, MASS. 02655
January 29 , 1986
John Kelley
Health Dept .
Town Hall
Hyannis , MA 02601
Dear Mr. Kelley:
This is to inform you of our receipt of an application
r . for water service connection on December 26 , 1985 for lot
#280 , House #224 Old Mill Road , Marstons Mills , under the
name of Thomas & Phyllis Ellis .
Please be advised that the Water Department has a back
log of approximately 15 weeks , which along with weather and
ground conditions will effect the completion date of this
water service .
Very truly�y73
Jon R. Erickson y
Adm. Assistant
cc : Gerry Dunning
A & B Conco
350 Main Street
W. Yarmouth, MA 02673
JRE/ec
-� S
BOARD OF WATER COMMISSIONERS
CENTERVILLE-OSTERVILLE FIRE DISTRICT
OSTERVILLE, MASS. 02655,
January 29 , ; 1986
,John Kelley
Health Dept .
Town Hall
Hyannis , MA 02601
Dear Mr. Kelley:
This is to inform you of our receipt of an application
for water service connection on December 265 1985 for lot
#280, House #224 Old• Mill -Road , Marstons Mills , under the
name of Thomas & Phyllis Ellis .
Please be advised ,that- the�Water Department has 'a back
log of approximately 15 weeks , 'which along with weather and
ground conditions will effect the completion date of this
water service. #-
• r f
Very truly u
J;
'on R. Erickson
Adm. Assistant
cc : Gerry Dunning
A & B Conco
350 Main Street
W. Yarmouth, MA 02673
JRE/ec