HomeMy WebLinkAbout0047 HIGH VIEW CIRCLE - Health I''
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form GJ. '
inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information _
Important:
When filling out 1. Plperty Information:
forms on therE- /`CC�
computer,use �l
only the tab key Pr pe Address r
to move your✓ C� C/` YL G
cursor-do not Owner's Name
use the return
key.
Owner's ss �
City/Town State Zip Code
U 8
Date of Inspection: Date Z C9
�J
2. Inspector: //11
4 o—oW4aR`J e S--In
Name of Inspector_
Company Name 1,7'�7� --
CompanyAddress �
City/Town State Zip Code
Telephone Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this addres and thief the ;.
information reported below is true, accurate and complete as of the time of the iU.pectlon TPe inspection,
%was performed based on my training and experience in the proper function and r ea ntenancp of on"�site
sewage disposal systems. I am a DEP approved system inspector pursuant ectionA-5.34 of
Title 5 (310 CMR 15.000).The system: r
nz
L
Passes ❑ Conditionally Passes ❑. FaiC
c-n
❑ Needs a valuation y e proving Authority
Ins o ' nature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
' � �J � Page 1 of 16
Z�I //g� V-(V,�� .5-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
Property Address
City/Town � State ' Zip Code
Owners Name Date of Inspection
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.
Co ments /
1/r/�G'�UI�'a
B) Syste Conditionally Passes:
❑ One or more stem components as described in the"Conditional Pass" section need to be
replaced or repa . The system, upon completion of the replacement or repair, as approved by
the Board of Health, ' ass.
Answer yes, no or not determine N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 yea old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infi ion or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is laced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally soun , of leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is av i ble.
ND Explain:
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Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
1 /e7t) C2
Property Address 11
City/Town State Zip Code
Owner's Name Date of Inspection
B) System Conditionally Passes (cont.):
❑ Ob ation of sewage backup or break out or high static water level in the distribution box due
to bro or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass insp \re
roval of Board of Health):
❑ broeplaced
❑ obved❑ dis led or replaced
ND Explain:
❑ The system required pumping more than 4 times a ar due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Boa of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C her Evaluation is Required by the Board of Health:
El Conditions which require further evaluation by the Board of Health in order to determine if
the system is failin rotect public health, safety or the environment.
1. System will pass unless Bo Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not fun ing 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 t ma.rsh
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Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
Property Address
/2wSvOys //1/e,is
City/Town State Zip Code
o-e5
Owner's Name Date of Inspection
N� C) Further Evaluation is Required by the Board of Health (cont.):
2. Syst will fail unless the Board of Health (and Public Water Supplier, if any)
determin that the system is functioning in a manner that protects the public health,
safety and vironment:
❑ The sys m has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet o surface water supply or tributary to a surface water supply.
❑ The system has eptic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic t k and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or
more from a private water supply wel *.
Method used to determine distance:
**This system passes if the well water analysis, performe t a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitro n and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are trigg ed.A copy of the analysis must be
attached to this form.
3. Other:
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Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
4- ,�,�h��-�/c�
Property Address
City/Town State ZipCode
,��s Tod cs-Z s-o P5
Owners Name Date of Inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes 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
❑Nl than '/Z day flow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
IAJ 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
❑ 4 tributary to a surface water supply.
❑A1A Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑N� 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.
Yes No
❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
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Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.) �
4-7 �� Ylell C11-
Property Address 01
/;-lai Tax 4/.--
City/Town State Zip Code
�4S
Owner's Name Date of Inspection
N/1 E arge Systems: To be considered a large system the system must serve a facility with a
desig w of 10,000 gpd to 15,000 gpd.
For large sy s, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Secti
YES NO
❑ ❑ the system is with) 0 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet o ibutary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sen . ' e area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a pub ater supply well
If you have answered"yes"to any question in Section E the system is cons) d a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or o ator of any large
system considered a significant threat under Section E or failed under Section D shall u de the
system in accordance with 310 CMR 15.304. The system owner should contact the appropria
regional office of the Department.
t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. ChecUst
-P �� �
Property Address
,�� 10,71S /GL S' j;/�t Oz�¢
City/Town /� State Zip Code
G='���F� 8 - Z s'• v g
Owner's Name Date of Inspection
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 owne occupant, or Board of Health
❑ [X' Were any of the system components pumped out in the previous two weeks?
rVr Has the system received normal flows in the previous two week period?
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
[] Was the facility or dwelling inspected for signs of sewage back up?
I� -❑ 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?
El information
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 (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts .,
Title .5, Official Inspection ;Form
Not for Voluntary Assessments
r` Subsurface Sewage Disposal System.Form s {p
D. System information
Property Address 4 Quo
Citylrown � State Zip Code.
J 7V IT
Gam , e-ZS-O.pj.
Owner's Name ;_ Date of Inspection
Residential i Flow Conditions:. '
Number of bedrooms(design): '� Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203..(for example: 110 gpd x#of bedrooms): 'tom U
Number of current residents: x
�`_"
Does residence havee-a garbage gander?. � � El Yes No
Is laundry on a separate sewage system?[if yes separate inspection required],, ❑ Yes No
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Y s No
Water meter readings, if available(last 2 years.usage(gpd)):
�Zoot� z�3r 'r�Zo�7�36G,ouu "9 duv
Sump pump? ----_..__ 9 Pd, ❑ Yes No
41
Last date of occupancy: Date
C%ofEs
dustrial Flow Conditions: -
Thment:
Design flow(based 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/pe ns/sq.ft., etc.):.
Grease trap present? ❑ Yes ❑ No
i
Industrial waste holding tank present? El 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):
t5insp.doc.doc•03/2006 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16-
Commonwealth of Massachusetts
Title 5 Official Insoecti ni Form
' Not for Voluinta' Assessments
y` Subsurface Sewage Disposal,System Form
D. System Information (cont.)
Property Address
' f/,r 171"L
Cityrrown State Zip Code
Owners Name Date of Inspection
General Information
Pumping Records:
040
Source of information:
Was system pumped as part of the inspection?, ❑ Yes �K No
If yes, volume pumped: I y/
gallons
How was quantity pumped determined? y�
T JYECSeZ
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
�
❑ cesspool
. Overflow
❑ Privy
r
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach.a'copy of the DEP approval.
.i
❑ Other(describe):
Approximate age f all compPnents, date installed (if known) and source of information:
� A
Were ewage odors detected when Lril\rlet site ! ❑ Yes No
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Page 9 of 16
• . Commonwealth of Massachusetts
'Title 5"Official-�Inspection . Form
' Not for VoWntary Assessments t . ° }
sr s
Subsurface Sewage Disposal System Form-:' L r = t
D. System inform tion (cont.)
1. ��'))
y
+ 7 ' //
Property Address Vyx 7
Citylrown / State „ Zip Code
Owner's Name Date of inspection
Building Sewer(locate on site plan):
Depth below grade /��'!� - feet
iobt 4570✓e✓
Material of construction:
❑cast iron 40 PVC ❑other'(explaln);'
,Distance from private water supply well or suction line ' -feet
Comments(on condition of joints, ve ting, videDoe of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: , feet bZ
Material of construction:
concrete ,❑ metal ❑fiberglassY ❑,polyethylene ❑other(explain)
If tank Is metal,,list age:
years
Is age confirmed by Certificate of Compliance?(attach a copy of El Yes ❑ No
...certificate?_
Dimensions: ��
^/d I"e
Sludge depth: ,;k '� '
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 2 `�
Distance from top of scum to.top of outlet tee or baffle~
Diistance.from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
}
t5insp.doc.doc•03/2006 Title 5 Offiicial Inspection Form:Subsurface Sewage Disposal System
v Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
° Not for Voluntary Assessments
r` Subsurface Sewage Disposal System Form
D. System Information (cont.)
Property Addres
ass/ ilk &
City/Town State Zip Code
�¢57a2t� c9-Z s y
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels a r lat d t et' vert evidence of le , e c.): ovFt
y � -�Q o� � ` a �
1-4
0- /ca./�/y S'au It
��,� Grea Trap (locate on site plan):
Depth belo rade: feet
Material of constru n:
❑ concrete ❑ m I ❑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 con di structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I
Tight or Tank(tank must be pumped at time of inspection) (locate on site plan):
�l�
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass olyethylene ❑ other(explain):
t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
y t,
f v S. hL .� n r
Commonwealth of Massachusetts `' L
:Title 5 Offici 4" Ins rection- Form
Not for Volunta .Assessments ,: ' f
ry � s k<, �� , �
Subsurface Sewage Disposal System Form `
D. System Information (cont.). .'...'
y
Property Address
City/Town State Zip Code
.015 �✓-2 - �-LS�og.
Owner's Name Date of Inspection
/K11-Ti ht or Holding Tank(cont.)
Dimen 'ons
Capacity:
gallons
Design Flow: `gallons per day .
Alarm present: "❑_Yes ❑ No
Alarm level: Alarri in working order: [I Yes ❑ No
Date of last pumping: ate
Comments(condition of alarm and float switches, etc.)-.
*Attach.copy of current pumping contract(required).,Is copy attached? ❑ Yes ❑ No 44
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert `3 a
Comments(note if box is level and distribution to outlets,equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
�!� Pump Cham e Ian):
Pumps in working order.. . ❑ Yes ❑ No
Alarms in working order: s ' ❑ No
t5insp.doc.doc 03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title ,5 -.Official Inspection form ,
Not for Voluntary Assessments
r` Subsurface Sewage.Disposal System Form
D. System Informatlo
Property Address
Cityrrown F. !`�F State Zip Code
Owner's Name `Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System,(SAS) (locate on site plan„excavation not required):
SAS t located, explain why: ts✓ A*
Type:
leaching pits number
leaching chambers number.
tAl
❑ ..leaching galleries =, number.
❑ leaching trenches number,)ength:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil,.signs f hydraulic failure, level of ponding, dam soil, condition of l
vegetation, etc.): ) �OovIt e ) CT'l,rr>nn> "� n�I /
�/
t5insp.doc.doc 03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
r :
Title 5 Official Ins e'dion' Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information�cont.)
Property Addres
City/Town' j State Zip Code
7oe OK-
Owner's Name Date of Inspection
4VI Cessp (cesspool must be pumped as part of inspection) (locate on site plan):
Number and config
Depth—top of liquid to inlet inve
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(I on site plan):
Materials of construction:
Dimensions
Depth of.solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, co on of vegetation,
etc.):
t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
r` Subsurface Sewage Disposal System Form
D. System Information (cont.)
Property Addresses "
Cityfrown State Zip Code
oz,
Owners Name Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two ermanent reference landmarks or benchm s. Locate all wells within 100 feet.
Locate where u Ic wa er supply enters a building, _
( ` s
N c5
®2-
to ,3
,d -4) 3(- 3�
l
zz
�. R7—
t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
�:CommomNealth:of Massachusetts
Title '5 Offi.ia[In p6bbon Form
Not for V®luntsry Assessments
Subsufface.Sewage Disposal System.Form
D. SpteQn Information
Property Addr s k
. ,?d,,� ill �•�> -:.� 9 6Z6 ��
City/Town State Zip Code
Sd-Z .p
t�
J �
Owner's Name Date of Inspection
Site Exam*
Slope.
Surface water
Check cellar
Shallow wells
Est!mat to ground water
• .. _
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/observabon hole within 150 feet of SAS)
El Checked with local Board.of.Health ,explain:
❑ Checked with local excavators, installers-(attach documentation)
Accessed USGS database-,explain
US D47W"'�
You must describe how you established the high ground water elevation:
t5insp.doc.doc•03/2006 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
F
r
r
,r oFTHElp� Town of Barnstable
Department of Health, Safety, and Environmental Services
+ BARNSTABLE,
Ass.
1639. Public Health Division
♦0
ArFD►�'�A P.O.Box 534,Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: David Houghton
Assistant Town Attorney
FROM: Thomas McKea6::;�.
Director of Public Health
RE: 47 Highview Circle,Marstons Mills
DATE: March 9, 2000
I am in receipt of your letter dated February 23, 2000 regarding 47 Highview Circle,
Marstons Mills.
I logged the complaint into the Public Health Division computer complaint system
database (case#2258) and assigned it to Health Inspector Jerome Dunning. He will go
out to the site within the next 24 hours and will return to discuss various options with me
in regards to what actions should be taken, which would include enforcement of Nuisance
Control Regulation Number One and the ABC policy of DER
I will keep you posted in this regard.
' I
i
41
Town of Barnstable
Legal Department - Town Attorneys' Office
367 Main Street, Hyannis MA 02601-3907
Inter-Office Memorandum
Robert D. Smith,Town Attorney Office: 508-862-4620
Ruth J. Weil, 1 st Assistant Town Attorney Fax: 508-862-4724
T.David Houghton,Assistant Town Attorney
Claire Griffen,Paralegal/Legal Assistant
Terri Cahalane,Legal Clerk
Date: February 23, 2000
To: Board of Health
From: Assistant Town Attorney David HoughtonkaL�J
(fit
Subject: Cheryl Kelly and Arthur Pastore
47 Highview Circle, Marstons Mills, Assessors Map 30, Lot 80
Legal Ref. #99-0183
Our office is currently defending an action brought by Cheryl Kelly and Arthur Pastore in
the Barnstable Superior Court appealing a decision by the Conservation Commission
requiring Ms. Kelly and Mr. Pastore to remove construction debris which they had
dumped in an old abandoned sand pit on their property within 100 feet of a wetland. The
debris consists primarily of broken concrete interspersed with steel reinforcing rods. As
part of the defense, we noted that DEP regulations (310 CMR 19.001 et seq.) govern the
disposal and classification of such material. We also noted that the tran
script sc r'ipt of the
Conservation Commission hearing on the NOI indicated that the Commission was unsure
whether this might involve issues within the Board of Health's jurisdiction (see Supp. R.
Vol. II, page 5, line 4)transcript of April 27, 1999 Conservation Commission hearing).
I therefore would like to take this opportunity to forward the Commission's question on to
you.
Cc: Conservation Commission
Bruce P. Gilmore;Esq., Attorney for Cheryl Kelly and Arthur Pastore
/tdh
4
i
i
V
l
99-0183 Bohmemo
i
' TOWN OF BARN-STABLE
LOCATION SEWAGE #
VILLAGE /9k n _ASSESSOR'S MAP & LOT45.9,0
INSTALLER'S NAME&PHONE NO.'`�-r Macomber Sots w-nc-
SEPTIC TANK CAPACrrY
i
LEACHING FAciLrrY: (type)
I
NO.OF BEDROOMS
BAR OR OWNER
PERMTTDATE: t �'' 4 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
c� s
tl
c
,,�-- TOWN OF BARNSTABLE
LOCATION �s1/ AW �o4, SEWAGE #
VILLAGE ';0 ASSESSOR'S MAP & LOT
NAME&PHONE NO.��/
SEPTIC TANK CAPACITY l^
LEACHING FACILITY: (type) 1-6 7' (size)
NO.OF BEDROOMS
BUILDER OR OWNER
=SATE: lv - - 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 f t of leachin faA ) Feet
Furnishe� y -
•s� �.
. �°%�. -
e `�� ,� � .
<T
,,
�.
�;
• TO OF BARNSTABLE
LOCATION _�'��� SEWAGE # _
VILLAGE ASSESSOR'S MAP&LOT _
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY _
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 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
Existing 1000 gallon
leaching pit.
ixisting Bo
1000 gallon an $]]
�� Proposed Y-330 Rechargers
CFO-
No. Fee�CP - a � 40.00
�`S �
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppIttatton for Mtgogo.r *pgtem Com6tructton Vermtt
i
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. 47 Highview Circle Owner's Name,Address and Tel.NoSteve Peckham
Marstons Mills.Mass.02648 Box 69 Hyannis,Mass . 02601
790-018
Installer's Name,Address,and Tel.No. 77 5—3 3 3 8 Designer's Name,Address and Tel.No. 77 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber Jr.
Box 66 Centerville Mass. 02632 1 Box 66 Centerville,Mass . 02632
Type of Building:
Dwelling XX No.of Bedrooms 4 Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 440 gallons per day. Calculated daily flow 11 Ox4 =440 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Medium sand to fine sand.
Nature of Repairs or Alterations(Answer when applicable) Adding #-330 Rechargers
To an existing 1000 gallon tank d-box and leaching pit.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issqed by this Boa of alV-4,
Signed Date 7/11/96
Application Approved by
Application Disapproved for the following reasons
Permit No. r - --3':?-5 Date Issued
No. / _3� S r. Fee$. 40. 00
- THE COMMONWEALTH OF MASSACHUSETTS t
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS�
.- 2P.Prtcatton for Mi.5poot *pgtem Construction permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. 47 Highview Circle Owner's Name,Address and Tel.NoSteve Peckham
Marstons Mills.Mass.02648 Box 69 Hyannis,Mass. 02601
' 790-•0185
Installer's Name,Address,and Tel.No.11 77 5—3 3 3 8 Designer's Name,Address and Tel.No. 77 5 3 3 3$
J.P.Macomber & Son Inc. J.P.Macomber Jr.
Box 66 Centerville Mass. 02632 1 Box 66 Centerville Mass. 02632
Type of Buildin
DwellingX No.of Bedrooms 4 Garbage Grinder( )
Other Type of Building 1No.-of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 440 all .pper day. Calculated daily flow 11 Ox-�, =440 gallons.
Plan Date Number of s' ets Revision Date` -
- 'Title
Description of.Soil \
Medium;sand to fine sand.
Nature of Repairs or Alterations(Answer when applicable) Adding X 330 Rechargors
To an existing 1.000 gallon tank d-box and leaching pit.
ff '
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed by this oa�of ealth.
Signed Date 7/11/96
Application Approved by6/
Application Disapproved for the following reasons
j
Permit No. Date Issued
-------=.T -- ---------
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of QCompliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced Y )on
b J.P.Macomber Jr. for
as 47 Hig view Circle Marstons Mills,Mass. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2'6 —J P-S` dated
Use of this system is conditioned on compliance with the provisions set forth below:
-----------------
No. 9�0 - J Fee $ 40.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
:fit.5poar &pgtem Conotruction Permit
Permission is hereby granted to K•P•Macomber Jr.
to construct( )repair(XX)an On-site Sewage System located at 47 Highview Circle
Marstons Mills,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.
All construction must be completed within two years of the date below.
Date: Approved by �Z�'/� ( ��
gi
!F
I 1
R
OIL SKCTCI-I AND APPLICATION FOR A DISPOSAL,
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
b
I, Jose-ph P Macomber Jr_ , hereby certify that the application for disposal works
Af
'%
construction permit signed by me dated 7/11/96 , concerning the
property located at _4.7 l iuhv oz+o
; ew r; ral a M +„ra ��' . I I 4 meets all of the
1
y
folluwirip crit�.ria: �
�1
There are no wetlands within 300 feel of the proposed septic system
• There are no private Wells within 150 feel of the proposed septic syslelrl
The observed groundwater table is N4 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed I
There are no variances requested or needed.
4
7
SIGNED : �� ; DATE: 7/11,19A
t
L.ICEN'1~ ! PTIC SYSTEM INSTALLER 1N THE TO\YN OF BARNS"TABLE NUMBER
C
e
f' ry
t
[Attar-!.w sl:e[c:i plan of the proposed system. Also if the licensed installer posesses a cer ified plot plan,
this plan should be submilied].
i
i
DATE:
PROPERTY ADDRESS:_ 4 _hwi6r Circle
Marstons Mills
'J U N 7 1996
Ma s s � • . . •
MM M DEFT. j
T tJ11OF13"gASLE
' . On the above date, I Inspected the septic system at the above address.
This system .conslsts of the:following:
1 : 1-1004: gallon e. tc tank'.
2;. 1-1000 gallon leaching pit, 00RSMAPNO.- �
Based bn my InSnectlon, I certify. the following conditions: ���
L, This is a title five se.ptx.a�=s�€stem
_"2. THIa.,system was filled' to capacity,.. ..
• 3'. The system is in failure.
Must be .upgraded to a title .five septic: syste�t..:
SIGNATURE:
Name: J:P.M,acomber
Company:_`J.P_MacoiQber.'I Soh—Inc .
.
_- ,
Address• '
_ Cente_rvill,e Mass ' �0.2-632 '
- Lam__-_.�- i
!�
Phone:---508. 7-5.33
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACO�RSER & SON,. INC.
Tanks-Coupools•Leachfields
• Pumped' 4 Installed
Town Sewer Connections
P.O. 80�,66'. Centerville, MA 02632-0066
w' 77.5.333,8 ,'.775-6412 „
Wpllam F.Weld Trudy Coxe
Gavom" 8—twy
llrgeo Paul C•Iluccl David B.Struhs
LL Gommor C.onuoh"101W
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: �ighview
66 g7� Circle Marstons Mills Address of owner.
Date of Inspeotion: (If different)
Name oflnspeotor. Joseph P. Macomber Jr.
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
I certify 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:
_ Passes
_ Conditionally Passes .`
_ goods Further Evaluation By the Local AApppro ' Authority
Fails
Inspector's Signal '%'/D 'G� Date:
The System Inspector submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner And copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B. C, or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as detned in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
- 4/1 One or more system components,need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes, ,or not determined(Y,N,or N ). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cr#Aed,structurally unsound,shows substantial infiltration or exilltration,-or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11103/95) I
One Winter Street • Boston,Massachusetts 02108 a FAX(617) 556-1049 • Telephone(617)292-5=
i�Printed on R"Ied Papu .
' � r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Address: 47 Highview Circle Marstons Mills,Mass.
Owner. Stephen Peckham
Date of Insp wo lon:6/3/9 6
Bl SYSTEM CONDITIONALLY PASSES(continued)
Wd-V6Sewa8e 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
,db 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 pipes)are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
tvD Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_V_8 Cesspool or privy is within 50 feet of a surface water
Alp Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Af 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.
�2S The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well.
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,unlew a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTQHER
(revised 11/03/95) 2
lu
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddreas: 47 Highview Circle Marstons Mills Mass.
Owner. Stephen Peckham
Date of Inspection: 6/3/9 6
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
V ,s Backup of sewage into facility or system component due to an 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.
4L *!, Static liquid level i�thi tribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
J Liquid depth in4esspool is less than 6"below invert or available volume is less than L2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
(� Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply,
Any portion of a cesspool or privy is within a Zone I of a public well.
�Q 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
the rstem 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
10 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 shell bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 6.00 and 6.00, Please consult the local regional office of the Department for Ai ther information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Add r... 47 Highview Circle Marstons Mills
Owner. Stephen Peckham
Date of Inspection: 6/3/96 '
Check if the following have been done:
� Pumping information was requested of the owner,occupant,and Board of Health.
one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
Zd 'Zt
that period. Large volumes of water have not been introduced into the system recently or as part of this inspection
plans have been obtained and examined. Note if they are not available with NIA
-L/The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-"aitary or industrial waste Aow
/The site was inspected for signs of breakout.
, All system components,-scluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on existing information or
a rozimated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub
Surface Disposal System.
(revised 11/03/95) 4
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL- a
Design flow: ons/ W d)1 Y Y
Number of bedrooms:
Number of current residents
Garbage grinder(yes or no):
Laundry connected to syste (yes or no): 1?.3
Seasonal use(yes or no): , �D
Water meter readings, if available: '� a 1'
Last date of occupancy:
COMMERCIAL/INDUSTRIAL,
Type of establis ent:_ NIL
' _
Resign flow:�gallons/day
Grease trap present: (yes or no),N—A
Industrial Waste Holding Tank present: (yea or no) ).6
Non-sanitary waste discharged to the Title 5 systerz: (yes or no)&
Water meter readings, if available:_
Last date of occupancy:
OR—
OTHER:- (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS an source of informa 'on:
c /—
System pumped as part of inspection: (yes or no)
If yes, volume pumped' U ga 79-fl
Reason for pumping D C.yeaCT
TYPE Og SYSTEM
Septic tank/Ai"4 /soil absorption aystem
--1� s�cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attacb previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
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: 47 Highview Circle Marstons Mills,Mass.
Owner: Stephen Peckham
Date of Inspection: 6/3/96
SEPTIC TANK: 1 ��'uo v Xk9 e
(locate on site plan)
Depth below grade:. 1�
Material of construction: concrete _metal _FRP—other(explain)
Dimensions:_ ' ��
1
Sludge depth:
Distance from top of udge to bottom of outlet tee or baffle:-O..--
Scum thickness:_ O
Distance_from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle._..s�
Comments:
(recommendation for pumping, condition of inlet and gullet tees or baffle. depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) PUMP t'A'i vary. 2,3 •liil d ou l+,_t= e
u' d was above outlet �jjve� e .an s� :,s
n Shows nos insdr. 1,ealmge.
GREASE TRAP.04/-
(locate on site plan)
Depth below grade:,,'44
Material of constrgrti6n;4V:oncrete _metal _FRP—other(explain)
Dimensions•
Scum thickness:_
Distance from top yr scum to top of outlet tee or baffle:_!(��
Distance from bottom of Crum in honom of outlet tee or baffle:.
Comments:
(recommendation for pumping, condih-ri of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
inte rity, evidence of leakage, etc.) .
I n 6.,vi✓ VW7s
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Address: 47 Highview Circle Marstons Mills ,Mass.
Owner. Stephen Peckham
Date of Inspeotlon: 6/3/9 6
TIGHT OR HOLDING TANK:/,jWC
(locate on site plan) e
Depth below grader
Material of construction concrete_metal_FRP_other(explain)
Dimensions: AM
Capacity: gallons
Design flow: 14 ons/day
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
JUe TITS
DISTRIBUTION BOX:A.de.
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER:_L&0rQ—
(locate on site plan)
Pumps in working order.(yes or no) '&/o
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
tid
(revised 11/03/95) 7
YArt 1 V • �
SYSTFM INFORMATION (oontinuod) /
Proporty Addro" 47 High view Circle Marstons Mills ,Mass .
Owner. Stephen Peckham
Date of Inspootiow 6/3/96
SOIL ABSORPTION SYSTF-14 (SA8):z
(locat.o on site plan, if possible; --vation not rvquut�l, but uuLy ue upprozuuated by non-intrusive methods)
If not determinod to be present, explain:
Typo:
leaching pits, number:
lunching chambers, number:
loathing gullerios, number:
leaching trenches, number,leogth:
leaching fields, number, enstolts: _—__
overflow cesspool, number:
Comments: (note condition of soil, siens of h drnulic faiiurv, level ui pondin , condition of vegetation etc.)
Loam sand to sand &�ravel;yes tihere are signs o y ran is a ure;
Water waste is above the inlet invert of the pit. : Vegetation
_ lush & green. The leachi_ ng nit � s in failure. Must be uagraeded to
title five requirments.
CFSSPOO 9:Q�
(locate on site plan)
Number and configuration: AM
Dopth•top of liquid to ialot invort:_ _
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: AIR. —.!_.-....._..
Materials of construction: AA —•--_-_--
Indication of groundwater: A/ — �n^/
inflow(cesspool must be pumped as part of i upvctiow '04-
Co enta• (note condition of soil, sib-s of hydruu!ic failu;v, level of pondirtg, condition of vegetation, etc.)
PRIVY: jP/�Q.
(locate on site plan) ~
Materials of construction: . ---_-- Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydmulic failure, level of poading, condition of vegetation, etc.)
('revised 11/03/95) b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddr,.,- 47 Highview Circle Marstons Mills Mass .
Owner. Stephen Peckham
Date of Inspeotlon:6/3/9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarka
locate all wells within 100'
Centerville Osterville Marstons Mills
Water Company
428-6691
.10
v.
DEPTH To GROUNDWATER
Depth to Vvundwater.l 6' PJus
method ofdaterminationorapprozimation: No water encountered when system installed in
1Q7F, Transit shot from top of leachp1t to the surface of
e Long VonU. _
(revised 11/03/95) g
�jti� IG,r�
� b
i
THE COMMONWEALTH OF MASSA.CHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
JoseP
h P. Macomber, Jr.
Has satisfied the Department's qualifications . as required and is hereby-
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 2 1 A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the -ion of Water Pollution Control
k r 'I'UWN OF Barnstable BOARD OF HEALTH
SUBSU11FAU SEWAGE DISWSAI, SYSTkM INS['ECTIUN FORM - PART D - CEft'fIFICATION
(;..._.....r..,...,..--.v:-.._—z.r..:..•r.:--:__._�-.^"_'rv—:.--........ ...---r.,-.-s.—tr:.^-.rtc--.zr—r..�—r�rxra:rtn r.-*m+••r.-rar. ..�rrr r. ;
-TYPE OR PRINT CI.EARLY•-
PROPERTY INSPECTED
STREET ADDRESS n 47 Highview Circle Marstons Mills
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' S NAME Stephen Peckham
PA1?1' D - CERI'IPWAT'ION r
NAME OF INSPECTOR Joseph P.Macomber Jr. •
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City Stag LIP
COMPANY TELEPHONE t 508 775 3338 FAX ( 508 790 1578
—_.r
._v
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
- this address and that the information reported is true , accurate , and
complete as of the time of :inspection . The inspection was performed and any
recommendations regarding ; upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems :
Check one:
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated
are as stated in the FAILURE CRITERIA section of
this form .
XXXXXXXX System FAILED*
The inspection whicl, I have conducted has found that the system fails to
protect the public health and the environment in accordance with 'title
5 , 3.10 CMR 15 . 303 , and. as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date 6/6/96
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF lIEAL1'll.
* If the inspection FAILED, the owner or,,•operato.r shall upgrade • the system
within one year of the data of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
nn -1
No. Fl�s.... U......�.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
O �. OF........ ... �y1.:...................................................
Allp iration -for Biip.usal Morks Tothi#rurtion Prruti$
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
Location• ess or Lot No.
--- /- ��-�--m--------, °............................ . --••- -••-----•..............................................
Ownei Address
a --- - ------ ' ------------••--•--------------•------•_----_----------------•- --------------------------------------------Address
d Type of Building, Size Lot--------- -----------------Sq. feet
U Dwelling No. of Bedrooms----- -----------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ._---__._-_--__-._-_--- No. of persons............................ Showers ( ) Cafeteria ( )
P4Other fixtures ----- ------------------------------------------------
W Design Flow___.,:<U_________________________________gallons per person per day. Total daily flow...a3.Q.Q-____--__-__-__--_-.----.....gallons.
WSeptic Tclnk—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 ( )
aPercolation Test Results Performed by-------------- ........................................................... Date---------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit-.------------------ Depth to ground water.--.--.-.---.------.---.
Ci. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-..------------.--------
---------- -----
O Description of Soil---------------------0 -I
x t
�.W -'yE �-=------- -•--- r----------------------------------------
----------------
U Nature of Repairs or Alterations—Answer when applicable..--------------------------------------------- ------
---------------------•-••--•------•-•------------------=----•--•----------•---------•--••----.---------------------•-------------------------------•--•-------------- ------------------------
Agreement:
The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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 bo rd o ealth.
Signed.. . ,� �` ..+ 0''l ". �
y ------
Date
Application Approved By--------- -- � •--••- ---------------------•-••------- ----- �- D t�?-a~--
Application Disapproved for the following reasons-------------------••---•-------•----•-----------------------------------•-••----.---------••-•-•----------------
--•-----•---•--------•---------•---•--.•------------------------•---••----------------------•----------
------------------
Date
PermitNo......................................................... Issued........................................................
Date
:.=tee'�-,t•""� - _ _ -
.... l.... 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ... .F HEALTH
....OF........ .6 4-41-A..... ----------------......------------.._...--------
, pphratiun -fur Uiipuuttl Vork,6 Tomitrurtiun Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
IL Lu
-------------------------------------------------------------------------------------------------
-Location-A ess�� ` or Lot No.
.:err `. A.7 7` /�
Owner Address
W
Installer Address
UType of Building, Size Lot----------------------------Sq. feet
-I Dwelling—No. of Bedrooms..._,....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures --•------- ---- -------------
W Design Flow-_.-,,�_O................................gallons per person per day. Total daily flow.._ ..U_0-_-..-____-__---.-........._.gallons.
WSeptic Tank—Liquid capacity............ h gallons Length---------------- Width................ Diameter-.......___..... Dept _____._..--- _.
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 "Pest Pit-------------------- Depth to ground water......__-.----_- ..___.
GTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-------------.__..
a , ----- r--• --
rjl�
x Description of Soil Q."..• 1 ----------••----------------- ----- .�.... v>�' : N - l 1
Ws''1 ' -� ��-L r -� ----------------
2 '=�-�--------- /%-{.-
---------- -- ---------------•--------------------------- -------••--••----------•--••••......------. _ � --•----••---......-----
.--
�'LC �vt'O !e G �d1 --U- C15
U Nature of Repairs or Alterations—Answer when applicable.-..-.................................__.____.:�..._-_-.....-.-.........__._-..............
-----------------------------------------------------------------------------------------------•----------------.........----------------•--------•---`�' �s 2.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I 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, ealth.
--_---_-- ... ---
� Date
Application Approved B r !l -----�--71 ..+_7 J.�---PP PP y. --------------------------------
•-..--•---•-----•-•------•--------------•-•-•---•-•-•--••-------------Date--------------
Application Disapproved for the following reasons:......................
----•..................•-•-•..-•--••-----••-••---•------...-•-•------------•--------•--._...--------•-----•--••---••---•------------•------•--••-•-•---.....---------------------•--•-------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
.......... � . ..........OF..... lyl/.�. .....................................................
Tntifiratle of Tontplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
at..............................................................-----•---- c ..-------`-------- ------•-- -.--- '`------.......................
' Installer
_y : . - - -
has been installed in accorda e with the provisions of A � I of The State Sanitary Code as described m the
application for Disposal Works Construction Permit No. 7--.--- _�---------------- dated'... .-.,1 -.T ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------------------------------------------------------------------............ Inspector------•-•--------------------------------------•----------------•------•----•-.-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tiw)�,
r _..... OF ......., - ,--------------------------------------- E d
No. --- FE /O..----•---
Di Voiial urk� Chun trttrtivat rrntit
Permission is hereby granted------------------------------------- ----------------- ----- ..........
to Constru ( )66r Repair ) ark Individ al/A�ew�ag Disp�saZystem
at No...... '`'i�t '..�' (<-�G�'� -----// . ---------------------------
street ----
/4';a—..
as shown on the application for Disposal Works Construction P, No.. --_-.-_-. Dated....._.._ - ------------------
��= l ----�"�- -._....----•------•-----------
Board of Health
DATE-------------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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