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HomeMy WebLinkAbout1375 MAIN ST./RTE 6A(W.BARN.) - Health 1375 Main Street/Rt. 6A A= 177-003 West Barnstable n i ,7 4; No. 4210 1/3 BLit ESSELTE 10% O 6! O 0 05/17/2010 MON 8: 21 FAX 5083627103 Barnstable CTY HealthLab --- Barnstable Health 0001/001 P d ^OFI;yn. CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Acnu Report Prepared For: Report Dated: 5/14/2010 Lynda Bryson Kinlin Grover R.E. Order No.: G1056887 PO Box 156 Barnstable, MA 02630 Laboratory ID#1: 1056887-01 Description: Water-Drinking Water Sample 4: Sampling Location: 1375 Main St.West Barnstable,MA Collected: 5/12/2010 Collected by: E.Lang Map 137 Parcel3-00 Received: 5/12/2010 Routine i ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 5/12/2010 Copper ND mg/L 0.010 1.3 EPA 200.8 5/12/2010 Iron ND mg/L 0.025 0.3 EPA 200.8 5/12/2010 I Sodium 17 mg/L 0.25 20 EPA 200.8 5/12/2010 Total Coliform Absent P/A 0 0 SM9223 5/11/2010 Conductance 170 umohs/cm 2.0 EPA 120.1 5/12/2010 1 pH 8.2 pH-units 0 SM 4500 H-B 5/12/2010 i Water sample meets the recommended limits for drinking water of all Ilse above tested parameters. f Attached please find the laboratory certified parameter list. Approved B (Lab D' ctor) 3 s E I i E f I i ii q S l ND=None Detected RL = Reporting Limit MCL—Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Commonwealth of Massachusetts C*5��1 Title 5 Official InspectionForm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM , 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Barnstable MA 02668 04/10/10 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important: A. General Information When filling out i forms on the I computer,use 1. Inspector: only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspections Company Name VQ P.O. Box 896 Company Address East Dennis MA 02641 MM Cityrrown State Zip Code 508-385-7608 S13742 Telephone Number Ucense Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: u.k ® Passes ❑ Conditionally Passes ❑ Fails 0-1 �; c&� ❑'! Needs Further Evaluation by the Local Approving Authority UO i c r j 04/15/10 LP- - Inspecfor's Signature Date -7! The system inspector shall submit a copy of this inspection report to the Approving Authority (Board C:) L of Kealth or DEP)within 30 days of completing this inspection. If the system is a shared system or t-- k„3 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. ****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. Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1375 Main Street Property Address Evelyn Lang Owner Owner's(dame information is required for west Barnstable MA 02668 04/10/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Barnstable MA 02668 04/10/10 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , ' 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Bamstable MA 02668 04/10/10 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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, perforated at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Barnstable MA 02668 04/10/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Barnstable MA 02668 04/10/10 every page. CitylTown State Zip Code Date of Inspection C. Checklist 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 NIA) ® ❑ 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (f any of the failure criteria related to Part C is at issue El approximation of distance is unacceptable) [310 CMR 15.302(5)] r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Barnstable MA 02668 04/10/10 every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available past 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 1375 Main Street Property Address Evelyn Lang Owner Owner's Flame information is West Barnstable MA 02668 04/10/10 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? 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) ❑ Innovative/Altemative 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): Approximate age of all components, date installed (f known) and source of information: 07/28/97 per BOH Were sewage odors detected when arriving at the site? ❑ Yes 0 No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M a 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Barnstable MA 02668 04/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.9 p g feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal 3'1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 27" W Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1375 Main Street Property Address j Evelyn Lang Owner Owner's Name information ir+ r+s West Barnstable MA 02668 04/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Bamstable MA 02668 04/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order. ® Yes ❑ No Alarms in working order: 0 Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Barnstable MA 02668 04/10/10 every page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): The pump, chamber and all appurtenances were working. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): This system has three flow diffussors surrounded by three feet of stone.The diffussors were dry with no sign of ponding or failure. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required for West Barnstable MA 02668 04/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): Commonweatth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required forWest Barnstable MA 02668 04/10/10 every page. City/Town State Tip Code Date of inspeetion D. System Information (cons.) 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. { C �7 3a 30 � y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1375 Main Street Property Address Evelyn Lang Owner Owner's Name information is required is West Bamstable MA 02668 04/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water i ® Check cellar ❑ Shallow wells Estimated depth to ground water. 8.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ 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: I augered to 8.0 feet and found no water. I adjusted to 8.0 feet. Bottom of leaching was at 3.1 feet I HIGH GROUND-WATER LEVEL COMPUTATION Date: p Site Location: (�� � � Permit: Owner: Phone: Contractor: Phone: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. /o �i0 GDUt C) 0 (depth is in feet below land surface) Date: mm/ d below Is STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well &PQ0� B) Water-level range zone " STEP 3 Using monthly "Current Water Resources Conditions" determine current depth to water 3 l 4� level for index well. mrn/yX STEP 4 Using Table of Potential Water Level Rise for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level 0- 0 0 zone (STEP 28) determine water-level adjustment. STEP 5 Estimate depth to high water by subtracting the (5.0 0 water-level adjustment (STEP 4) from measured depth to water level at site (STEP 1). NOTE* Tables 1-3"Potential Water-Lure! Rise-are attachedas worksheets to this file. monthly index well data: www.capecodcommission.org/wells.html I `` '` CERTIFICATE OF ANAILYSIS Pa e 1 �` ��: Barnstable County Health Laboratory Report Dated: 4/11/2005 Report Prepared For: Order No.: G0529619 Evelyn Lang 1375 Main St. W Barnstable, MA 02668 Laboratory ID#: 0529619-01 Description: Water-Drinking Water Sample#: 29619 Sampling Location a375 Main St,W-Barnstable,MA Collected: 4/4/2005 Collected by: E.Lang Received: 4/4/2005 Routine ITEivi RESULT UNITS RL , MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen BRL mg/L 0.1 10 EPA 300.0 4/5/2005 LAB: Metals Copper BRL mg/L 0.1 1.3 SM 3111 B 4/6/2005 Iron 2.0 mg/L 0.1 0.3 SM 3111B 4/6/2005 Sodium 8.9 mg/L 1.0 20 SM 3111B 4/6/2005 LAB: Microbiology Total Coliform . Absent P/A 0 Absent 307 4/4/2005 LAB: Physical Chemistry Conductance 120 umohs/cm I EPA 120.1 4/4/2005 pH 6.9 pH-units 0 EPA 150.1 4/4/2005 Sample has higher-thWaverage-levels of Iron that may have cosmetic effecis(such as toothror-skin discoloration)or aesthetic, �efcts(such.as,taste,odor;`or`cblor)of the drinking water. ` Approved By: (La irector) i RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TOWN OF BARNSTABLE LOCA.PON I. �r &AWNSEWAGE # s VILLAGE VI�--- a �`� y- ASSESSOR'S MAP & LOT /7.�40 3 INSTALLER'S NAME&PHONE NO. d . 11y�- ,10 Aco a eee< 9"50M SEPTIC TANK CAPACITY l 0 00 — A O d 0 POMP C d LEACHING:FACILITY: (type) ' X P C A A Ge (size) 3 so S NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: -7 ' .4 -9'y COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well'and Leaching Facility (If any wells exist on site or within 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 �� i:- t l ;z d� TOWN OF BA.RNSTABLE :# 97-3757 _ �fLs/q� LOCATION SEWAGE 1 VILLAGE Gf✓ %cam ASSESSOR'S MAP LOT/77-003 INSTALLER'S NAME & PHONE NO, _ SEPTIC TANK CAPACITY LEACHING FACILITY:([ype) (sLze) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: n_lANCE GRANTED: Yes No Ao, t 4 vs/ LOCATION EWAGE PERMIT NO. /Z'75" Hfl l(y 64+2Le VILLAGE INSTA LLER'S NAME & AD RESS 10 Hecom k)(?(-t-U 1D 6z)� ,J-nL- R R.,�E R OR OWNER E DATE PERMIT ISSUED rl- l0-7g DAT E COMPLIANCE ISSUED 7 O 4- f RA�u hat- 9 p Sao a _ ,q o0 No. Fee $ 50.00 THE COMMONWEVTH F MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Mi5pont *pgtem Cow5truction Permit Application for a Permit to Construct( )Repair MUpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1375 Route 6A Owner's Name,Address and Tel.No. West BARNSTABLE,MASS. 02668 Evelyn Lang Assessor'sMap/Parcel 1375 Route 6A West Barnstable,Mass. 02668 Installer's Name,Address,and Tel.No.508-775-3338 Designer's Name,Address and Tel.No. 508-775-3338 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 CENTERVILLE,MASS. 02632- Box 66 Centerville,tkss. 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building R:Re2 No..of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3x110=330 gallons. Plan Date 7/24 97 Number of sheets Revision Date Title Size of Septic Tank Existing 1000 Type of S.A.S.Existing-1000 leada pit Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Adding 3-330 cultec rechargers to existing 1000 a�llon tank 1-pump- chamber 1-pump on & off floats light & alarm Date last inspected: 7/24/97 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 t to place the system in operation until a Certifi- cate of Compliance has been issue y this B diH . Signed Date7/24/97 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ! ——————————————————————————————————————— 4 NO. 7 Fee $ 50°00 ' Entered q,.computers` THE COMMONWEVTH OF MASSACHUSETTS _ -Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ' 0(ppYication for Mi5pool *p.5tem Construction Permit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 1375 Route 6A Owner's Name,Address and Tel.No. West BAMNSTABLE,MASS. )@08 Evelyn &ang Assessor'sMap/Parcel 1375 Route 6A West Barnstable,M€l.ss. 02668 Installer's Name,Address,and Tel.No. Des" ner's Name,Add ress and Tel.No. ,J.P.Macomber & Son Inc. J.?Macomber & Son Inc: Box 66 CENTERVILLE,MASS. 02632 Box 66 Centerville,Mass. 0263321. Type of Building: Dwellings No.of Bedrooms Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building RR9 No. of Persons 3 Shoo ers( ) Cafeteria( ) Other Fixtures Design Flow 330 _, gallons per`day.•Calculated daily flow 3V0--330 ' 'gallons. 'Plan Date Number of sheets Revision Date 1000, T Title . Size of Septic Tank Existing 1000 Type of S.A.S.Existing 100.0 each _bit Description of Soil Sand Nature of Repairs or Alter tions(Answer when applicable) Adding 3-330 cultec rechargers to existing 1000 gallon tank-&W_1"W a e jt .t. 1=pump enalit er 1-pump on 9 off floats'-light & alarm Date last inspected: 7/24/97 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 t to place the system in operation until a Certifi- . cate of Compliance has been issueWby this B `d o H i � Signed /: _ "' Date7I24/97 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued '"" ,f——————————————————————————————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO'CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired (Xq Upgraded( ) Abandoned( )by J.P.Macombotj Son Inc. '. at 1375 Route 6A West Barnstal.e,Mass:. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N E dated j Installer J°P.Macomber & Son Inc. DesignerJ°P3qA on Inc The issuance of this permit shall not be construed as a guarantee that the system will-.function as designed. Date ' `! Inspector �\ - No. � P +r � ' �� .� ———————————————— -----Fee $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migool *pztem Construction Permit Permission is hereby granted to Construct( )Repair(T U grade( )Abandon( ) System located at 1 375 Route 6A WEST Barnstable,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 t ' rmit. s Date: ""'.e�- 'r Approve _ r � . CERTIFICATION Or 5KL'rCll AND APPLICATION FOR A DISPL.- WORKS CONSTRUCTION PEIZ�,11'1' (W1'I'flOU'I' DESIGNED PLANSI I Joseph P. Macomber Jr. :..r:i-y ccrtily that tite application for disposal works construction permit signed by me ;:::ted _ 7/24/97_ , concerning the property located at 1375 Route 6A West MnSTABLE,MASS meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system �• There are no private wells within 150 tvel of the proposed septic system �/• The observed groundwater tablr is ftct ur greater below tlw bottom of the leaching facility There is no increase in flow and/or cliangc in use proposed • There are no variances requested or needed. SIGNED : r DATE: 7/2 /97 LICEN ' SEPTIC SYSTEM INSTALLER IN T iE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposes s;,tem. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. r P °-� • r i O 4 i DATE: _5/1.6/97 PROPERTY ADDRESS: Evelyn -Bang 1375 Route 6A West Barnstable,Mass. On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 " 1 -1000 gallon septic tank. 2. 1-Disttibution box. 3. .1-1000 gallon leaching pit. Based bn my Insrsection, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code ) 2. The septic' system. is in- failure. • 3. Both -units have waste and waste water above the invert pipes and also over the outlet invert of the tank - 4.Pres'ent system must be upgraded to a title five -septic system repair. . SIGNATUR!,: 140L Nagle J P Macomber Jr_._______ i Company:_J.P_Macorgber & Son-Inc ; Address: Centerville jMAss_:_0.24632 ' t. Phone: THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tank&-Ce"poola-Laachflelds . Pumped & InsUlled Town Sewer Connectlons. P.O. Box 66' Centerville, MA 02632-0066 77.5.3338 775-6412 Conyr)omealth of Mossochusetts Executive Office of Envlronrmentol Affoirs Department of • Environmental Protection MUM F.Weld Trudy Core GOAMw &000-r ArW Paul Ceiluocl David B.Svuha LL Ow.vna fef e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Addreea 1375 Route 6A West Barnstable MA Address of Owner. Date of LnsPpuo&6 5/1 9/9 7 (It different) Namactlaspeotor.Joseph P.Macomber Jr. Company Name,Addrwa and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I mrUty UW I have personally inspected the"wage disposal system at this address mad that the Information reported below is tsys,socauate and complete u of the time of iaspectloa The inspection was performed based on my traiaing Lad experience in the proper lltnction and maiateaaaoe of on4it4"wage disposal systems. The system: _ Passes _ Conditionally Pass e eeds Further Evaluation By the Local Approving Authority Inspector's Signature The System Inspector shall submit a copy of this inspection report to the Approving Authoriq within thugs(30)day*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 systam owner shall submit the report to the appropriate regional od ce of the Department of Enviroamsatal Protection. Tee original should be seat to the system owner:wd copies seat to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A. B. C, or D: A) SYSTEM PASSES: _&Z2_ I have not found any iaformatioa which indicates that the system violates any of the Ulluse criteria'as defined in 310 CUR 15.303. Any UDurs criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: _4M One or more system components need to be replaced or repaired. The rystem,upon completion of the replacement or repair, passes Indicate yes,1w,or act determined(Y,N,or ND). Descsils basis of determination in all instances. It aot determined',explain why not) The wptic teak is metal, cra:ked,structurally unaoaad,show*eubstantlal inAltration or exsltration,.or tank failure is imminent. The system will peas inspection if the existing septic tank is replaced with a ponforming septic tank as apprw.d by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachuaatta 02104 a FAX(617)SWI049 a Telephone(617)292•5500 t. /MIW on a cyc4d r•pn SUBSURFACE SEWAOS DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Prop*AyA dr*" 1375 Route 6A West Barnstable,Mass . Ow"n Evelyn Lang Date of Lwpeotiow 5/1 9/7 5 B)SYSTEM CONDITIONALLY PASSES (continued) A&2 Sewsp backup or breakout or T static waist I"obearved in the distOution boa is dus to b:akaa or obs %wted pip.(, or dw to a b:oka4 settled or uneven distrLbution boa. The gstaa will peas inspection if(with approval of tba Soared of Heabh): broken pipe(&)are npl&oad obewction is removed distrib<ttbo boat Is Is velled or rep aced The system requLed pumping more than four times a Fear due to broken or obstructed pips(s). The system .ill pe„ inspection if(with approval of the Board of HealtW: broken pipe(s)are nplacod obstruction is removed I Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTHr Jed Conditions rust which require Aullwr evaluation by the Board of Health is osdar to determine if the gstam L failing to prWea cb, public b"kh.safety and the eavbvnmeat. 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: I �6 Cesspool or privy is within 60 feet of a surjaoe water Cesspool or privy is withla 60 festV a bordering vegetated wstkad or a salt march. 3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER.IF ApPROPRLATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONINO IN A HANKER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEN n TL system ha*a septic tank sad Doti absorption gst+m and L within 100 feet to a surface water.uppb or trtlxawy to e surfaos water ouppb'• ?(Q The gstam has a saptk tank and*oil absorption system Lad is within a Tone I of L public water suppb'vs, at The system has a septic task and*oD fbwrptioa system and Is within 60 feet of a private water suppb well The*T*tam has a septic teak and soil absorption eye"m and is Lea than 100 jest but 60 fist or more t}om a privet, water euppbr w4 ualaa a well water aaalysL for coliform bacteria and volatile orgaalo compounds Indicates that the wall i, tea, iron pollution ham that facility and the presence of aatmonia nitrogen and aitreta nitrogen is equal to or lw than 6 ppm 3) OTHER (revised,11/03/95) 3 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropertyAdd,"a 1375 Route 6A West Barnstable,Mass . Owner. Evelyn Lang Date of Inspeotion: 5/1 9/9 7 D) SYSTEM FAIL&: *4, I have determined that the syst m violates one or more of the following failure criteria as darned in 310 CMR 15.303. The basis for this determination is identified below. Tha Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of oowage jaw facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of aMuont to the surface of the pound or surface waters due to an overloaded or clogged SAS or cesspool. l ca Stacie liquid level in the distribution bout above outlet invert due to an overloaded or clogged SAS or ce"pool. )kC Liquid depth in cesspool is less than r below invert or available volume is less than lrl dray flow. �L Required pumping more than 4 times is the last year NU due to clogged or obstructed pipe(s). Number of times pumpd IM Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. 42D Any portion of a oasspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. tt Any portion of a cesspool or privy is within a Zone I of a public well. Aqy portion of a cesspool or privy is within 60 feet of a privets water supply well. Any portion of a cesspool or privy is less than 100 feet but"tar than 60 feet from a private water supply well with no ecceptabls water quality analysis. If the well has been analysed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammoais nitrogen and citrate nitrogen. Well has to be relocated when new system is installed. E)LARGE SYSTEM FAILS: The following criteria apply to age systems in addition to the criteria above: 40 The system serves a fadlity with a design flow of 10,000 gpd or pester(Large System)and the system is a signifleant threat to pub&c 'I health and safety and the environment because one or more of the following conditions curt: .0y the system is within 400 foot of a surface drinking water supply 4[7 the system is within 200 foot of a tributary to a surface drialdng water supply Q the system is located in a nitrogen sensitive area(Interim wellhead Protection Area(IWPA)or a mapped Zone U of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 6.00 and 6.00. Plaass consult the local teglonal olMce of this Department for flusher information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECXLIST PsopestyAdds«K 1375 Route 6A West Barnstable,Mass . Owner. Evelyn Lang Date of Iaspeotioa: 5/1 9/9 7 ' Check if the have been done. Pumping information was requested of their oaupaat,and Board of Health. ZNons of the system oomponagis have been pumped for a<least two weeks and the system has been teosiviag normal flow rases darinr that period. Large volumes of watar haw not been introduced into the system recenty or as part of this inrpectiom ZAsbuilt pleas have been obtained and wmine& Note if they are not available with N/A. �Tbe facMV or dwelling was inspected for signs of"wade back-up. 'ZI, system do"not road"wu-sanitary or WdustsW waste Bow The site was inspected for signs of breakout. All system oompoasats,4ehWirg the Soil Absorption System,have been located on the site. �Ths"ptie tank manholes were unwisred,opened,aad the interior of the septic task was inspected for Condition of baIDes or tees,material of constriction,dim4sions,depth of liquid,depth of ahidge,depth of scum. 27U size and location of the Soil Absorption System on the site has been determined based on existing information or �Thsa pr�a�by non-intrusive methods. facility owner(and oocupants,if Wforent from owner)were with information on the Surface Disposal System. provided prOP"maiateaaace of Sub. (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddreas: 1375 Route 6A West Barnstable ,Mass. Owner. Evelyn Lang Date of Inspectiow 5/19/9 7 FLAW CONDITIONS RE91DF.NI'IAIt Design S.L_as�pJ,�� s • Number of bedrooms Number of aurWA rssidsats•1 j Garbage Mader(yes or no):, . L w=dr7 connected to systans(yw or noQLS Sea+oaal use(yee or no): 'V(� Water meter readings,if available: Last date of oocupaacr. COMMERCIAL NDUSTRLAL: Type of establish; }ent:_ A) Design flow:_&_galloas/day Grease trep preseat: (yes or ao�14 Industrial Waste Holding Tank preseat: (yes or no) � Non-sanitary waste discharged to the Title 6 system:(yas or no),&4 Water meter readings,if available: 42A Last date of occupancy: OTHER:(Describe) A/4 Last date of occupancy: /L GENERAL INFORMATION PUMPING ORDSpnd of r�aptio / e-` .T X1C System pumped as part of inspection:(yes or no) S If yes,volume pumped: < 0D p1lons � Be— a for pumping � �//� Septic YSTEM UzVdistrbution b=/soil absorption system _2m single spool "_ Overflow cewpool Privy ID Shared system(ya or ao) (if yes,attach previous inspection records, if any) Other(explain) P )aMATE A E of all oo poasats,date installed(if known)and source of iaformatlon: YYi � �y Sewage,odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C• • • SYSTEM INFORMATION (continued) Property Address: 1375 Route 6A West Barnstable ,Mass . Owner: Evelyn Lang Date of Inspection:5/19/97 SEPTIC TANK: o � 74 vk. (locate on site plan) Depth below grade:p Material of construction: -concrete _metal _FRP_other(explain) Dimensions: f '40 r .�' 7 ' Sludge depth:, Distance from top ofsludge to bottom of outlet tee or baffle:_._ Scum thickness: ,/1 , Distance from top of scum to top of outlet tee or baffle:,_ Distance from bottom of scum to bottom of outlet tee or baffle. Comments: (recommendation for pumping, cond•ion of inlet andd utlet tees r baffle., depth of liquid IPv i ref io to outla tnv rt, structural •rity,,evidence of leakage, etc.) ,Mp sept�'c . tan once a year: �n�e out ete tees —ara--in •place Septic an is structuraiiZ soun o edi enct; o ea ag GREASE TRAP.A4WL (locate on site plan) Depth below grade:,," Material of consir,irti6na4zoncrete _metal _FRP_other(explain) AA Dimensions Scum thickness:, Distance from top w( scum to top of outlet tee or baffle: �IIIS� Distance from bottom n( crorn in honnm of outlet tee or 6hte:A1A JF- Comments: (recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struaural integrity, evidence of leakage, ettI Grease trap is not present, s ' (revised 8/15/95) 6 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinuW) PropwiyAddre" 1375 Route 6A West Barnstable ,Mass Owner. Evelyn Lang Da4 of hwPoctiont 5/1 9/9 7 TIGHT OR BOLDING TANMdLV�, Oocate on site pbm)Depth balow • Malarial of o as ',Q tsuc ( ==*te,x»tal—Y"otha(UPlaW - Ditnandons: A/A CaPacih: ./r4 aallcns D*4p flow: Aiasm (condition of inlet toe,condition of alarat and float swkeboe,Stc.) DISTRIBUTION BOJL•Z Goes"on die plan) Depth of liquid level above"lot inwrt:,L&, Commaats: (note if Lvei and dista'bation is equal,evidance of soli&carryover,evidence of leakap into or out of boa,etc.) Dlstri buti nn hnx i G 1 airal Rnv haS nna 1 atarn1 '11J1L1gYidgage A is ri u ion box, PUMP CHAMBER:A aocale on sw plan) Pumps in wo um ordan(Y"or no)—AL Commaata: (note condition of pump chamber,condition of Pumps and appurtananoa,Ste.) Pump chamber is not present_ (revised 11/03/95) 7 C •+ SUBSURFACE SEWAGE DISPOSAL SYW= INSPECTION FORM PART C SYSTEM INFORMATION(oontlnuod) ProP*AyAddreee, 1375 Route 6A West Barnstable ,Mass Ow"A Evelyn Lang Date of Inap.oU" 5/19/9 7 SOII.ABSORPTION nTM (SA9k2 Oocau oa ate PIA4 If poodble;excavation Got required,but my be app:wdmatd by aoadatruaiw methods) If Got deeermined to be pseeent,explain: 'lyPK leLeaia�cpit&, Lachiai .had,aamberkaith: le.chia j E.Ids,number,tiim�ioas:_ overflow oeeepoal,aumb.r Ccmmeata:(aou ooad)doa d soil,suns d kydmulie UM-ra,level of pondimi,oonditian of veietatioa.eta.) r1a_y f � eOP�d i n". v ge a ion is norma ac ink i as tal lect CESSPOOLS, (locate ca at.PILO N— Lad ooa4uatloa: D.ptA of liquid to inlet inva•t: Depth d eoiida Lyer. Depth of scum layer. DLz=Aoas of oeaspool: maw"of oonatrvdtion_ ladicatica of iroaadwat r. inflow(o.eapool must W PM*as part of inePection)_A& esspoo s are not present. - Commeata:(aou oonditiaa of soil,sips of hydraulic(ait^level of poadiay condition of venation, etc.) e•sspeels RSze 4;et pres6iitPRM (locate maw plaa) lrateriLl.of ooaatructian:_ Rllf Depth of solids:_,( , Cam—It (note ooadition of.oil,diaa of lydnaulie Unure,level of pondla&condition of..i.casioa,its.) Privy is not presen f • (revlaed 11/03/9S)• i E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM _ PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE LTSPOSAL SYSTEM: include ties to at least two permanent references landmarks. or benchmarks locate all wells within 100 ' -Well Water a Ei DEPTH TO GROUNDWATER depth to groundwater r+,Rthod of determinction or,approximation: :1 Du .es o e. ew.: . - ems. _ 2 e, a mus a re oca e 4. :,�. ;�,. ey. •nnr{r•..—n.•rR-Trsntan•n*en/rnrta7ndnlrr.'7'+1�.rJ�ln7gtA7�n�rt1T FJ � T7."1"!T-Vim.'•-:..�..r TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CE11TIFICATION �. F.-•an-T•:-: .—n.ta-.-rnmr+n•rr.�r+rn+e•aerran-nrr.�a•t.�ven�,v+�"�'nnws�ns+ws.��-rw� �n -TYPE 09 P9114T CLEARLY- PROPERTY INSPECTED STREET ADDRESS _ 1375 Route 6A .West Barnstable ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Evelyn Lafig PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & S-ot' Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State tIF COMPANY TELEPHONE ( 508 775 - 3338 FAX ( 508 ) 790 - 1578 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 experien6e in the proper function and maintenance of on- site sewage disposal systems . Check one: System PASSED t The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public hea1Lh 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. .XXXXXXx� System FAILED* The inspection which I have con Feted 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 C Date . , _Zj One copy of this ertification must be provided to the OWNERj the BUYER ( where applicable ) and the DOARD OF HEALTH. * If the inspection FAILED, the owner or" perator shall upgrade he sYste within one year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 CMR 16 . 305 . partd .doc Fee------- 'r- - - BOARD OF HEALTH TOWN OF BARNSTABLE Zipplication-*rVe[C Con5tructionPermit Application is hereby made for a permit to Construct (>o, Alter ( ), or Repair ( )an individual Well at: ----� ------ma`-� - �,►>=� �-�;5 --------------------------------------------------------------------------------- Location — Address Assessors Map and Parcel -�- - -___ -- -�3'(5-----rn i -----S----,----------�`- f- �- Owner Address -----weA 1 -Dr i 9 - Sandwcn Installer — Driller Address Type of Building C.I 1l we-it Dwelling------------ -------------------------- Other - Type of Building------------------------------- No. of Persons-------------------------------------—---------- Typeof Well--------_—---------------------------------------------- Capacity---------------------------------------------------— - ----- Purpose of Well---oiiSN =nq----I'--altex- --------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. - Signed� -- - 1''�-��=- ------------- ace Application Approved By ------ - - --- -- ---------- � date Application Disapproved for the following reasons:------—------------------------------------------------------------------------------------------------------------------------------------------ --------- ---- -------------- -------------------�A/—! ---- date -�Permit No. ----------- ----------------------------- Issued--------------------------------------------- ------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (�), Altered ( ), or Repaired ( ) by- � ----m -------1------ l_—d JS_)L�► ------------------------------------------------------------------- - ------ Installer at- �`�� �\�]-- �—_5�1!_-le1C Iry 4--------------------------------------------------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protections Regulation as described in the application for Well Construction Permit No. -W--f2--3Dated---�-- ---/ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------- --- --- ------ -- Inspector------------------------------------------------------------------------- No.-- Fee------- -`�- - - t TOWN OFARBARLN `TABLE 1 ApplicationArlVet[ Cootruet ionj3erttut `- Application is hereby made for a permit to Construct (X), Alter ( ), or Repair ( )an individual Well at: Location - Address ! Assessors Map and Parcel - — - _-.-- 5----- ------si-._ 4Q 1�a.` ------------ Owner Address -t�u2.11 Dr�_�1;_ c;� - 3 n:s�_eai c� tSG n d w c_n - Installer - Driller `" "- Address Type of Building�(. 11 f y,,Q Dwelling-------------------- --- - -------- y. -------- - ._Other- Type of Building ---------------- * No. of Persons------------------------------------------------- Typeof Well- ---------=--==-- -- - - Capacity---------------------------:------------------------------ ------ Purpose of Well-orbt_",nq---%-)''- - - Agreement: # The undersigned agrees to,install the aforedescribed individual well in accordance with the provisions of The } Town of Barnstable Board of Health Private Well Protection.Regulation - The undersigned further agrees not to 7 place the well in operation until a Certificate .of Compliance has been,issued by the Board of Health. A Signed ^ _ ! _ 9� Application Approved By 4 -- !- // -�7 date Application Disapproved for the following reasons:------------------------------------------------------------------------------------------ - date ,r Permit No.— `�`�2-5- - ----- Issued--- -- -`- y— ?--------------------- — date �I BOARD OF HEALTH K vTO'WN OF BARNS,TABLE Cert firate ®f CoMphance l - l THIS IS TO CERTIFY, That the Individual Well Constructed (N Altered ( ) or Repaired ( ) t b �-- e1_ -x�-------1� 11_-_Qz 11�_n_ l y- — Installer at- -- -- - i has been installed in accordance with the.provisions of the Town of Barnstable Board of Health Private Well Protection a f Regulation as described in the application for Well Construction Permit No. —�---- 2_3"fDated--- ---—--------- - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- -------— - ---- — -- Inspector--------------------------------------------------------------------------- u . a BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Con5tructionpermit No. ---Al Fee------`-- ---- va d Permission is hereby granted,----'�:�}- + — - to Construct (X), Alter ( ), or Repair ( ) an Individual Well, t !`_ a:-- No. -------- ----- ------------ Street as shown on the application for a Well Construction Permit No. - - �"- - - --- - -.-------------- Dated -= —k' 4-r =� --------------- - - -` ;. c c s / oar o ea B fHt Health DATE-- aA .X • t July- 9, 1979 Mrs 4Joaeph P.:•Macomber Joseph P. ,Macomber,& Son,- Xnc Box 66 Centerville, MA. r , Dear Mr. .Macombers You are granted an.',emergency variance to install a -1000 gakloh.. . septic tank 100 feet from"a 4well .,-in. lieu `of the requiied,:150., feet and a 1000 .gallon_ ,leaehng.,pit 75- feet from a- stream'at - 1375 Main Street, West Barnstable, for Sadie Parquhar." All`other :provisions contained ,in Title ,5, of the State<Enuiroh-o:' mental Code,and the 'down of"Barnstable, Health Regulations` apply• } . Mo urs, ,T Ro ert L, ,Chlds, Chairman •A,,W 'Mandelstam, M. , - BOARD. OF HEALTH TOWN OF BA,RNSTABLE JMK/Mm c r JOSEPH P. MACOMBER & SON, INC. BOX 66 - CENTERVILLE, MASS. 02632 - PHONE 775-6412 775=3338 Town of Barnstable Board of Health° Hyannis, Mass . 02601 July 3, 1979 Dear Members of the Board of Health, Joseph P. Macomber & Son, Inc: , of Centerville., - requesting a special variance for: Sadie Farquhar, 1375 Main' Street, West Barnstable, to install a 1000 gallon septic tank and 1000 gallon leaching pit. On this property we are unable to meet law requirements. This property has a very bad sewerage problem. We would like to beable to install the 1000- gallon tank within 100' of the well and 75' from the leaching area of the pit to the stream as presented on plan. The Conservation Commission has approved this system. Sincerely, Joseph P. Macomber & Son, Inc . 1-77 F,4R a S - r, we�L r THE FIRST NATIONAL BANK OF YARMOUTH YARMOUTH PORT, MASS. DATE WE ARE SENDING YOU THE FOLLOWING SECURITIES. PLEASE SIGN AND RETURN OUR RECEIPT WHICH ACCOMPANIES THEM. SHARES OF STOCK _ �"1 NUMBERS OF OR PRINCIPAL DESCRIPTION OF SECURITIES CERTIFICATES AMOUNT OF BONDS OR BONDS PURPOSE:- NUMBER OF SHARES j_ e NEW SECURITIES TO BE ISSUED AS FOLLOWS:- PFD. COM.f NAME ADDRESS - INSTRUCTIONS:- _ PLEASE RETURN THE NEW SECURITIES TO US. VERY TRULY YOURS, 1 PRESIDENT-ASSISTANT CASHIER ' A.E.MAflTE LL CO..NE ENE.N.H.