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Home My WebLink About0100 BAYBERRY LANE - Health 10oorA �Y LANE, ) _ A=335.035 IV 0 ;R r v. ` N �S a .. ,�E •- 6.':4i•-. c+ - ...- v v Zv ^_ - x.'� y,. i=;. ♦ ,i.. r� c„q Kt a "•. � ..'�:.Xi:a ck n- - •.. 9`W- ,-,ii.. a tr .i "'-''"d:,r'.,x.-L0.' C^{• � .Y'K[- , r� - o , i r•, r, 'p � •Mb.::'a Y -�'�_ � v ',__; .. / i' - � z .,+tom . _ ♦ A .. -- r. .'sc - - ., f�. max: j ry , - s r Commonwealth of Massachusetts W Title 5 Official Inspection Form s _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 100 Bayberry Lane �M Property Address Elizabeth Hooper C Owner Owner's Name information is required for Cummaquid -� j Ma. 02637 6/1-8/2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered iRan way. 'S" •r Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not use the return Name of Inspector key. Capewide Enterprises,LLC Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 m _ CitylTown State Zip-Code (508)428-4028 = Telephone Number License 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: E Passes ❑ Conditionally Passes ❑ Fails ❑ Need urther Evaluation by the Local Approving Authority • i � r 6/18/2007 Y Inspec or's Signature Date N The system inspector shall submit a copy of this inspection report to the App%oving Authoritye(�oard of Health or DEP)within 30 days of completing this inspection. If the system`sl a shared•system or has a design flow of 10,000 gpd or greater, the inspector and.the system own r'shall submitztl e. report to the appropriate regional office of the DEP. The original should be sei it to the systemwner and copies sent to the buyer, if applicable, and the approving authority. o► r+7 ****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. a„ lr t l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 1`6ge,1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. 02637 6/18/2007 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: The septic system is in proper working order at the present time. 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 c ❑ obstruction is removed t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments G1,y 100 Bayberry Lane Spey`' Property Address Elizabeth Hooper Owner Owner's Name information is Cumma uid Ma. 02637 6/18/2007 required for q every page. City/Town 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. t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 100 Ba ber Lane Y rY Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. 02637 6/18/2007 every page. City/Town 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, performed 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 El ® 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 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 r Commonwealth of Massachusetts W Title 5, Official Inspection .Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name' information is q required for Cumma uid Ma. 02637 6/18/2007 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. I 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 Il 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. t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. 02637 6/18/2007 every page. City/Town 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? Z ❑ 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 (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] - i t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. 02637 6/18/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 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 last 2 ears usage d 2005:85000 g ( y g (gpd)): 2006:85'000 Sump pump? ❑ Yes ® No Last date of occupa 6/18/2007ncy: Date Commercial/Industrial Flow Conditions: I 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): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts H - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. .02637 6/18/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•08/06 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 l \., Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. 02637 6/18/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cone.) Building Sewer(locate on site plan): _ Depth below grade: 20"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 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: 8'6"x4'10"x57" 2" Sludge depth. Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 9" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. 02637 6/18/2007 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.): Pump tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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): t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is umma uid Ma. 02637 6/18/2007 required for C 4 ' every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 no 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,): Box is level and has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. 02637 6/18/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-1000 gl.stacked ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-2'x20' ❑ 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.): Sandy soil. No signs of hydraulic failure.No ponding or damp soil.Water to invert was 1 Vat time of inspection.Leaching pits are stacked one ontop of other.No visible stain lines higher. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts - Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Bayberry Lane. Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. 02637 6/18/2007 every page. City/Town State Zip Code Date of Inspection D. System Inflormation (cont.) 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.): t J t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I -0, <L3Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is q required for Curnma uid. Ma. 02637 6/18/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. � l l f t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 { s y Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 100 Bayberry Lane Property Address Elizabeth Hooper Owner Owner's Name information is q required for Cumma uid Ma. 02637 6/18/2007 every page. . City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 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: As-Built Card. ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: Youmust describe how you established the high ground water elevation: Used:Gaherty& Miller Model 12/16/94 ground water elevations.Used:USGS Observation Well Data June 1992.Used:Technical Bulletin 92-000-01 Plate#2 Annual ranges of groound water elevations. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 DATE:1/13/00 —___ PROPERTY ADDRESS: -----ry f, _________ Q 1 Cumma uid Mass ..-� - ---- 02637 On the above date, I Inspected the septic ,system at the above address. This system consists of the following: . 3 �- 1 . 1-1000 gallon septic tank. 2 . 2-1000 gallon precast leaching pits . These pits are stacked . One on top of the other . Based on my Inspection, I .certify the.following conditions: 3. ,This is a title five septic system. ( 78 Code ' 4. , The septic system is in proper working order at the present time ., 5.;. :=The leaching pits are practically empty .Has never seen waste water any higher than it is now. SIGNATURE:,f N a m e:_,L kLr--,,Lr------- Company: J e.h_P. Macomber & Son, Inc. Address:_ Box_66_------------ Centerville L Ma_ 02632-0066 Phone:_ 508 775_3338_______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY (j6SEPH P. MA COMBER & SON, INC. Tank:-Cesspools•Leachflelds Pumped & Installed , l Town Sewer Connections P.O. Box 66 Centerville, MA 026320066 775.3338 775.6412 ;oo Vop tE JA N 2 5 2000 qAU c+r . �01 i 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Vj ONE WINTER STREET, BOSTON MA 02108 (617)292-6500 TRUDY CO . SecretF ARGEO PAUL CELLUCCI DAVM B. STRUI Governor Commissior SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIRCATION Property Addreu: 100 Bayberry Lane Nam.of owner G e n e v i e z e White Cummaquid ,Mass . 02637 Addressofownw: 17 C arlemnnt- Qtroct Data of4►spection. 13Lnn JOSQPhzP:Mac6fhber Jr . Dorchester ,MA 02122 Name of Inspector: F-1511 1 am a DEP approved systam 4upector pursuant to Section 15.340 of Title 5(310 CUR 15.000) Company Name: J.P.Macomber R Ron T n r Maiin9 Address: 2 6 3 2 Telephone Number: —7 7 5—3 3'i R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below Is true, accurate and complete as of the time of 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 Needs Further Evaluation By the Local Approving Authority _ Fails 4ispectors Signature: Gj/ Data: The System Inspector hall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)whNn 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 shoWd to•sent toitw system owner and copies sent to the buyer,If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 ��Printed on Recycled Paper 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(conWxied) Property Address: 100 Bayberry Lane Cummaquid ,Mass . Owner: G. White Date of InsPecti— 1/13/0 0 , INSPECTION SUMMARY: Check A, B, C, " A 'A. SYSTEM PASSES: ' I have not found any Information which Indicates that any of the failure conditions described In 310 CMR 16.303 exist. Any failure zriteria 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. Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank la metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the Inspection;or the septic tank, whether or not metal,Is cracked,structurally unsound,shows substantial Infiltration or exfdtration, or tank failure is imminent. The system will pass Inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 4 C,, Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced - The system required pumping-more than`four-dmes-e yeardus to broken or obstructed pipe(s). The system wif lass' inspection if(with approval of the Board of Health): - -- - broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 l ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Pr,pyAddre"• 100 Bayberry Lane Cummaquid ,Mass . Owner: . G. White Deft of Inepe-dm:l/13/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: it _ 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.]INILLPAOIECT THE PUBLIC HEALTILAND SAFETY AND.THE ENVZONMEKT- 4)0 Cesspool or privy Is within 60 feet of surface water 43 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 NEATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless 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. Method used to determine distance 664 _(approximation not valid).- 3) OTHER 44 revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 Bayberry Lane Cummaquid ,Mass . Owner. G. White Date of Inspection:1/13/0 0 D. SYSTEM FAILS: You must Indicate either"Yes" or"No" to each of the following: VQ I have determined that one or more of the following failure conditions exist as described 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. Yes No -1� Backup of sewage into focilivy-or-vptem-component-due%.to an overloaded orviegged•SAS-or•cesspod. --lam Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _j4A% _ Static liquid level IrAthe distribution box above;outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in oseepeel is lean than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped�. 4 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. 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. - E: LARGE SYSTEM FAILS: You must Indicate either"Yes" or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: 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: Yes No the system is within 400 feet of a surface drinking water supply the system•is•tivitWa 200 feetof�tribuiar�r ton sudaoe drinking+�wter.supply•....- --. .. —.» _._ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone If of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Infor,Ination. revised 9/2/98 Page 4oril i .l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST - Property Addres3: 100 Bayberry Lane Cummaquid ,Mass . Owner: G. White Date of kwP-_d`1/13/0 0 Check if the following have been done:You must indicate either"Yes"or"No" as to each of the following: Yes No -s•/ Pumping Information was provided by the owner, occupant,or Board of Health. • it _ -None of the system-compooents.hawsAmen pawiped4ovat•Jeast,two-%v9Ww andsthe'aystem hasbaeaas.cei9ingwrial Jlow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. s The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. 4 _ The site was inspected for signs of breakout.. . _ s All system components;;esccluding 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 orrthe site has been determined based on:- ie Existing information. For example, Plan at B.O.H.. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)] _ The facility owner.(and.----p-n•=.Jf ditleraot tranuoiAmar)Auare.prawWad w th t^forn"oaDn• A prcp_►.maint f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 100 Bayberry Lane Cummaquid ,Mass Owner. G. White Data of in*P—o :l/13/0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: N fl.p.d./bodro m. Number of bedrooms(des( n) Number of bedrooms(actual): Total DESIGN flow , Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (des or ►r& ra:_, If yes,sepa o.Inspectlon.required Laundry system Inspected Qys�or no) Seasonal use(yes or no):q�T Q ' C' A Water meter readings,If available(last two year's usage(gpd): / O Sump Pump lyes or no) ,,.� �, GZd Jp �!!�� Pc7 �"'•� Last date of occupancy:." i COMMERCIALMIDUSTRIAL• Type of establishment: AIA Design flow: A,,,'* oad (Based on IS.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no)A Non-sanitary waste discharged to the Title 6 system:(yes or noWA Water meter readings,If available: Last date of occupancy: IV-19 OTHER:(Describe) Last date of occupancy: J GENERAL INFORMATION PUMPING RECORDS and sourcq of Information: System pumped as part of inspection:(yes or no) -10 If yes,volume pumped: gallons Reason for pumping: TYPE O�SYSTEM Septic tank/dieiributlaalioadsoii absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,If any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank A)* Copy of DEP Approval Other 4A APPROXIMATE AGE of all components,date InstaAed{if known)-end sources of4dormation: Sewage odors detected when-arriving at the site:(yes or no) r revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 Bayberry Lane Cummaquid ,Mass . Owner: G . White Date of Inspection: 1/13/0 0 BUILDING SEWER: (Locate on site plan) Depth below grade: / Material of construction:� � ast iron�4D PVC44other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of feakage,-etc.) - — - e s stem is yentod SEPTIC TANK: (locate on site plan) Depth below grade: ) Material of construction: 4-concrete 4metakAFiberglass.M_Polyethylene&ther(explain) If tank is fnetal,list age_ Js.age.confirmed by Certificate of Compliance(Yes/No) Dimensions: 7 Sludge depth: CAZL Distance from op ludge to bottom of outlet tee ort affie: e Scum thickness: Distance from top of scum to top of outlet tee or baffie:`,,t.� — p Distance from bottom of scum to bottom of outlet to or baffle::iZ-b�� How dimensions were determined: Comments: (recommendation for pumpin ,-condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) (?ump the septic tank every 2-3 years Inlet & outlet tees are in place Liquid level - at the outlet invert is fifty one i.,rhP- ir Tha tan i c �+tr„rt„ra l tTaAtiyad gild r.hQiJ S a sv�del}6A Q9 leakage , GREASE TRAP: (locate on site plan) Depth below grade: Material of construction concreted metaWAl`iberglassN�PolyethyleneQAother(explain) AIA Dimensions: — 1114 Scum thickness: Distance from top of scum to top of outlet tee or baffie:4M Distance from bottom of s um to bottom of outlet tee or baffler Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural Integrity, evidence of leakage,etc.) Grease trap i g not i rpgpnt revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 Bayberry Lane Cvmmaquid ,Mass . Ownw: G. White Date of Inspection:1/13/00 TIGHT OR HOLDING TANK:4,Wo.(Tank must be pumped prior to, or at time of,inspection) (locate on site plan) Depth below grader Material of construction:+VAconcretowAmetal4aFiberglass{&Polyethyleneqaotherlexplain) WA Il/ Dimensions:_ AM Capacity: Nil gallons Design flow: A14 gallons/day Alarm present A(A Alarm level: A14 Alarm In working order:Yes/ja Now/ Date of previous pumping: AIW . Comments: (condition of inlet tee,condition of alarm and float switches,etc.) iQ t or holdinR tanks are not present . DISTRIBUTION BOX; , (locate on site plan) Depth of liquid level above outlet invert:— Comments: (note-if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) —Distribution box is not present _ PUMP CHAMBER.A&t (locate on site plan) Pumps In working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) umpc am er is not present . . revised 9/2/98 Page 8of11 v ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 Bayberry Lane Cummaquid ,Mass . Owner: G. White Data of Inspection: 1/13/0 0 SOIL ABSORPTION SYSTEM(SAS)2 (locate on site plan,if possible;excavation not required,location may be approximated by non-Intrusive methods) If not located,explain: Type: leaching pits,number: leaching chambers,number. leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimenslon overflow cesspool,number- Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) Clay to coarse Rand No Ri gnc of h1rdra„1 i r failure ex:ms;Qn li ng . CESSPOOLS:d,646 (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Al Depth of solids layer: i1tIQ Depth of scum layer: Dimensiohs of cesspool: Materials of construction: 44 Indication of groundwater: Inflow Icesspool must be pumped as part of Inspection) esspoo s are not present. Comments: (note condition of soil, signs of hydraulic failure,.level of pending,condition of.vegetation,etc.) esspoo s are not present . PRIVY: (locate on site plan) Matedos of construction: AIR Dimensions: Depth of solids:A14 Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.) rivy is not present revised 9/2/98 Page 9of11 L v ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 Bayberry Lane Cummaquid ,Mass . Owner: G. White D.R.of lnspec$oo:1/13/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes Into house) to r Qoo•� a,• �• a l i r� v OQ . 0 i . revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 Bayberry Lane Cummaquid ,Mass . Owner: G. White Date of Inspection: 1/13/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 1� Observed.Site(Abutting property baervation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map. Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11of11 wwnr�.�n.•.+r•tir s.wran•w.nr..r,.rt�nns�rnw+nw►+w+wwn.nws�u n�w��n�•+ TOWN OF Barnstable BOARD OF HEALTH SUBSURFACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION -.�..•.-::.—*,e-.r.,-..rt r.+n•rtn..,.,.�s,..n-.n,,.•-a,.,v..w'..,n...-.�......w...n....,.., ..,,, -TYPE OR PAINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS _100 Bayberry Lane Cummaguid ,Mass , ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Genevieze *White ( Deveney ) PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr, COMPANY NAME J.P.Macomber & S-a�fi' Inc , COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City stag LIP COMPANY TELEPHONE ( 50.� ) 775 3338 FAX ( 508 .1 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa°1 system at this address and that the information reported is true , accurate, and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Chec 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. System FAILED* The inspection which I have con ted has found that the system fails to protect the jiublic 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 . le 1 q Inspector Signature Date op— ne copy of this c rtification must be provided to the QWNER, the BUYER ( where applicable ) and the BOARD OF HICALTII. * If the inspection FAILED, the owner or""oparator shall upgraade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 , 306 . ' partd .doc .' TOWN OF BARNSTABLE L-, / �9 LOCATION SEWAGE # VII.LAGE 1. WA6e ASSESSOR'S MAPS&LOT INSTALLER'S N &PHONE NO.' � I� X'V .zt-,a SEPTIC TANK CAPACITY LEACHING FACILr Y: (type)Z_i/I � JTAO-�, (size) NO.OF BEDROOMS BUILDER OR OWNER ~ PERMIT DATE: ✓ "7 COMPLIANCE DATE: �� V Separation Distance Between.the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland 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 fe g faci ' ') Furnished / fin✓ .mA® Dle� rol /n _ _7 No......!N ........ F�a.. �.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF Hy�, Xo -------.OF..... ....... - ',........................ ,Noptiration -for Bi-qVn,itt1 Workii Towi#rurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( �n Individual Sewage Disposal Syst at �?.f tiai -' -•------•----------•-----•----------------•-------------------•-------_--------------•-- 100 f.6• �� Location-Addressor Lot No. .,... d ...................................... Owner � Address Installer Address Q ype of Building Size Lot----------------------------Sq. feet U Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ------------_---------------- - - W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. Ga Septic Tank—Liquid capacity-_--._ --___gallons Length................ Width................ Diameter........-------- Depth---------------- W x Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area----------------....sq. ft. Seepage Pit No--------------------- Diameter.................... Depth b/dl!,�nl otal lead n area.. .._ . .___ q. it. M Other Distribution box ( ) Dosing tank ( ) ''Vii�� /�✓ Percolation Test Results Performed by.......................................................................... Date--------------------------------------- ,a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_.-.----_--.---._-.--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit..-- ___-_______-- Depth to ground water------------------------ -- / . --- .----•• Descr' ion Soil j ` ------------------------------------------------------------------- AAA - -- -- ----- -- ----- `" W ---------- -----------------'---------------------------------------•------------------------------------------------------------------------------------------------ ; !�� U Nature of Repairs or Alterations—Answer when applicable--------- -------��-1�............... .........��...____._.._._... ._ ". .......... ----------------------------------------------------------••--•------. ----•----- -••--•-••.-•••------•-....-•-•--..._•------•-----•-••----••----_._.............._.....-----...-------•------•------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article 1I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b4en issue by eobord+of health Signed r ------=----- � - ale Date ApplicationApproved By----------------------------------------------------------------•-------------•-•---------------- ---------------------------------------- Date Application Disapproved for the following reasons:---..._..-•................................................................................•-......-•••--•--•••- .........................••-•--_.._.......---.--••-------------•---.......------•---_._..._.....------••. / Date Permit No.......................................................... Issued....te-- . .,......s �r Date W---------- ............... THE COMMONWEALTH OF ,MASSACHUSETTS Al BOARD OF H — 'L—TH OF "f— ?AM1 ,1...................................... r 640410��....... ,vvvfiravon -for Di!ivasal Workii Towstrurtion Vrrufit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Sys, at: ------------------------------ -- ...........-- ------------- -------4Z .....4"��...........................................or.Lot.No..........................--------------- Location-Address ... ..... .................................................................. ................................................................................................. tOwner Address - — --------- - -------_--_-------- ------------------------------------------------------------- ------------------------------------ Installer Address <tl ype of Building,,,' Size Lot.............................Sq. feet U Dwelling 1—`No. of Bedrooms------------------------------ -------------Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons.----_-_-----__--___------__ Showers Cafeteria P4Other fixtures ---------------------------------------------------------------------------------------------------------------- .................................... Design Flow............................................gallons per person per day. Total daily flow--_--_-_____-----_--__________ -_--._...-_.gallons. 04 i Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter..._-_.......... Dep-li---------------- Disposal Trench—No..................... Width___--__--_--_----_-. Total Length............._._._.. Total leaching area....................sq. f t. Seepage Pit No..................... Diameter....._.____._....._. Depth Other box bel I otal leacl no area..._. (I. f t. Oth Distribution b Dosing tank t.�, Ay. �� p �j �llC� Percolation Test Results Performed by.......................................................................... Date:-------------------------------------- Test Pit No. I--------------..niinutes per inch Depth of Test Pit.................... Depth to ground water...--.--_-_--.-.._.-__-- 44 Test Pit No. 2................minutes per inch Depth of Test Pit................__.. Depth to ground water------------------------ 9 0, .............. ..............e._SC/----------- 0 Descriptiotri of Soil__-_ ------ ........... ---------------------------------------------- U ------------------------------------------------ ...............................----------------------------------------------------------- -------------------------------- A .4 . .. .................. q---7---W------------------------ -----------;07------------------------------------------ e of LRe/p s or., er when applicable------ ............77------ I . .............11-1---------I--------- U Na Ze i or-Alterations teolf Z.....--f...S----------- ------------------------------------------------ ....................................................................... ,v 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 bee'is issued b the oardy ealth. 0.. ...Signe---- ----Iy........ ..Application Approved By...................................I .......................................... .................. ........................................ Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date Permit No. ........................... ......................... Issued........................................................ Date THE,COM40,NWEALT' H OF MASSACHUSETTS BOARD OF HEALT, ............ ...... 101rdifirate of To jaurr T ISIS Te CER#FY livid T Sewagepf ki d/1 Disposal/Systetyconstructed or Repaired (Z-4-1 ....I-e.......................................................... ---------- by_ s aller at ...... ................................... ................................................................. . y --------------- ----- of he State Sanitary Code as descr 0 in the has been ins lied, in ac dance with the proviltb,?ts of*Arti application for Disposal Works Construction Permit No..._. ................................. .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE..'CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTJOI� SATISFACTORY. DATEj.............................................................................. Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL .......................................OF N.......................... FEE--- .................. R-spaiial Workii ClIanstrurtillin Vrrmtt Permission is hereby granted._._._...................f ..................................................................................................................... to Construc?'( O)Aepair Individual,, e,/ age Disposal,f System qw.~.. ----------- ..........I- -------------------------------------------1.............. ........ as shown on the application for Disposal Works Construction it J. Dated../0_777.1��_?.....7y...... . ......... . ... .. ......................... Boar of jVt 7X i A4 ZR- -------------------- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS a - . rAwIlk es<( 1 lk Ito �u:+ d IS -- - ---- TOWN OF BARNSTABLE LOCATION / ®A✓ • V SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S N &PHONE NO.� ✓��r5f �j" -� SEPTIC TANK CAPACITYr- LEACHING FACILITY: ( S' �J/ _ size' NO.OF BEDROOMS _ BUILDER OR OWNER �1U PERMITDATE: to'1� 7 COMPLIANCE DATE:` j Separation Distance Between.the: Maximum Adjusted Groundwater Table to the 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 Facibty(If any wetlands exist within 300 fe a g facili ) F ,,,, Furnished ( i' 11i.,�� 09 1 Z: 16 north port h i storsoc i eta 6317573398 p. 1 'I? - 1 All ti Z. raq; H ,I ax TO: Donna, Barnstable Health Department c,. {nIrli Fax Number:508-790.63D4 Date: 11/25/08 r" ; From: phineas and Johanna Fiske, 631 t-8652 Number of pages including cover, 2 k'±( Regording:Septic system at 200 Bayberry Laine Hi; Attached is a copy of a FAX we received from our real estate agent, d ; which he of from the filies of the company that succeeded 9 P y Macomber. It a photocopy of the front and back of a 4 by ppe�r��j a h®t®c® 6 card,The diagram shows an existing leach fleld and distribution w" box, so we can but assume what was being installed was a now ' leach pit.We'd like to know whether this changes your impression of the way the system had developed. Many thanks, i' phineas Fisk. !- ' ; L i j t 1�5�ft• y � _ 25 08 12: 16p northport historsociety 6317579338 p . 2 i TOWN OF BAR"ISTABLz LoC 'nON"/Y s • , idU.. r�3SASS 'IL'SI_tkP�.L01 aS� APHONEAli LE AC C'No FACX,i SE Ff.". TANK CAPA(MY � ,Y •�..-...,�-mom Sop j'18 nis%b$�C!`.N:r.E1 EIS;! u , k � �;� b7 stic�t�r_•>I.�.�tz,�[o1 C"Rr�,±.eajt•sr•F�b1C to h�.�n`�ot1 the L:�;f,i®E Fs.:iii;y �.______ - ,..< oe$.ile Es,%Vjal n!a()kc;ot•lucilins f'accd¢gj; E481t or w-BLIfiod and Yos tln Faai3 wa ciandsex, ¢ _ t 1 3 .h `i R, ,pfp f i h